The Nutrition Debate #249: Type 2 Diabetics: You Have a Choice.

If you have been diagnosed a type 2 diabetic, your doctor (YOU actually) have a choice of long-term treatment options: 1) insulin injections, 2) oral antidiabetic medications, or 3) major dietary changes. I’ve oversimplified it, but this is an overview so the unschooled reader can see the “big picture.” Besides, I’m not without my own biases, as you’ll see.

To illustrate the insulin route, I cite a rather pedantic article, originally published in 2011 in Diabetes in Control, a source which bills itself as “News and Information for Medical Professionals.” It was re-posted on September 11, 2014, to promote the Humumin R insulin product. Why do I say that? From the advertising. The article is accompanied by ads for Eli Lilly and Company’s Humulin R,* as you scroll down the screen, 5 of them: top (1), side (3) and bottom (1). In fact, a hyperlink under the title reads, “Humulin Insulin Special Edition September 2014.” Maybe the whole article is just a paid advertisement.                                  * Specifically the U-500 version, a concentrated form for insulin-resistant patients requiring more than 200 units a day.

I have nothing against injecting insulin. Insulin is a good thing, and it works. And I have nothing against advertising. I do have a problem, however, when advertising and clinical practice advice get mixed together. I have an even bigger problem when the first two authors of the piece just happen to be Editor-in-Chief and Publisher, respectively, of the Diabetes in Control “newsletter.”  I didn’t know that, however, because it is revealed in the “disclosures,” as it is in a peer-reviewed medical journal. There are no disclosures. I knew it because I have been reading this “information source for medical professionals” for years.

But if you didn’t know, and care to go to the trouble, Google David Joffe (the Diabetes in Control Editor-in-Chief), and learn, “Dave speaks on diabetes, hypertension, and related co-morbidities for Abbott, Bayer, Pfizer, Novo Nordisk, Lilly, Sanofi, Sankyo, and Medtronic” (emphasis added). Or, “Dave is a non-physician member of the Lilly Primary Care Diabetes Advisory Board.” Admittedly, conflicts aside, reading his full curriculum vitae, the guy has mega bona fides.

Nevertheless, the “Practice Pearls” for insulin as a treatment for newly diagnosed Type 2s are a good “takeaway”:

●     By removing the glucolipotoxicity you can improve beta cell function.

●     Since Type 2 diabetes is a progressive disease and will worsen over time, by improving beta cell function the progression of diabetes can be slowed down to prevent complications

The 2nd long-term treatment option is also pharmacotherapy. Oral antidiabetic medications have evolved from the early days when insulin-secreting sulfonylureas were the only option. Today most newly diagnosed type 2 diabetics and even “pre-diabetics” (those that can “tolerate” it) are started on metformin. The dose is quickly increased (“titrated”) until you are “maxed out” and then a second agent, and even a third med is added to the “cocktail.” Since, as we’ve seen above (in the 2^nd bullet), the “perceived wisdom” is that “type 2 diabetes is a progressive disease and will worsen over time,” the assumption is that many type 2 diabetics who are treated with orals will “progress” to insulin dependency.

The major downside to injecting insulin is hypoglycemia, or low blood sugar. It can lead to coma and death. That is because you, the patient, has to decide on the amount to inject before each meal or snack.  Your care giver can help on the amount of “basal” insulin you inject once or twice a day, but only you can decide how much to inject before each meal ‘cause your doctor is not at your side 24/7. Even if you have a pump and continuous glucose monitoring (CGM), which few do, you have to figure the dose of mealtime insulin that you inject each time. As a result, many patients, and their caregivers including clinicians and CDEs, do not try for “tight glucose control.” They inject too little to avoid the danger of hypoglycemia.

The exception to this would be the pioneer on glucose meters, glucose monitoring, and low-dose insulin regimens, Dr. Richard K. Bernstein. His book, Diabetes Solution, is an authoritative source for all diabetics. And Dr. Bernstein’s Diabetes Forum (registration required), accessed from the same link, is a great place for learning about all aspects of diabetes.

The downside for oral antidiabetic medications is 1) all drugs have side effects and 2) if you do nothing else and just let your doctor monitor and treat your worsening glucose metabolism, your type 2 diabetes will “progress” and “worsen over time.” And if the progression of the disease cannot be slowed down, you run the risk of developing “the dreaded complications,” not to mention macrovascular complications like heart disease.

Now, the 3^rd long-term treatment option for type 2 diabetes or pre-diabetes: major dietary changes. Pros: no insulin (and no hypos), few if any oral meds (and no side effects from same), and greatly improved (not worsening) glucose control, plus a bonus: improved BP and blood lipids (higher HDL, lower triglycerides, stable Total Cholesterol and LDL). Less of that nasty MG (see The Nutrition Debate #246 here) stuff too. And another under recognized benefit: you will lose weight, have lots of energy and feel great! Cons: you have to give up the processed foods and carbohydrate-loaded junk that made you sick in the first place. It’s your choice. And yours alone.