June 20, 2007

Type 2s: Insulin Early is Easy, Insulin Late is Not

I keep reading postings here and there on the web from people with Type 2 diabetes that say something like, "My A1c was 11.5% even with Metformin, so my doctor told me it was time to go on insulin."

It is postings like this that bring home to me why so many Type 2s develop terrible complications, and even more importantly, why even those who are taking insulin often have dangerously high blood sugars.

The most conservative of medical groups--the ADA--tells doctors that an A1c over 7% is going to cause serious diabetic complications like blindness and kidney failure. Yet these people's doctors have encouraged them to dick around with oral drugs when their A1cs were 10% or higher!

The years they've spent at those dangerously high blood sugar levels waiting for oral drugs to do what all the research evidence shows oral drugs cannot do have wreaked havoc on their organs that may not be completely reversible, no matter what their blood sugars might be in the future.

In fact, a recent survey I read somewhere on the web found that most family doctors don't put their patients on even an oral drug until the patient has spent a year with an A1c of 8% or higher. That is a whole, long year where dangerously high blood sugars are producing early retinopathy, advancing neuropathy, and making small changes that lead to kidney failure.

Since none of the oral drugs is capable of lowering A1c much more than 1%, this kind of treatment is criminal. A patient whose A1c is 11.5% on metformin probably started out with an A1c of 12% or even higher. If you don't believe me, go read the Prescribing Information for each of the common diabetes drugs. They show exactly what the median change in A1c is that their drugs can achieve, and you'll see it is rarely much more than a 1% drop in A1c. For a patient with a 12% A1c, even a 3% drop would be pitifully insufficient. But that is how these people's doctors are treating them.

All that unnecessary suffering. It makes me want to weep!

For patients with an A1c over 8.5% there are only two therapies that will reliably bring blood sugars into the safe zone. Let's look at them now, very carefully.

Carb Restriction

Many newly diagnosed Type 2s with surprisingly high A1cs have reported online that they have been able to bring their A1cs down from 10% or higher to the safe 5% range by cutting the carbohydrates out of their meals until they were able to get a blood sugar under 140 mg/dl at one hour and 120 mg/dl a two hours after eating.

Though doctors pay lip service to the idea that their patients can control diabetes with "diet" a depressingly high proportion of these doctors seem to think that "diet" means "weight loss diet" rather than "Carb control diet" so their patients end up starving on high carb/low fat meals that push up their blood sugars to levels guaranteed to destroy eyes, nerves and kidneys.

Cutting out the carbs that raise blood sugar is the only "diabetes" diet that will improve blood sugars for every person diagnosed with Type 2 diabetes. So for the newly diagnosed Type 2, or the Type 2 who has never tried cutting way back on their starch and sugar intake, a stint of eating a true diabetes diet, one that avoids all starchy foods, no matter how full of "whole grains" they might be, a diet made up almost entirely of healthy greens, cheese, lean meats, nuts, berries and nonstarchy vegetables may be all that is needed to perform blood sugar rescue.

But if cutting your carbs doesn't make a dramatic difference in your A1c within a few months, there is only one sane therapy to consider, and the faster you demand it, the less likely you are to end up as another tragic diabetes disaster story.

That therapy involves insulin.


Unlike every other diabetes drug you may read about, insulin, prescribed properly (and those words are key) always works. Insulin is the only drug that will lower blood sugar in every critter that has a blood stream with glucose floating around in it. Rodent, fish, monkey, or you, insulin WILL lower the blood sugar. And insulin can lower blood sugar however much you need it lowered, if--and it is a big if--you learn how to use it correctly.

This is such a simple concept, you have to wonder why most doctors treat insulin like it was devil's blood, trying every other possible treatment--some of them quite dangerous--before putting their patients on the one treatment that is capable of giving them normal blood sugars.

In the past, doctors seem to have assumed that needles were so terrifying to patients that they would not use them unless faced with immanent death, and as a result, insulin wasn't prescribed until Type 2s were on death's doorstep. (Which, unfortunately, has made a new generation of diabetics assume that if you get prescribed insulin, you are on your way out.)

But look what happened when Big Pharma came up with a new treatment, Byetta, that was rumored to cause weight loss. Despite the fact that Byetta treatment requires not one but two needles a day and can cause projectile vomiting, patients lined up demanding it and thousands of Type 2s are happily injecting themselves and whoopsing their way to happiness. So clearly when patients perceive a benefit in a treatment, they'll put up with needles.

The benefit of insulin can be much greater, since Byetta only works to lower blood sugar significantly for a subset of those who take it. Insulin always works.

Insulin Early is Easy, Insulin Late is Hard

My belief--and this is how I treat my own diabetes--is that if diet (defined as cutting carbs) plus the one safe med, metformin, and possibly Byetta, don't give you normal blood sugars, it is time to move to insulin while the beta cells still have enough life in them to make insulin safe and easy to use.

This is a huge point many doctors miss. If your pancreas is a mess of scar tissue, you probably have lost your alpha cells too, and this means that you may have little or no ability to secrete glucagon to raise your blood sugar if it goes too low.

If, on the other hand, you start using insulin when you still have 20-30% of your beta cells living, you can use lower doses of insulin and if you take too much your body will push your blood sugar out of the hypo range, because it still has the other pancreas-produced hormone it needs to do so.

People with no beta cells have a much tougher time using insulin, especially when they use it to control post-meal blood sugars. The stories you hear from Type 1s who veer from 35 to 350 mg/dl in a few hours give you some idea of what it can be like to use insulin when you have a dead pancreas.

But most Type 2s don't have a dead pancreas, and though only a few of us have pioneered the "insulin early, not insulin late" strategy, those of us who have find that it makes living with diabetes far easier than we ever thought possible. Insulin supplementation takes the burden off our struggling beta cells. It can let us fine tune our blood sugars to where they stay relatively flat and do not ever go near the zone where glucose floods into nerves, eyes, and clogs up tiny kidney filtration units.

As Dr. Bernstein points out, small inputs make for small mistakes, and when a Type 2 starts insulin early, the doses are much smaller than later, when they have no beta cells, and the mistakes are much smaller too.

Here are some things your doctor might tell you if you want to start insulin that you might want to question.

Insulin Myths

1. You'll gain weight.

This is what kept me from starting insulin for years, when I should have been on it all along. It turned out NOT to be true as long as I use insulin in a way that matches my carbohydrate input.

If you take more insulin than you need, you will get hungry. "Feeding the insulin" will pack weight on you. But if you learn how to determine your "insulin/carb" ratio, and inject an amount of insulin that matches your food, you should not gain weight. If you are taking a basal insulin, Levemir is also reputed to avoid weight gain.

And I also find that for me, the analog insulins seem to provoke hunger. But R insulin (the cheap kind) does not, and I even managed to lose a couple pounds last year while injecting R insulin 3 times a day.

2. You'll have hypos.

Using insulin requires using your brain. If you just want the doctor to tell you how many units to inject, and blindly do whatever you are told, hypos are a possibility.

But if you read up on how to use insulin--using the books and materials intended for Type 1s who, unlike Type 2s, get training in how to use insulin properly, you won't. I have not had a blood sugar reading under 60 mg/dl fifteen months of using insulin with my meals.

3. Needles are Painful

The shots don't hurt. I was as needlephobic as anyone, but it took about a day to figure out that my lancet for testing my blood sugar is a lot more painful than the hair thin needles I use for injecting. The first time I stuck myself with one, it was so painless I had to look down to make sure I really had stuck myself!

Right now one company is marketing an inhalable insulin, one that isn't very easy to use and which is very tough to match to carbs, by playing on people's fears of needles. It is much more expensive than even the most expensive injectibles, and it may harm the lungs. It is completely unnecessary.

Give yourself a few days to get over your needle phobia, and you'll end up laughing at how huge it used to loom in your mind. Injecting insulin really is No Big Deal.

4. All you need is one shot of basal insulin

There are two kinds of insulin. One lowers your fasting blood sugar and runs slowly in the background. Lantus, Levemir, and to a lesser extent NPH insulin are in this category. This kind of insulin does NOT bring down high post-meal blood sugars, it just lowers the point from which the post-meal spike begins.

Most Type 2s get put on basal insulin, because it is easy to use. But if your diabetes is mostly about very high post-meal blood sugars, a basal may not solve your problems. So you may think that insulin doesn't work for you, when in fact, the problem is you are using the wrong kind of insulin.

The meal-time insulin or "bolus" insulin is the insulin you match to your carb intake. The key for a Type 2 to making meal-time insulin work well is to keep your carb intake reasonable. Type 2s still have a small bit of homemade stuff that kicks in after a few hours, unlike a Type 1. It is not realistic to think you can eat 100 grams of carbs and match it with insulin, because the variations in timing of all that carb hitting your system, mixed up with your "sputtering pancreas" occasionally throwing a dollop of the homemade stuff, are too complex to calculate. And if you dump huge amounts of insulin into your system and it misses those huge amounts of carbohdyrate, well, yes, you do have a problem--one that can, worst case, put you in the ER.

But most people with Type 2 can match 30 grams of carb or even 40 with insulin without problems, especially after some practice, and possibly by using the slower R insulin which is more gradual in its effect.

It may take you a lot of cautious experimentation to figure out exactly how much carb and insulin you can use safely--starting out with a very low dose and a small amount of carbs and carefully adjusting carbs and insulin until you reach a level you can live with that gives you blood sugars that are safe and normal.

When Is Insulin NOT Useful

The only people for whom insulin is not a good idea are those who are still producing high levels of insulin, whose diabetes is caused entirely by insulin resistance, not beta cell failure. Many of these people are very, very large.

Typically, if your diabetes is caused by insulin resistance, your blood sugar will drop to normal levels very quickly as soon as you cut out most carbs. By "normal" I mean fasting blood sugars in the 80s or better. But if your diabetes is caused by beta cell problems, though your blood sugar will drop in response to a low carb diet, your fasting blood sugar may still be over 100 or worse no matter how low your carbohydrate intake.

You may also be able to determine if you are highly insulin resistant by having your insulin levels tested. If they are much higher than normal while fasting, then you may be seriously insulin resistant and adding insulin may not be the answer for you since your problem is that your body isn't using insulin, not that you don't have enough.

Doctors often seem to believe that all Type 2s are seriously insulin resistant, but in practice, this turns out not to be true. Mine told me I "obviously" was insulin resistant, but when I finally started taking insulin, my response was that of a Type 1 not a Type 2, showing I had very little insulin resistance at all--and that I really needed insulin supplementation.

That's enough for now. We'll come back to this topic again, though!


Jonah said...

One of the problems with putting type 2s on insulin is that taking insulin increases insulin resistance long term.
But you're right; at an A1c of 10%, that's not an excuse.

Laura G. said...


Just ran across this blog and wanted to congratulate you. This whoe project is so great!!

I'm a longterm type 1 with a few type 2 friends and I'm angry on their behalf.

I get: a pump, Symlin, 10 test strips a day, and a fine-tuned diet with constant awareness of GI, current and desired BGs, and exercise. I get A1C's of 6.5 and a doctor's advice to try harder if they go above that. Sure it's all a pain in the ass, but I have no complications after 27 years.

My friends get this: Your diabetes is mild, or let's call it "prediabetes." Try to avoid "sugar" and lose some weight and here's some metformin if you can't. Test strips are only covered if they put up a big fight, sometimes not even then, and no education is provided on how to use the information if they do test. My best friend gains weight each year despite a restricted diet and already has neuropathy and leg circulation issues.

Why the discrepancy??!

Thanks for helping Type 2's fight back against this policy of poor care. "Insulin Early" cuts right to the chase.


Rachel... said...

This was a great post - have you considered submitting to Grand Rounds? It might open some eyes.

Rachel... said...

Very good post examining the "real options". Have you considered submitting to Grand Rounds? It might open some eyes.

Jenny said...


I do not think there is any proof of the idea that giving insulin to someone who is insulin deficient will increase insulin resistance.

What we know DOES increase insulin resistance is blood sugars over 180 mg/dl!

So by normalizing blood sugars, we are more likely to decrease, rather than increase insulin resistance.

Giving people huge doses of basal insulin to counter huge doses of carbs at every meal may be a different story, because in this case, the blood sugars after meals are still high enough to increase insulin resistance (and damage the remaining beta cells.)

Borgesian said...


Well, I was diagnosed last January as a type 2. FBGL was 400+, with an A1C of 13%+

Now, my FBGL is usually 90- (today was 74), BGLs during the day always 94-, and my A1c (tested last May) was 5.4%.

What did the trick (at least I belive so) was carb restriction + a lot of exercise. And, of course, blogs and websites like yours. I try not to get over 115 at any time due to your posts about what happens when BGLs reach specific tiers.

Thank you!
Borgesian, from Spain.