September 14, 2009

Insulin vs Expensive Orals: Higher Satisfaction, Less Weight Gain

Doctors have been so brainwashed by the drug companies as to the superiority of their oral drugs to insulin that it is rare to find anyone newly diagnosed with Type 2 diabetes who was put on insulin at diagnosis except for those whose diagnosis occurred during a hospital admission where blood sugars were found to be over 500 mg/dl.

This is true, even though there is compelling evidence that putting people with Type 2 on insulin immediately after diagnosis provides long term benefits, even if the patients stop the insulin a month or two after they start it.

There are three reasons why doctors fight against putting the newly diagnosed person with Type 2 diabetes on insulin: Fear that the patient will not comply with the treatment because it involves shots, fear that insulin will cause dangerous hypos, and fear that the patient, already battling a weight problem will gain more weight.

It does not take a new study to debunk all these fears. The patients who supposedly refused needles rushed to adopt Byetta as soon as they were told it would cause weight loss or rejuvenate beta cells--claims that in many cases were untrue. Patients taking the sulfonylurea drugs Amaryl or Glyburide routinely experience dangerous hypos if they neglect to eat high carb meals throughout the day. Actos and Avandia cause dramatic and permanent weight gain in many of those who take them, because the drugs' mechanism of action lowers blood sugar by creating new fat cells and clearing glucose by transforming it to fat and storing it in the new cells, but doctors prescribe them anyway.

Nonetheless, for those of us who consider insulin the best of all the diabetes drugs, a new study published in Diabetes Care confirms our belief that insulin should be the first, not the last, drug prescribed to people with Type 2 who cannot normalize their blood sugar with diet alone. Insulin, rather than the obscenely expensive oral drug cocktails doctors prefer.

Here's the study:

Insulin-Based versus Triple Oral Therapy for Newly-Diagnosed Type 2 Diabetes: Which is Better? Ildiko Lingvay, et al. Diabetes Care July 10, 2009, doi: 10.2337/dc09-0653

This was a three year study. One group of patients were put on insulin plus metformin. The abstract does not specify whether the insulin was basal insulin (Lantus or Levemir) or a combination of basal and fast acting insulin. Given what I hear from my correspondents, my guess is it was basal insulin alone.

The other group of people with Type 2 diabetes in this study were put on a typical drug cocktail regimen consisting of metformin, glyburide, and Actos.

Blood sugars as measured by A1c were very similar in both groups, however there was less weight gain in the insulin/metformin group" than in the drug cocktail group. Not only that, but as reported in Diabetes in Control the researchers said,
"... while the weight gain persisted over time in the group treated with oral hypoglycemic agents, the weight gain in the insulin-treated group leveled off after 18 months and even regressed towards baseline.
Fewer people dropped out of the insulin arm of the study than the oral drug arm, too, suggesting that it was easier to comply with.

There is a reason why early insulin might be so helpful for people with Type 2 diabetes and it is, that, when prescribed properly, insulin is much more likely to lower blood sugar below the level that produces secondary insulin resistance,.

Secondary insulin resistance is a phenomenon doctors are often unaware of. It turns out that when blood sugars rise to a certain point--somewhere around 180 mg/dl--this rise causes an increase in insulin resistance, so that once blood sugars are high they stay high, because it takes more insulin to lower blood sugar than it does when blood sugars are below the threshold. This secondary insulin resistance also makes weight gain more likely.

This is why so many people with Type 2 see a dramatic drop in their blood sugar when they cut carbs out of their diets. Their insulin sensitivity improves as soon as the blood sugar drops under that threshold and their remaining insulin is far more effective. In addition, the drop in secondary insulin resistance often makes it easier to lose or maintain weight on the same calorie intake.

Giving people insulin in doses that drop blood sugar below that same threshold has a similar effect and makes it much easier to control blood sugar, too.

Injecting insulin does something else--it gives the battered beta cell a chance to recover. Alternative drugs like Byetta, Januvia, Prandin, Starlix, Glyburide and Amaryl all force the exhausted beta cells to secrete insulin, stressing the already stressed cells. Injected insulin replaces beta cell insulin, giving the beta cells a chance to rest.

Many people with newly diagnosed Type 2 diabetes don't need any drug at all. I hear daily from people who have adopted the strategy described HERE and lowered A1cs from well over 8% to the 5% range that prevents complications.

But if like me, you have something going on in your own, unique metabolism that means that you can't get normal blood sugars eating under 100 grams of carbohydrate a day, don't be shy about asking your doctor for insulin.

Insulin works. Combined with a low carb diet it won't pack on the pounds--especially if you use Levemir rather than Lantus. Fears that use of insulin might increase cancer appear to be unfounded, at least for people who combine insulin with metformin. You can read more about the insulin/cancer scare HERE.

In contrast to the unsupported fears about insulin, the known side effects of Actos are ugly, and getting uglier by the month. The sulfonylurea drugs, Amaryl and Glyburide, are sold with an FDA warning that they may increase the risk of heart attack. Januvia and Onglyza lower blood sugar using a mechanism that turns off a cancer suppressor gene.

If you worry about the confusing data about Lantus and cancer (which is far from conclusive) ask your doctor about using R insulin which is identical to the insulin your own beta cells produce. Many people find that R insulin is the ideal insulin to use along with a low carb diet as it is slower in action than the much more expensive analog insulins and matches the digestion curve of a higher protein/higher fat meal far better.


Meerkatdon said...

A big "seconded" to all your comments, Jenny. I am a type 2 who was put on insulin at diagnosis, probably because I fit the "admitted to hospital with above-500 mg/dL blood glucose" paradigm.

Two years later, keeping up a basal/bolus insulin regimen and low-carb diet, my A1C tests routinely come back 5.6 or 5.7. In that time I've gained back the weight I lost in the 3-week hospital stay, but haven't added any more.

I recently got a new doctor, and in my first visit she said, "It's odd to have a stable type 2 like you on insulin, do you have any idea why they put you on it?"

I answered, "Take a look at my A1C numbers and tell me if you think we should change anything."

She did, and said, "Okay, don't change a thing you're doing. Now explain to me exactly what you do, so I can share it with some of my other patients."

Bottom line: Insulin is great for type 2s. And everyone should be paying attention to what you say, Jenny.

Rishara said...

I really wish I would have found your site a long time ago. The more I read your information, the more I think I should be on some sort of insulin. I am taking the max dosage of Januvia and Metformin and on a strict low-carb diet (no more than 20 per day--Atkin's induction levels) and still struggle with morning fasting numbers around 140-150. During the day I fluctuate from around 90-130. I just don't think I should have to struggle quite so much, and it seems pretty obvious the meds aren't doing much of anything except maybe stressing out my poor beta cells even more. While my diet is controlling everything decently, can I really live on a mere 20 carbs a day for the rest of my life?

I'm still pretty confused on whether I should try to make a change or wait and see if losing weight will help things or not.

Jenny said...


I was in exactly the same situation as you are for seven years. I could not eat more than 30 grams of carbs a day and maintain my blood sugars. Doctors gave me no help at all and told me insulin would me gain weight when I asked for it.

I finally nagged a doctor into giving me basal insulin. I had such a strong response to it--hypoing on tiny doses, that he sent me to an endocrinologist. I did the research myself to figure out I probably had MODY and the doctor was willing to write some prescriptions for me to try things out.

I use about 6 units a day of fast acting insulin with my meals now and it lets me eat about 100 g a day and get reasonable blood sugars.

I still eat low carb a lot of the time but I can handle up to about 45 g of carbs at once without spiking, which makes it possible not to feel like I'm denying myself things all the time.

Many people do well on basal insulin alone when they restrict carbs. My particular form of diabetes is a bit weird, and for me the meal time insulin works much better than the long acting.

It may take some hunting to find a doctor who will support you, and it does take some reading and studying to learn how to use insulin properly. Dr. Bernstein's "Diabetes Solution" is a good place to start, though he doesn't seem to be familiar with Novolog and Apidra both of which I find work much better for me than the Humalog he recommends. The theory he gives is extremely useful, though.

Vern said...

If its hot and you take sugar shot, what would you do, remember I am talking about a devastating storm from the Gulf? I know the doc won't put you on this if your doing well with the blood sugar. I know my sister and my friend have had very high highs and very low lows and I don't trust this and I refused to get something shot in my tummy, I got a lot of pressure from my family, to prevent blood clots, and if a punch in the tummy is a good thing, this would be too. I took my shot in the regular shot place, in the shoulder. I am encouraged to get my blood sugar better so I won't need this. I am not interested in the diabetic magazine since they push the shots, I had them removed from my emails too, but if you do well, I want you to be successful with this. Thank-you for doing this. My A1C was 6.4% and now it was 5.6% and I want to get it down to 5.0% although I am not sure about it. The 5.6% was before my walking, so I am not sure how it is now and I am not sure when I will get it checked again here. The expense of healthy foods is the hardest part since I am on food stamps.

Jenny said...


It sounds like you are doing a wonderful job of getting your sugars down!

Insulin needs to be injected into fat, not muscle. When you get a shot in your shoulder area for a vaccine, it is supposed to go into muscle. But insulin is absorbed best from fat.

The fat on your thigh and tummy and fatty parts of your upper arm are best. If you shoot into a muscle the insulin may be absorbed too quickly and that causes lows.

The heat without refrigeration or a/c can be a big problem. A cooler with ice under some folded up paper bag can keep your insulin cold for quite a while. But missing a few days of insulin while still taking metformin will not cause long term trouble.

Rishara said...

Thanks for the info Jenny. I've only been doing very low carb for about a month now. Before, I was still doing lower carb, probably about 100 per day, and my A1C numbers just kept steadily climbing. I think my doctor will be okay about insulin, because he suggested it as a possibility a few months ago. Of course, back before I'd read your site, it scared me to death, thinking that meant I was beyond all hope. I still figured that I was lazy and fat and if I'd just lose weight all my diabetes problems would be magically solved. It's amazing how much the mainstream media and society can brainwash us.

Vern said...

I am grateful for the kindness since that blessed me, but I wasn't meaning to come across as judging those on insulin since I am sensitive about my weight and such, so I need to make it clear I know diabetics who need insulin would love to be off it, even if it is cheaper or not.

My scale at the hospital today said I had lost 11 pounds since May 29th, but if you include the scale at my dads house, I have gained Labor Day, but no matter I have lost a good amount of weight and no matter how much good this is for my blood sugar, I am still concerned about my heart too.

Vern said...

Thank-you Jenny for the Good Words and I know that losing more weight will not make me lower my A1C as a promise, and yet I know I will feel better no matter what for me when I was walking too. My focus is good blood pressure, blood sugar and other such health items. I know all of you are not giving up on your weight, health and diabetics. I knew a girl named Jenny in Elementary school who I saw in High School and she encouraged me a lot while we were in third grade and would have in High School, but I didn't talk to her much, my loss. I can't let anything hold me back, gotta not give up, but keep working on this and not use anything as a reason to set my heart for bad results.

Jenny said...

No researcher has EVER followed people with Type 2 diabetes who attain 5% A1cs by cutting carbs for any significant period of time.

Most of the medical world whole doesn't know about the power of cutting carbs to lower blood sugar. When they do study low carb diets, they are often diets that include 150 g of carbs a day.

trinkwasser said...

Bingo! That secondary insulin resistance is one of my problems, even a brief spike will shut down my glucose transporters for a few hours. I know this because my muscles become weak despite my meter telling me there's excess glusose in the blood. It also happens to Type 1s looking at how their ratios change bringing down a low high compared to bringing down a high high.

Fortunately eating sufficiently few carbs that I don't spike and enough fat that I preferentially run on fat/ketones seems to have solved the problem.

But if it hadn't I'd have wished for bolus insulin over the less controllable oral drugs judging from the experience of those who have been given the choice.

This ancient paper

has some good things to say for early insulin use