Wednesday, October 23, 2019

Retrospective #249: Type 2 Diabetics: You Have a Choice.

If you have been diagnosed a Type 2 diabetic, you and your doctor have a choice of 3 treatment options: 1) insulin injections, 2) oral antidiabetic medications, and/or 3) major dietary changes. I’ve oversimplified it, but this is an overview so the unschooled can see the “big picture.” Full disclosure: I’m not without my own biases, as you’ll see.
To illustrate the insulin treatment option, I will use an 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 Eli Lilly and Company’s fast-acting Humulin R (Insulin Regular). Why do I say that? Well, based on the advertising. As you scroll down the screen, the article is accompanied by 5 ads for Humulin R, 1 on top of the article, 3 on the side and 1 at the bottom. Then, I saw the hyperlink, “Humulin Insulin Special Edition September 2014.”
I have nothing against injecting insulin.  Exogenous 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 article are the Editor-in-Chief and Publisher of the Diabetes in Control “newsletter.” I didn’t know that because it was revealed in the “disclosures,” as is done in peer-reviewed medical journals. There were no “disclosures.” I knew it because I have been reading this “newsletter” for years.
I Googled the Diabetes in Control Editor-in-Chief and learned he “…speaks on diabetes, hypertension, and related co-morbidities for Abbott, Bayer, Pfizer, Novo Nordisk, Lilly, Sanofi, Sankyo, and Medtronic” (emphasis added). And, he “...is a non-physician member of the Lilly Primary Care Diabetes Advisory Board.” This guy has mega bona fides.
Nevertheless, the “Practice Pearls” for insulin as a treatment for Type 2s are very revealing, particularly the 2nd one.
     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 [like amputations, for instance].
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.  Your care giver can help on the amount of “basal” insulin you inject once a day, but only you can decide how much “bolus” to inject before each meal because 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 with each meal. As a result, many patients, and their caregivers including clinicians and CDEs, do not try for tight glucose control. They tend to inject too little to avoid the dangers of hypoglycemia, including hospitalization and death.
The 2nd 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” are started on Metformin. The dose is increased (as your disease “worsens”) until you are “maxed out.” Then a second agent, and probably a third will be added to the “cocktail.” Since, as we’ve seen above (in the 2nd bullet), the accepted 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 eventually “progress” to insulin dependency.
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 you with drugs, your Type 2 diabetes WILL “progress” and “worsen over time.” Eventually, you are likely to develop some of the microvascular and macrovascular complications, like heart disease.
The 3rd treatment option for Type 2 diabetes or Prediabetes: major dietary changes. Pros: no insulin (and no hypos), few if any oral meds (thus no side effects), and greatly improved (not worsening) glucose control, plus a bonus: improved BP and blood lipids (higher HDL, lower triglycerides, stable Total Cholesterol and LDL). And in addition to all this, you will lose lots of weight, have lots of energy and feel great! Cons: you have to give up all the highly processed foods and carb-loaded junk that made you sick in the first place. It’s your choice. And yours alone. 

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