DIABETES 2 INSULIN QUESTION

[Indy51]

Some people don't have a choice.
Even insulin produced diabetes don't deserve to suffer a life of rotting flesh and organs due to an anti-fat society, surely?

I did say "personally". I can only comment from my own POV and my experience of diabetes. It's for others to make their own choices based on their own circumstances.

 

[Jenny15]

So this doctor would be weighing up the 'possibility' of hyperinsulinaemia against the benefit of insulin therapy. My point is that the 'possibility' element of that scenario could be eliminated by the use of further testing. Of course, in the interim, insulin would be the best treatment and especially in emergency situations.

Every treatment decision doctors make is supposed to involve weighing up the pros and cons.

I don't know what the cost of the insulin testing is but let's assume hypothetically it costs the government 50 GBP, which isn't too far off what other lab tests cost. The cost of lab tests varies widely from say 15 GBP to 500 GBP. The whole cost must be counted, not just the machine running the batch tests. The sample taker, admins, transport, overheads, regulatory compliance etc.

Some in this thread are saying they would never consent to insulin therapy without having this test. That's their choice and I have no problem with that. I like my choices to be respected, too.

I think that the reason this test isn't used for this purpose by the NHS and comparable govt systems in other countries is as follows. (Please respond to the whole scenario rather than just one part of it thanks. That was an issue in a post above in the thread.)

The NICE and other guidelines ask doctors to assess treatment options when an HbaA1c result is above the agreed target range.

Personally, I ask my doctors to agree that the top of my target range is 42. Others could choose 48, or 55, or 65. (The NZ guidelines say 55 is a good threshold to aim for. They also say intensification should be offered at 65, and that it may include insulin or other meds.)

The first step in T2 is to treat high BG with dietary changes alone or with dietary changes + one drug.

3 months later, if the HbA1c is the same or higher, doctors are asked to review the dietary changes and advise, and to consider adding a drug or changing the drugs. (IIRC)

At the 6 month point, if the HbA1c is the same or higher, the doctor is asked to again consider changing and/or adding to the drug regime, and/or adding insulin.

I think the medical consensus for the population as a whole, is that at this point, the risk of hyperinsulinaemia would be low compared to the reality that the patient has had a high HbA1c for at least 6 months, usually more, and the probability of complications and risk to life must be viewed as high priority issue in the decision.

If hyperinsulinaemia were to develop, that could be addressed by reducing or stopping insulin if necessary. I think the number of such cases is likely to be small, but I have not looked for the data on this.

Now, if an insulin level test were to be required at this point of the doctor's decision process, it would cost the taxpayer quite a lot, given the large number of people having the test. If a test adds enough value to a decision making process, then it is worthwhile and not to test would be "false economy."

IMO a doctor can make a safe and appropriate decision to offer a trial of insulin in such a scenario without necessarily using this test. Any doctor prescribing a drug or insulin is legally required to follow up with monitoring and regular consultations with a nurse or a doctor. In this way, the doctor can manage the risk of negative effects.

Having said that, I believe that if a private laboratory wishes to offer this test, it should be free to do so. One of the personal values I hold most dear is the freedom to choose whatever medical tests or interventions I want. I have wasted thousands of dollars doing this, but it is good to have the options.

 

[Jenny15]

Definitely.
It is heart wrenching that so much is in the dark because the truth costs more money.... from the nhs.
I know for sure my notes are filled with notes I'm not aware of.
I'm not ready to read my current health risks but need to focus on the future. Luckily I have one.

I'm the same. I used to read my notes and it has helped improve my treatment but sometimes the stress of it all is too much and I won't ask for copies. During those times I make a trade off and choose to trust my GP, who I think is incredible and would never knowingly allow me to come to any harm. Other doctors, I'm not so sure, but he keeps them on their toes for me.

There have even been times when it's been obvious that HCPs are saying stuff to other HCPs in writing but managing to avoid the info being released to me. I chose to pick my battles and stick to focusing on the here and now and staying alive, like you.

 

[Guzzler]

Every treatment decision doctors make is supposed to involve weighing up the pros and cons.

I don't know what the cost of the insulin testing is but let's assume hypothetically it costs the government 50 GBP, which isn't too far off what other lab tests cost. The cost of lab tests varies widely from say 15 GBP to 500 GBP. The whole cost must be counted, not just the machine running the batch tests. The sample taker, admins, transport, overheads, regulatory compliance etc.

Some in this thread are saying they would never consent to insulin therapy without having this test. That's their choice and I have no problem with that. I like my choices to be respected, too.

I think that the reason this test isn't used for this purpose by the NHS and comparable govt systems in other countries is as follows. (Please respond to the whole scenario rather than just one part of it thanks. That was an issue in a post above in the thread.)

The NICE and other guidelines ask doctors to assess treatment options when an HbaA1c result is above the agreed target range.

Personally, I ask my doctors to agree that the top of my target range is 42. Others could choose 48, or 55, or 65. (The NZ guidelines say 55 is a good threshold to aim for. They also say intensification should be offered at 65, and that it may include insulin or other meds.)

The first step in T2 is to treat high BG with dietary changes alone or with dietary changes + one drug.

3 months later, if the HbA1c is the same or higher, doctors are asked to review the dietary changes and advise, and to consider adding a drug or changing the drugs. (IIRC)

At the 6 month point, if the HbA1c is the same or higher, the doctor is asked to again consider changing and/or adding to the drug regime, and/or adding insulin.

I think the medical consensus for the population as a whole, is that at this point, the risk of hyperinsulinaemia would be low compared to the reality that the patient has had a high HbA1c for at least 6 months, usually more, and the probability of complications and risk to life must be viewed as high priority issue in the decision.

If hyperinsulinaemia were to develop, that could be addressed by reducing or stopping insulin if necessary. I think the number of such cases is likely to be small, but I have not looked for the data on this.

Now, if an insulin level test were to be required at this point of the doctor's decision process, it would cost the taxpayer quite a lot, given the large number of people having the test. If a test adds enough value to a decision making process, then it is worthwhile and not to test would be "false economy."

IMO a doctor can make a safe and appropriate decision to offer a trial of insulin in such a scenario without necessarily using this test. Any doctor prescribing a drug or insulin is legally required to follow up with monitoring and regular consultations with a nurse or a doctor. In this way, the doctor can manage the risk of negative effects.

Having said that, I believe that if a private laboratory wishes to offer this test, it should be free to do so. One of the personal values I hold most dear is the freedom to choose whatever medical tests or interventions I want. I have wasted thousands of dollars doing this, but it is good to have the options.

People can be insulin resistant for decades before diagnosis. Catherine Croft (PHD research into the Insulin Assay and its findings by Dr. Kraft) has discovered that there are people who are non Diabetic but who live with a measure of IR. It must be remembered that raised bg levels is one of the last symptoms of T2 but the HbA1c is the preferred diagnostic tool when a serum insulin test would catch/screen for IR far, far earlier.

 

[Jenny15]

People can be insulin resistant for decades before diagnosis. Catherine Croft (PHD research into the Insulin Assay and its findings by Dr. Kraft) has discovered that there are people who are non Diabetic but who live with a measure of IR. It must be remembered that raised bg levels is one of the last symptoms of T2 but the HbA1c is the preferred diagnostic tool when a serum insulin test would catch/screen for IR far, far earlier.

That is a slightly different issue to the one you mentioned before, but it's good to know the test would achieve those effects if it became part of government diabetes strategy.

Another way to screen people for IR is by looking at them. I don't imagine many thin people would have increasing IR.

I have been overweight since around 5-6 years old. In my case and that of most of my extended family, just looking at photos of us and knowing we have the genes for it, would have indicated we were likely to get T2.

I had regular screening tests and didn't cross the prediabetic threshold until 39 years of age. I thought that was fairly young, then I met a 21 year old overweight woman who had just been diagnosed with T2. I read about people in their 20s and 30s being diagnosed all the time.

The number of people with blood glucose dysregulation disorders is definitely exploding. Hopefully if testing insulin response is shown to be more cost effective for the funders of the NHS, then they can be persuaded to adopt it.

In the meantime, BG/A1c testing does pick up more people than doing nothing would. I'm grateful for that.

 

[kokhongw]

I think the medical consensus for the population as a whole, is that at this point, the risk of hyperinsulinaemia would be low compared to the reality that the patient has had a high HbA1c for at least 6 months, usually more, and the probability of complications and risk to life must be viewed as high priority issue in the decision.

If hyperinsulinaemia were to develop, that could be addressed by reducing or stopping insulin if necessary. I think the number of such cases is likely to be small, but I have not looked for the data on this.

Here you are assuming that hyperinsulinemia develops after the therapeutic used of insulin. But the reality is that hyperinsulinemia develops years before glucose impairment.

This is the generally accepted progression chart for T2D.

What it clearly shows is that hyperinsulinemia, ie elevated insulin response and insulin resistance occurs 10 to 15 years BEFORE diagnosis. AND it continues for up to TEN years AFTER diagnosis. After which the loss in beta cells mass AND functionality reach a point where reversal and restoration is unlikely.

That is a span of 20 years window where the right dietary intervention which reduces insulin load, may help to prevent the unnaturally accelerated beta cells loss in mass and functionality and possibly restore much of the functionality.

 

[Indy51]

I think the current guidelines are also suffering from the research gap - researchers estimate that it takes 15+ years for medical research to become part of clinical practice. Research studies indicate that treating hyperglycemia in Type 2s with aggressive medication regimes has worse outcomes than doing nothing. I feel really lucky that lifestyle interventions have worked for me. Trying to work out which of a bad bunch of pharmaceutical options to take is my nightmare. I don't envy anyone who has to face it.

 

[Guzzler]

That is a slightly different issue to the one you mentioned before, but it's good to know the test would achieve those effects if it became part of government diabetes strategy.

Another way to screen people for IR is by looking at them. I don't imagine many thin people would have increasing IR.

I have been overweight since around 5-6 years old. In my case and that of most of my extended family, just looking at photos of us and knowing we have the genes for it, would have indicated we were likely to get T2.

I had regular screening tests and didn't cross the prediabetic threshold until 39 years of age. I thought that was fairly young, then I met a 21 year old overweight woman who had just been diagnosed with T2. I read about people in their 20s and 30s being diagnosed all the time.

The number of people with blood glucose dysregulation disorders is definitely exploding. Hopefully if testing insulin response is shown to be more cost effective for the funders of the NHS, then they can be persuaded to adopt it.

In the meantime, BG/A1c testing does pick up more people than doing nothing would. I'm grateful for that.

Looking at them? I am now a thin T2. I was slim on diagnosis. I have never been overweight and before embarking on LCHF I had never dieted in my life. I beleive that I went undiagnosed for so very long exactly because of the way I look (my A1c on diagnosis was 98). You may like to use the forum search for info on TOFI.

 

[Jenny15]

Looking at them? I am now a thin T2. I was slim on diagnosis. I have never been overweight and before embarking on LCHF I had never dieted in my life. I beleive that I went undiagnosed for so very long exactly because of the way I look (my A1c on diagnosis was 98). You may like to use the forum search for info on TOFI.

I think you misunderstood a little, I was referring to the majority of people who are going to get T2 in a few years and who are overweight and developing IR. Here is my comment in its context:

"That is a slightly different issue to the one you mentioned before, but it's good to know the test would achieve those effects if it became part of government diabetes strategy.

Another way to screen people for IR is by looking at them. I don't imagine many thin people would have increasing IR."

I had just written a very long, detailed post addressing an issue you raised, then you changed the subject. We were talking about ways to cost-effectively screen the whole population to detect abnormalities before people start showing increased BG levels. I specifically said I don't imagine many thin people would have increasing IR. I already know about TOFI. Are you saying you believe everyone in the UK should be tested for IR?

 

[Jenny15]

I think the current guidelines are also suffering from the research gap - researchers estimate that it takes 15+ years for medical research to become part of clinical practice. Research studies indicate that treating hyperglycemia in Type 2s with aggressive medication regimes has worse outcomes than doing nothing. I feel really lucky that lifestyle interventions have worked for me. Trying to work out which of a bad bunch of pharmaceutical options to take is my nightmare. I don't envy anyone who has to face it.

Hi @Indy51, thanks for this info. I'm curious to read more about a study finding that "treating hyperglycemia in Type 2s with aggressive medication regimes has worse outcomes than doing nothing." I'm wondering what the parameters were, ie what the starting BG or A1c levels were, and what meds they studied etc.

Trying to choose medication options has been my nightmare for the past 30 years, when I've gained long term conditions one after the other, usually with long delayed diagnoses. My current tally ranges between 8 and 15 conditions, depending on how one counts them. Some of them have no available treatment, or surgery only, or only medications that are borderline effective/safe. For me, medication has become a necessary part of life. I am always trying to keep the number down to an absolute minimum but sometimes it just can't be done.

 

[Guzzler]

I think you misunderstood a little, I was referring to the majority of people who are going to get T2 in a few years and who are overweight and developing IR. Here is my comment in its context:

"That is a slightly different issue to the one you mentioned before, but it's good to know the test would achieve those effects if it became part of government diabetes strategy.

Another way to screen people for IR is by looking at them. I don't imagine many thin people would have increasing IR."

I had just written a very long, detailed post addressing an issue you raised, then you changed the subject. We were talking about ways to cost-effectively screen the whole population to detect abnormalities before people start showing increased BG levels. I specifically said I don't imagine many thin people would have increasing IR. I already know about TOFI. Are you saying you believe everyone in the UK should be tested for IR?

In an ideal world, yes, everyone would be screened. But we do not live in a utopia, we live on a planet suffering a modern plague. It has been said that our NHS will be bankrupt by 2030 so the whole premise is moot anyway.
And I did not misunderstand.

 

[Jenny15]

In an ideal world, yes, everyone would be screened. But we do not live in a utopia, we live on a planet suffering a modern plague. It has been said that our NHS will be bankrupt by 2030 so the whole premise is moot anyway.
And I did not misunderstand.

If you think screening should be done using this test, then that would need to be analysed and compared to the status quo. This thread was originally about this question:

"Why is Insulin given to us, many/ and thousands, when they have too much Insulin already?"

Several explanations have been given for this and I found them logical. Sorry to hear your own diagnosis was delayed but it's great to see you are now doing so well. Keep up the good work.

 

[Indy51]

Hi @Indy51, thanks for this info. I'm curious to read more about a study finding that "treating hyperglycemia in Type 2s with aggressive medication regimes has worse outcomes than doing nothing." I'm wondering what the parameters were, ie what the starting BG or A1c levels were, and what meds they studied etc.

Trying to choose medication options has been my nightmare for the past 30 years, when I've gained long term conditions one after the other, usually with long delayed diagnoses. My current tally ranges between 8 and 15 conditions, depending on how one counts them. Some of them have no available treatment, or surgery only, or only medications that are borderline effective/safe. For me, medication has become a necessary part of life. I am always trying to keep the number down to an absolute minimum but sometimes it just can't be done.

This is just one of the studies, but seems to be quoted frequently (the ACCORD study). The increase in all cause mortality is a worry:
https://academic.oup.com/jcem/article/97/1/41/2833135

As to minor benefits of the various medications, Dr James McCormack has an interesting slide in one of his many song parody videos about overtreatment:

Dr Jason Fung's opinion piece on the various trials:
https://idmprogram.com/accordadvancevadtorigintecos-t2d-39/

 

[Jenny15]

This is just one of the studies, but seems to be quoted frequently (the ACCORD study). The increase in all cause mortality is a worry:
https://academic.oup.com/jcem/article/97/1/41/2833135

As to minor benefits of the various medications, Dr James McCormack has an interesting slide in one of his many song parody videos about overtreatment:

Dr Jason Fung's opinion piece on the various trials:
https://idmprogram.com/accordadvancevadtorigintecos-t2d-39/

Thanks for the links, @Indy51, I will have a read.

 

[lindisfel]

I guess all the doctors should read Joseph Kraft and his book on Diabetes in situ.
It's hyperinsulinemia causing the CVD and this happens before high blood glucose is manifest.

This is why I think Prof Taylor's cause is an effect.

Also, it's likely also flogging the pancreas to death to cope with BG that causes it to give up in T2D.
D.

Hyperinsulinaemia is, in my opinion, just as harmful as hyperglycemia. We monitor very easily at home the hyperglycaemic effects of food but we have no access to measuring the insulin responses to the same foods and, as has been said, insulin serum tests are not widely or freely available.

 

[NicoleC1971]

Hi Nicole, i'm interested in why insulin would not protect from diabetic complications. Could you expand on this please?Is this just for type 2?

Hi . I take an interest in this both as a type 1 and as someone who works with type 2s but am just a girl who's read a few books the most helpful one being Jason Fung's latest The Diabetes Code. This book clearly explains that managing type 2 is a balance between the toxicity of high glucose levels (what the orthodox treatment of type 2 focuses on) versus toxicity of insulin (the root cause of many metabolic [problems of which diabetes is only 1).
The idea is that in at least 3 studies (Advance, Accord and Origine - titles maybe misspelt as I transcribe from an audio book!), the group which had their blood sugars aggressively managed with insulin or other agents that encourage production of insulin, saw no better outcomes in many of the diabetic complications. So a type 2 on insulin with HBA1c of 6.5% fared no better than a poorly controlled patient with HBA1c of 10.5%. He is saying that taking the glucose out of the blood stream with insulin or oral hypoglycemics is analagous to cleaning the streets by shoving rubbish into your house...The streets are clean but your house soon starts to smell! Just because the sugar is not in the blood it doesn't mean that it isn't damaging your eyes, kidneys and heart (most type 2s die from heart disease he says). Also insulin is known to cause weight gain and exacerbates insulin resistance thus making the root cause of type 2 worse and increasing CV risk factors.
The newer class of drugs (SGLT inhibitors and GL4 mimetics) seem to do better in trials (much less heart and kidney disease in 2 rcts done recently) than metformin and insulin because they reduce insulin in the body even though they do not lower blood glucose by very much (they work by helping you excrete glucose in your pee).
Ultimately the answer is to turn off the glucose tap by eating low carb or doing IF which is what many on this forum are doing.
With regards to type 1 the benefits of keeping glucose under control seem to out weigh the risks of becoming insulin resistant wherein some type 1s end up gaining weight and insulin resistant (also known as double diabetes). Dr Ian Lake is a UK GP and type 1 is someone who is using keto to achieve both normal blood glucose levels and minimal insulin use.
Hope that makes sense! I think Jason Fung;s book offers lots of up to date and clear help on why the current way we manage type 2 is wrong!

 

[NicoleC1971]

Using insulin may or not be associated with weight gain because what it does is allow you to move more of the glucose from the blood to the muscles. It is this that causes weight gain, not directly the insulin itself. If the person keeps their carb intake the same or less, it is unlikely they will gain weight because of using insulin.

Insulin does protect from diabetic complications because it is intended to reduce blood sugar. That is why we use it.

If it reduces blood sugar then it does make your condition better.

There is a limit to how much some T2s can reduce their insulin resistance. The only other ways to address high BG is to reduce carbs and/or add insulin. A person might do one or both of these things. If reducing carbs is not enough, then the only remaining option is insulin.

Hi I think insulin tends to get used more in the US for type 2 but as you say there are many lines of treatment to get though before insulin is needed. Jason Fung (and other's ) point is that whilst insulin and SUs do lower blood glucose they have been shown in large RCTs to not prevent complications hence the development of newer drug classes that help the body excrete glucose and do help with complications compared to metformin/insulin.
On average I believe people do find it easier to gain weight on insulin but of course that doesn't mean everyone has to...

 

[Jenny15]

Hi I think insulin tends to get used more in the US for type 2 but as you say there are many lines of treatment to get though before insulin is needed. Jason Fung (and other's ) point is that whilst insulin and SUs do lower blood glucose they have been shown in large RCTs to not prevent complications hence the development of newer drug classes that help the body excrete glucose and do help with complications compared to metformin/insulin.
On average I believe people do find it easier to gain weight on insulin but of course that doesn't mean everyone has to...

I have looked into those newer drugs and I found some of the risks from them to be too serious to trial for myself, especially given the reading I have done about insulin therapy, and that two doctors in my medical team recommended insulin. I haven't asked the others but they probably would have too. I think Fung's work is interesting from a theoretical point of view but I don't see it as being applicable to my own situation.

 

[bulkbiker]

I think Fung's work is interesting from a theoretical point of view

Except of course that his "work" is far from theoretical and is widely used in his clinic to help people.
I'm also slightly worried by your statement that the risks of some of the newer drugs are too serious but that insulin therapy is recommended to you by your doctors especially as you have begun low carbing again. That is a fairly risky practise too.

 

[Jenny15]

Except of course that his "work" is far from theoretical and is widely used in his clinic to help people.
I'm also slightly worried by your statement that the risks of some of the newer drugs are too serious but that insulin therapy is recommended to you by your doctors especially as you have begun low carbing again. That is a fairly risky practise too.

Everyone is different.