Bruce, doctors who practice what they call Evidence Based Medicine (EBM) have reasons for using orals before going to insulin, primarily in people who are very insulin-resistant, producing gobs of their own insulin, and who therefore need help USING their OWN insulin, rather than introducing more into their systems. These are the people who are most likely to gain weight on insulin.
Natalie, I've had a bit of time to mull this comment of yours over, and I just don't buy it. Many of the Rx oral meds for T2 diabetics have serious side effects and carry serious risks, yet they continue to be Rx'd with little thought of moving the T2 patient to insulin. For example, Avandia continues to be marketed to T2s even though it carries with it serious risk of heart attack. Sulfonylureas are still Rx'd, and they induce lows by causing the beta cells pancreas to dump insulin in to the blood stream. Extra insulin is extra insulin, and sulfonylureas can indeed cause weight gain if one does not manage diet. Rx insulin would definitely put more control in the patient's hands.
Take a look at Actos, the med my former PCP Rx'd when I was intolerant to Metformin: Thiazolidinediones such as Actos have been linked to CAUSING congestive heart failure. My mother had congestive heart failure, and I had two coronary stents put in over a year ago. My PCP was aware of my family history, and she was the one who discovered my abnormal EKG and had me see a cardiologist. Yet, she continued to Rx me Actos. Even Metformin, with its nasty side effects, only efficaciously reduces insulin resistance in patients who have HbA1C's under 10. Moderate exercise does the same thing. I can see its use for those T2s who have difficulty exercising, but what about those T2s who can exercise but choose to not do so? Shouldn't they be counseled to get out there and exercise or be placed on insulin? When it comes to Rx insulin, why the snub?
Sorry, the medical community in general does not get a pass with me. They are failing many T2 patients by continuing to Rx them oral medication when Rx insulin would be a better choice. I am deeply disappointed and somewhat resentful that I was put on the pill-pushing merry-go-round for so long when insulin would have made better sense all along. Thank God I have a smart endo now who get it.
I am attending CDE sessions with a friend and I am astounded at the number of carbs they are saying I “SHOULD” be able to eat. When I told the CDE that I could not possibly eat that many carbs she asked me if I were sure I weren’t a Type 1. I’m finding it interesting, because I AM, myself, a fairly new diabetic…7 months in. But I’ve been low to moderate carb all the way…50-70 carbs at most.
One must always be careful about interpreting fasting c-peptide tests. If you are actually insulin deficient, your insulin production will be low even though you may have a high blood sugar level. The estimate will tell you that you are insulin sensitive, but you might get that result whether you were insulin resistant or not, simply becuase you poor pooped out pancreas is not producing much insulin. I would tend to interpret a low fasting c-peptide with a high glucose as indicating insulin deficiency.
There are tests that can be done during an Glucose Tolerance Test (GTT) that measure your c-peptide and insulin in response to chugging a 75g carb drink. That will give you an estimate of insulin sensitivity. In the end, using insulin for a carb bolus will reveal your actual insulin sensitivity.
Well, I seem to have cleared the first hurtle for insulin. My internist thinks I should be on a night time dose of Lantus or Levemir (probably a small dose…only 5 units)… And THIS is the one who asked me 2 visits ago whether I were “still diabetic?” I think that my Endo had a little talk with her, actually! Now waiting to hear from the Endo…
Ok, here is something I have never understood. Insulin enables the uptake of glucose into your body. Your body can do two things, burn the glucose for energy, store the glucose by binding it with water and forming glycogen or convert to fat for storage. Each gram of glucose gets stored with 2.7 grams of water. Glycogen storage varies, but an average person stores about 400 g. in their muscles and perhaps 150 g in their liver. So by my math calculations, that means that you could eat 150 g of carbs and totally top off your body’s stores of glycogen.
So what I want to know is in someone who eats a huge amount of carbs, after your glycogen stores are full where does the blood sugar go? Does it really all go to fat? How can the insulin enable further uptake if your body is totally topped off? In a non-diabetic, pigging out (like my 16 year old son) his blood sugar doesn’t escalate over 200 mg/dl, he is thin as a rail and he doesn’t pee it out. I want to know where the glucose goes.
This bothers me. Perhaps your partner, Dr. Feinman can help.
Good point MossDog. In my response I did say "choice many of us T2s face", but I agree it's important to always make sure not to make blanket statements regarding diet. "Life without lots of carbs vs life with diabetic complications" is a true statement for me, however, and as you say my meter tells me this is true.
The ADA folks are really the ones making blanket statements, they claim everyone can eat a lot more carbs than I, for one, can handle. The complications are explained away as inevitable. That may be true, I'm only a couple of years into my diagnosis but I shudder to think where I'd be now if I was following their guidelines.
BSC…sorry were you responding to me about fasting c-peptide and the insulin sensitivity comment? I wasn’t sure.
Because my c-peptide was not done while I was fasting. My Endo did not want to “put me through a glucose tolerance test” since she had my glucose meter with MANY over 200 readings in response to relatively low carbohydrate meals…SO…instead, to get the insulin senstivity reading, she instructed me to eat my favorite HIGH carbohydrate breakfast and show up 1 hour later at the lab for my blood draw.
JUST to make sure, a ate some candy on the way driving over…AND took my BG in the parking lot before walking in (225) to make doubly sure nothing was TOO low…
Then they did the BG AND the C-peptide test right at the same time to see what my sugar and my insulin levels were…at THAT time.
Now, something has changed since my TSH went very high again.
Either, I have lost beta cells or cell production…OR I’ve become suddenly insulin resistant (HIGHLY unlikely as I was NOT insulin resistant at all after the first time I became hypothyroid and thus became diabetic initially) OR something very odd is going on otherwise metabolically that NO ONE understands - as I’m sure you know they are investigating some digestive enzymes that go to work early in the digestive process…which they think may be responsible for people who have gastric bypasses becoming NOT diabetic any more…
Yes, I don’t know exactly how I managed to respond in the middle of nowhere, but my c-peptide comment still applies. You took a stimulated c-peptide test. All you can tell was that your insulin response was deficient.
Makes total sense…because that is what she told me…I was insulin deficient. However, she said that by looking at my c-peptide vs my BG she could tell I was not very insulin resistant because my absolute c-peptide level would have been so much higher had I been insulin resistant…does that make any sense? So she said at that point, Metformin would do no good as an oral medication…but did put me on an insulin stimulating oral drug… which seemed to work for a time…but…maybe not so much any more…as now my insulin levels are really rising overnight. So initially my basals were doing okay. But now, they are rising…I don’t know how to interpret what the heck is happening now. All I know is I am getting worse. I hope to see the Endo soon.
Natalie…no…I would not try insulin on my own. I’m not so inclined and it looks as though my Internist thinks it is in my best interest…so my thinking is that perhaps my Endocrinologist may have already discussed it with her! Who knows.
In an active 16-year old, a lot of glucose gets burned for energy. If the 16-year-old is also growing, a lot of energy is consumed in making new cells. He’s probably adding a lot of muscle. And the brain uses a lot of energy, even more when thinking, although some people might suggest that 16-year-olds don’t do a lot of thinking (grin). Remember, even when you’re not active, some energy is required just for maintenance.
Think of your house. It takes a lot of energy to build an addition. But it also takes energy to vaccuum, clean up the junk the 16-year-old dropped all over the house, and do the dishes. That’s maintenance energy.
Does your son really go up to 200? That’s high for a healthy young person, even one eating a lot of carbs.
April, I forget. Have you been tested for antibodies? You sound like LADA.
Gretchen – I recommended your Type 2 book to a friend and he loved it! Thank you for your work!
Ginger, Thanks. Hope to see you next week in S.D. I enjoyed your book too. Your energy is inspiring!
Well, all that might be true, but for non-diabetics, they can eat arbitrary amounts of carbs and still maintain normal blood sugars. They do this without specifically gaining fat, having high blood sugars or excreting sugar in their urine. I just don’t understand. And I know all about BMR and the adjustments for activity levels, it doesn’t account for this observation.
ps. My son has an absolutely normal blood sugar (I’ve tested) and can eat 250g of carbs and not go over like 120 mg/dl. Where is the glucose go? I have no idea.
I thought that the point of Taubes’ book was that the overabundant carbs get converted to fat? The “Why are we Fat” book didn’t reference diabetes much at all, except, of course, as a consequence.
It is often hinted at, that as you age, if you don’t decrease calorie consumption (which is driven highly by carbs in a normal person) you gain weight because the BMR and activity factors usually decline as we age. So wouldn’t the next logical step in that line of thinking be that those young healthy folks you are referencing do actually burn all that glucose?
Anni, Since Levemir lasts longer than Lantus, and such a small dose, you would be better off with Levemir. I think someone just posted that it lasts for 42 or so days and some people swear that they can’t get the full 30 out of Lantus.
Having gone through the “Six 16 year old guys hanging out in my basement” routine in the past few years…I actually CAN believe that BSC’s son can eat 250 carbs in one day. Perhaps even in one sitting… One sitting is perhaps more believable. My son’s best friend resembled a snake…he ate one HUGE meal per day… one could almost see the lump…(he is quite tall and lanky)…
Actually, it was I who referenced the 42…I think…because I had looked up the Rx info. And I’ve just heard a lot better reports from people using Levemir in general than those using Lantus…so we shall see. Still waiting to hear from my Endo.