“You’re cured,” the clinician told me. “You no longer have Type 2 diabetes.” You’d think I would greet this news with a sigh of relief since years ago I had an A1c as high as 8.9%; but I did not, because I knew it simply wasn’t true.
I was not, however, surprised with that doctor’s response. I had just told her that, although I had been diagnosed a Type 2 34 years ago, my A1c was now 5.0% and my average FBG was in the mid-80s. From the clinician’s point of view, as one who treats patients according to the ADA’s Standards of Medical Care, her goal was for her to manage my diabetes to get my A1c to ≤7.0%, or even ≤6.5%, the diabetes diagnosis threshold. Thus, to her, clinically speaking, I was “cured.” I asked her, “Would you then write on my chart that I no longer had diabetes?” She replied, “Yes.”
When I shook my head in dismay, she asked me why I wouldn’t accept this “good news.” I replied, “Because I will always have Insulin Resistance and therefore will always be diabetic.” She just smirked, not wishing to get into an argument. We were, after all, just chatting in a social setting after a panel discussion in NYC with Gary Taubes. Nevertheless, she said dismissively, and with medical authority, that what I said was untrue. I left it at that. The divide between us was too great. In her view, unlettered dotards like me shouldn’t be taken seriously.
This doctor wasn’t my doctor and wasn’t going to be. Except for my MD friends who read this blog – and there are a few – I leave the one-on-one re-education of the trained professional to others. But, as the Dr. Eric Westman sadly said to me a few years ago, in Retrospective #402 here, “Ignorance is the biggest problem.” Gary Taubes expressed a corollary sentiment to me that night. He said the Low Carb “movement” has increased 100 fold in just a few years from 1/100th percent to 1 percent. That’s a huge relative improvement…yet still an abysmal state of affairs. There is yet so much work to be done to overcome the entrenched positions in the political, agribusiness, big pharma, public health, medical, and other special interest establishments.
But I digress. Insulin Resistance is a dysfunction of a biological process, in those genetically predisposed, such that the insulin receptors on cells that ordinarily open to allow glucose energy to enter and nourish them, no longer function properly. When these insulin receptor cells “resist” opening, and the uptake of glucose is impaired, the pancreas secretes more insulin to help out. Type 2 diabetes is thus a disease of too much insulin in the blood stream. Characteristically, Type 2s have both an elevated blood glucose and an elevated blood insulin.
The elevated blood glucose is what clinicians use to detect the presence of incipient pre-diabetes or Type 2 diabetes. Today the hemoglobin A1c (HbA1c) blood test is used for diagnosis. Previously, an elevated fasting blood glucose (FBG) was used. The gold standard, still used by most endocrinologists, is the Oral Glucose Tolerance Test (OGTT). It takes at least 2 hours (mine was in a hospital outpatient department) and is thus more expensive. The easiest test is to measure your waist/hip ratio (for visceral adiposity); anything over 1.0 (male) or .8 (female) signals insulin resistance.
The elevated blood INSULIN causes OBESITY. While insulin is elevated, the body must rely on food by mouth for energy. Most people eat carbohydrates in every meal and frequently between meals. So, if you have a little Insulin Resistance, your blood INSULIN level stays high ALL THE TIME. That’s why you are always hungry and why, when we eat more and more often, extra calories, whether carbohydrates or fat, are stored as fat. Only when your blood INSULIN level drops will the liver look for an alternate energy source. It will first use glycogen (stored glucose in the liver) and then, after a day or two, turn to breaking down body fat for energy. But to do this, a person either must eat VERY LOW CARB at virtually every meal, and not snack, or FAST for a day or two, or BOTH.So, while I have no clinical signs of Type 2 diabetes, because of my low A1c and average FBG, and doctors in a clinical setting may regard me as “cured,” I know that I am still Insulin Resistant. I know that it is only because I eat Very Low Carb most of the time, and fast a few days most weeks, that MY INSULIN RESISTANCE IS NOT EXPRESSED. But my Insulin Resistance will always be there, albeit somewhat less dysfunctional because it is less stressed, and that is why I will always be a Type 2 diabetic – A (THIN) TYPE 2 DIABETIC, IN REMISSION, BUT ONLY BECAUSE OF THE WAY I EAT.