Monday, August 26, 2019

Retrospective #191: Insulin-Dependent Type 2s

Okay, this is going to be an opinion piece. I admit to bias, but I will strive to present the subject in a factual way. That being said, I am not a doctor. I am a Type 2 diabetic with 33 years of experience, all of which gives me certain bona fides (and contributes to my bias). In fact, the revelation that my pharmacist was an insulin-dependent Type 2, and died prematurely, was the impetus for “The Nutrition Debate.” His death was a totally unnecessary tragedy.
First, a little background. There are two types of diabetes: Type 1 and Type 2. Type 1 is an autoimmune disease. The onset usually occurs in childhood, permanently destroying the body’s ability to make insulin, a key hormone produced by the pancreas. Until the discovery of man-made insulin in 1922, most Type 1s didn’t live long. The only medical treatment was a strict medical “ketogenic diet” in which the patient’s dietary intake (food) was 90%+ fat.
Type 2 diabetes, formerly called “adult onset diabetes” but now found in children, is a disorder of metabolic disregulation resulting from insulin-resistance at the cellular level. The pancreas thus overworks to produce insulin. It is diagnosed by testing blood glucose since one of insulin’s key duties is the transport of glucose, the molecules that originate in food as complex carbohydrates and simple sugars. If the cells are resistant to insulin, glucose doesn’t get taken up into the cells and the level of glucose in the blood rises. The diagnosis of Type 2 diabetes is made with an elevated fasting blood glucose (on 2 consecutive office visits), or preferably one elevated hemoglobin A1c test, reflecting a 3-month average of circulating glucose as measured on the surface of red blood cells.
Type 2 diabetes is often suspected in overweight and obese individuals. Why? Because insulin stores fat.  When we consume carbohydrates, the body chooses wisely to use the sugars and starches in foods (that all convert to glucose) as its primary energy source. It conserves body fat for use when food is not available. It’s a brilliant design, since fat is a very good storage vehicle. It is more than twice as dense in energy (9 calories per gram vs. 4 for carbs).
When a doctor determines a patient is a Type 2 diabetic, the conventional medical treatment is to 1) council weight loss via “diet and exercise,” and/or 2) prescribe an oral medication to help. If the patient is not successful in losing weight, the doctor adds another oral med and then maybe a 3rd med to the “cocktail.” More recently, new injectable medications (GLP-1s) are sometimes prescribed. Insulin injections are usually reserved as a “last resort.”.
Many patients who are treated using the ADA’s standards for blood glucose control, which are much too lax, will eventually progress to becoming insulin-dependent Type 2s. The medical community acknowledges this. They consider Type 2 diabetes a progressive disease, with a decrease of 10 years in the expected lifespan for T2 adults and 15 years for T2 children, compared to non-diabetics. In reality, however, Type 2 diabetes is a dietary disease.
Normalized glucose control is essential to reduce the complications of long-term elevated blood glucose levels: peripheral neuropathy (nerve and microvascular damage), commonly resulting in amputations; retinopathy (damage to the blood vessels of the retina, resulting in blindness); and nephropathy (end-stage kidney disease).
Insulin therapy for Type 2 diabetics usually begins with “basal” insulin, injected once a day. To this is added “meal time” insulin in which you, the patient, estimate the amount of carbohydrate you will eat at a meal and then inject an appropriate dose 20 minutes or so before each meal. Some people now wear an “insulin pump” in which a needle, embedded under the skin, injects an amount that you determine by making an adjustment on the pump.
If you are a Type 2 diabetic, what does this suggest to you? If your pancreas still makes insulin, couldn’t you do the same? 1) Eat only small amounts of carbohydrates and thus only need to use small amounts of the body’s precious supply of insulin? And 2) Avoid glucose spikes, and thus protect your pancreas from further damage.  I think you can! Remember: Type 2 diabetes is a DIETARY disease, and YOU control what you eat!

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