Type 2 progression to insulin

[Oldvatr]

Another HCP chestnut that is often requoted on this site. Since Gliclazide is a sulfonylurea, it must cause beta cell death because it overworks the pancreas to produce insulin
No, it does not seem to be responsible
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3310990/

I had a stand-up argument with the diabetes consultant on the ward, but eventually, she read the paper and reinstated my gliclazide medication forthwith. I suggest this also feeds into the progressive rationale.

 

[Lamont D]

Frightening the level of ignorance about how hypos occur in medical staff, regardless of the role diet takes.

This is because they are not trained, the confusion is caused by the diversity of types and the stage of the condition. If you think of the different levels of the progress from prediabetes to insulin, the need for a diverse range of medication for treatment. The symptoms change and the nice guidelines on which the doctors follow, it really is confusing. Because if the solution doesn't work, more meds,.

 

[ert]

A comment was made on another thread that many type 2 progress to insulin within 10 years due to beta cell damage. (In order not to derail that conversation I though it would be interesting to continue this here.)

Is that an assumption based on continued consumption of high carb levels and a medication only approach, and is it often more than 10 yrs?

To my view it is an “assumption” is that beta cells have worn out due to type 2. It’s likely many of these are caused by the wringing out every possible drop of insulin of the already massively overproducing pancreas by medications such gliclazide. It’s also highly likely that many still overproduce, not under, but have become hugely insulin resistant which mimics underproduction.

Few type 2 are actually tested for insulin or c peptide production at diagnosis nor before being moved onto insulin. Even fewer have beta cell checks made (can that even be done?).

So how do we know why so many progress to insulin - if in fact they even do so - and at what point in time after disease onset/diagnosis.

Beta-cell function is calculated using the HOMA formula. It's more reliable than just c-peptide alone. Something my specialist calculated when I was diagnosed as type 1: https://www.dtu.ox.ac.uk/homacalculator/
The physiology behind beta-cell death is here: https://pubmed.ncbi.nlm.nih.gov/16306347/

 

[HSSS]

This is because they are not trained, the confusion is caused by the diversity of types and the stage of the condition. If you think of the different levels of the progress from prediabetes to insulin, the need for a diverse range of medication for treatment. The symptoms change and the nice guidelines on which the doctors follow, it really is confusing. Because if the solution doesn't work, more meds,.

Admittedly I didn’t finish - for non educational reasons (a need to move across the globe for family and finances) - but my Australian nursing degree definitely covered the basics of diabetes. Ie Diabetes is a condition of high blood glucose and hypos are usually caused by medication in excess of the current immediate requirements - with the exception of a few rare conditions (like your RH).And whilst nutrition was not covered in any great detail they did confirm that in the digestive process glucose comes from carbohydrates.

but yes I accept there is a huge amount to be covered and that is why there are specialists.

 

[HSSS]

Beta-cell function is calculated using the HOMA formula. It's more reliable than just c-peptide alone. Something my specialist calculated when I was diagnosed as type 1: https://www.dtu.ox.ac.uk/homacalculator/
The physiology behind beta-cell death is here: https://pubmed.ncbi.nlm.nih.gov/16306347/

Thanks. More reading.

I am aware of the HOMA calculation, am hoping to do it myself for insulin resistance purposes but as a type 2 we don’t get offered any testing at all usually beyond hba1c so it’s private or not at all. And it’s not cheap. I wasn’t aware of the beta cell estimations it provided. We type 2 rarely have anything beyond a gp or a practice nurse either, particularly if we are not managed by the heavier hitting meds or insulin.

 

[lucylocket61]

I may well be wrong here, but wouldnt it be better to use insulin for a while than to take medicines which squeeze every drop of insulin or whatever out of my pancreas? I am very insulin resisitant.

 

[HSSS]

I may well be wrong here, but wouldnt it be better to use insulin for a while than to take medicines which squeeze every drop of insulin or whatever out of my pancreas? I am very insulin resisitant.

I’ve got post 21 on my list (and wherever that takes me) before I can comment. At the moment both options make some sense to me.

 

[lucylocket61]

Anecdata warning: some of you many remember my brother, who was diagnosed same time as me, but took the medication route? Well, he has has been only on insulin for about a month now and is really, really well. Much better health wise than he ever was on the various other meds. He has energy, is losing weight and this has made him now start to lower his carbs as his depression is lifting - he is an emotional eater and being so depressed for so long meant he wasnt able to address his issues and use the help needed to look at his coping strategies

. So for him, its a good solution. Mental health has its part to play in our choices, doesn't it.

 

[LaoDan]

I haven’t read all the research, but it seems getting to a low body fat and high muscle mass percentages is pretty much all we can do. To get there requires a tremendous amount of work. Not everyone is in a position to do this, so we can just try our best.

As I posted when I joined, it’s my goal to get lean and jacked. I’ve retired from work to focus on this, I’m all in 100%. In the end, if I still require insulin, well, I’ll know I fought the good fight.

Even if I need insulin, I want to be as healthy as possible. I don’t want to use that as an excuse.

 

[HSSS]

Anecdata warning: some of you many remember my brother, who was diagnosed same time as me, but took the medication route? Well, he has has been only on insulin for about a month now and is really, really well. Much better health wise than he ever was on the various other meds. He has energy, is losing weight and this has made him now start to lower his carbs as his depression is lifting - he is an emotional eater and being so depressed for so long meant he wasnt able to address his issues and use the help needed to look at his coping strategies

. So for him, its a good solution. Mental health has its part to play in our choices, doesn't it.

As you say for him this medication is suiting him better than other medications. That’s great. If he needs or choose the medication route then find the best one for you undoubtedly. But it’s comparing apples and pears when you look at medication alternatives v diet alone.

 

[lucylocket61]

But it’s comparing apples and pears when you look at medication alternatives v diet alone.

Many find that diet alone is insufficient. It's not either/or for some. Therefore it is relevant.
Is this thread about insulin versus diet only?

I thought it was about various medications versus insulin when diet is not sufficient.

Mental health issues affect choices just as much as the health of ones pancreas.

 

[LaoDan]

Mental health issues affect choices just as much as the health of ones pancreas.

Absolutely! If I were totally miserable, or just tapped out I’d consider the medication route. Nothing wrong with that, everyone is in a different position.

 

[Oldvatr]

Many find that diet alone is insufficient. It's not either/or for some. Therefore it is relevant.
Is this thread about insulin versus diet only?

I thought it was about various medications versus insulin when diet is not sufficient.

Mental health issues affect choices just as much as the health of ones pancreas.

My understanding of this thread is that the OP was asking "what evidence supports the NHS mantra that Type 2 Diabetes has a progression to insulin therapy regardless of medication or lifestyle and if the evidence supports a 10 year timescale for this process." So insulin therapy is an endpoint or outcome

As far as I can see there are no statistics kept on how many T2D had not progressed onto inulin at the time of death - usually, such deaths are recorded as comorbidity events not death by sugar.

 

[lucylocket61]

My understanding of this thread is that the OP was asking "what evidence supports the NHS mantra that Type 2 Diabetes has a progression to insulin therapy regardless of medication or lifestyle and if the evidence supports a 10 year timescale for this process." So insulin therapy is an endpoint or outcome

As far as I can see there are no statistics kept on how many T2D had not progressed onto inulin at the time of death - usually, such deaths are recorded as comorbidity events not death by sugar.

OK. I must have misunderstood the original point.

 

[HSSS]

Many find that diet alone is insufficient. It's not either/or for some. Therefore it is relevant.
Is this thread about insulin versus diet only?

I thought it was about various medications versus insulin when diet is not sufficient.

Mental health issues affect choices just as much as the health of ones pancreas.

Agreed, a maintainable, sustainable diet (to the individuals point of view) is not enough for all. Some require medication support too. And it’s not just about the number of carbs. As you say mental health can have a huge effect of what’s sustainable and suitable for an individual as can many other factors. I’m not and never meant to suggest treatment is an either or situation. I’m sorry if it read that way.

My post was more about why type 2 is seen as progressive and insulin use is likely, and if 10 yrs is an accurate assumption of when it becomes likely.

I was speculating that it is because historically type 2 was only treated medically or not at all as opposed to successful diet only (or even diet as much as possible and minimal possible medication). And that medical treatment alone doesn’t seem to prevent gradual worsening only slow it, hence considered progressive. And that treatment was with medications that might actually be making an underlying problem (IR) worse in some cases whilst masking the symptoms of high blood glucose. And simultaneously assuming it’s because of lack of insulin (not IR) rather than actually testing insulin levels to establish facts.

 

[AndBreathe]

I think we mustn't forget there are many other reasons a person could end up on insulin, hefty doses of steroids, or treatments for other conditions throwing "stuff" out of whack - just as an example. It isn't all about individuals or professionals not understanding the benefits of lifestyle modification.

I think "Life getting in the way" should be added to the list.

 

[HSSS]

I think we mustn't forget there are many other reasons a person could end up on insulin, hefty doses of steroids, or treatments for other conditions throwing "stuff" out of whack - just as an example. It isn't all about individuals or professionals not understanding the benefits of lifestyle modification.

I think "Life getting in the way" should be added to the list.

Again it my point isn’t to judge people that use medication or insulin. But to question if it is inevitable that we will progress and what does or does not make this happen. As you say the reasons for deteriorating are multiple. Some may be avoidable, others less so. We should be identifying which are the more avoidable ones and acting on it where we can.

The example I keep referring to is if someone is moved onto insulin because it is believed they have run out of insulin production surely this should be checked not assumed. If their problem is in fact increased IR then address this real problem, if that’s possible, not make it worse by masking it. If their problem is for instance other necessary medications or other conditions and there aren’t realistic or achievable alternatives then that is the time for insulin/glic etc to step in and help.

 

[ickihun]

My understanding of this thread is that the OP was asking "what evidence supports the NHS mantra that Type 2 Diabetes has a progression to insulin therapy regardless of medication or lifestyle and if the evidence supports a 10 year timescale for this process." So insulin therapy is an endpoint or outcome

As far as I can see there are no statistics kept on how many T2D had not progressed onto inulin at the time of death - usually, such deaths are recorded as comorbidity events not death by sugar.

Many die because of misuse of insulin. I've read. I'll try and find it. Although I think it's all insulin users lumped in. Hence why many are given a consultant to oversee the transition.

 

[ickihun]

Again it my point isn’t to judge people that use medication or insulin. But to question if it is inevitable that we will progress and what does or does not make this happen. As you say the reasons for deteriorating are multiple. Some may be avoidable, others less so. We should be identifying which are the more avoidable ones and acting on it where we can.

The example I keep referring to is if someone is moved onto insulin because it is believed they have run out of insulin production surely this should be checked not assumed. If their problem is in fact increased IR then address this real problem, if that’s possible, not make it worse by masking it. If their problem is for instance other necessary medications or other conditions and there aren’t realistic or achievable alternatives then that is the time for insulin/glic etc to step in and help.

While all those points are tested and actioned on a person could damage their sight irretrievably or lose their walking ability. Hence what has been proven without fail is insulin therapy then improvement in mental health, vision threat and neuropathy etc. Insulin does work when all else fails. IR is a side effect of too much insulin unused which can also be improved on. As an urgent treatment insulin can be lifesaving but not a substitute for lazy investigation or management. Most hospitals will spend the money on a consultant as the money saved is boundless. Especially in today's climate.

 

[Lamont D]

The problem with modern health care regardless of where you come from is the bean counters.
If the provision is there, there usually isn't a problem, but if it is expensive, then that is where it can fall down. Unless of course you have insurance or can pay for the treatment.
And it also depends on where you live. It's called postcode lottery. This is because for some reason, probably political, that certain areas within the country get more resources and specialty hospitals. The hospitals in major cities seem to be the ones to suffer the most.
The rundown of the best health care system is criminal. It is a strategic plan to privatise our health services. The lack of investment, lack of staff, the lack of doctors and even before covid the lack of appointments, due to the policy of austerity.
The PPE crisis, the breathing equipment, ICU wards and the staff, and so on.
The misinformation and the restrictions are just to prove that the NHS can't cope.
If only politics would keep its nose out of health care!!