Insulin and how we live with it.

Last week I received an e-mail from a man in the United Kingdom that made me think a lot about insulin and how we live with it.

Dear Mr. King

How can I (as a diabetic) reduce, to a minimum, the unwanted effects of injected insulin? Is it question of keeping the dosage level as low as possible without losing control of blood sugar levels? Which is worse, in the long term, for the physiological system - slightly higher blood sugar levels or higher doses of insulin? I realize that any precise answer would have to be quantatively based but there must be a graph that shows the consequences of changing these variables. If not there should be!

Les. Walton - Shropshire, UK

Dear Les,

Janus-faced insulin gives life but it also brings death.

Your question made me think about my own paradoxical relationship with this hormone. In my 23 years with diabetes I figure I have injected more than half a million units in some thirty thousand injections. Every injection lowered my blood sugar and raised the probability of heart disease.

Syndrome X

I vividly remember something I heard years ago following a lecture by Dr. G. Reaven of Stanford University on insulin resistance (called "Syndrome X" at the time). He said that the single most accurate predictor of vascular disease in people with type 2 diabetes was fasting insulin levels and in short, the more insulin, the worse for arteries, and the more heart attacks. Two clinical diabetologists behind me were talking as we left the lecture hall. "I just don't believe Gerry is right. Insulin helps my patients. It doesn't hurt them!"

If you culture muscle cells in concentrated insulin, they become fat cells. In type 2 diabetes, where insulin levels are higher than normal all the time, muscle cells in blood vessels turn into fat cells and eventually atherosclerosis. The mechanism may not be as direct as that, but it is true that high insulin levels predict fatty arteries that lead to heart attacks, just as Gerald Reaven said.

Insulin is your opponent & your benefactor

Les, your question is perfect: "Which is worse, in the long term, for the physiological system, slightly higher blood sugar levels or higher doses of insulin?" The truth is, medical science really does not know the answer. The DCCT study (type 1 diabetes) showed that the lower the average blood sugar (as measured by hemoglobin A1c) the smaller the chance of micro-vascular problems like retinopathy and kidney failure. Many studies in type 2 diabetes have shown that the lower the insulin the smaller the chance macro-vascular problems like heart attack. (Data on insulin in type 1 and blood sugar in type 2 is scarce.)

Insulin for me is not a hormone, it is a harmful friend. My advice is don't take insulin, because it will over many years lead to a heart attack. My other advice is take enough insulin to keep your blood sugar down. The problem is you cannot do both.

Maybe the link of insulin to a person with diabetes is a bad marriage.

Disclaimer

The remainder of this column is medical advice based on my personal experience of managing type 1 diabetes and my readings of the medical literature. I am not an M.D. so I am not qualified to give such advice.

Advice for my friends with type 2 diabetes

If your therapy is keeping your sugars under reasonable control tilt your changes toward lowering your insulin level. In order of efficacy:

1. Exercise or move more
2. Eat less
3. Eat foods with lower glycemic effect

Notice I don't say cut your insulin if you are injecting it. When you exercise more you will need to cut your insulin so keep an eye on your blood sugars.

Note I say "exercise or move." They used to tell us 20 minutes "aerobic" three times a week. The latest studies show half the effort more often is as effective. Don't go to the gym if you don't want to. Walk over to the flower store or the coffee shop or around the block some days. It will make a difference. There is no amount of activity that won't help.

Advice for my friends with type 1 diabetes

Friends, your system is on manual override as they say on Star Trek. Take care not to burn out your dilithium crystals with too much insulin!

I am a very bad diabetic; I don't weight my food, I drink (California champaign and martinis are my favorites), I travel too much. So far, after 23 years, no complications, but maybe I have good genes. Anyway, when I can, I push toward cutting the amount of insulin I take.

I remember talking many years ago to a diabetologist in a major city who gets all the really bad cases - type 1 diabetes so out of control that the other doctors don't want to deal with it. I asked how much in the end he had the raise the insulin levels. His answer jolted me. He said the first thing he did was cut the insulin - almost every one was taking too much insulin for good control!

Les, you don't need a graph on the relationship of insulin to sugar, you just need the range 0.6 to 0.7 units of insulin per kilogram body weight. (Your weight in kg is your weight in pounds time 0.45.) If you are taking more than 0.7 units per kilogram over 24 hours, you might be taking too much insulin. Talk to your doctor about cuts.

I know as I cover high sugars after a big (and delicious!) meal at my favorite French restaurant, I might creep up to 0.75 or even 0.8. If I keep eating over the coming days my incidence of hypoglycemia goes up, and I feel sort of "stretched." For me, once again, the time has come to get insulin down! I cut all my insulin's at once to my familiar basic level, and for a day or so I eat much less, check sugars a lot, and exercise as usual. After two more days the better and familiar blood sugar stability returns, and hypoglycemia disappears.

So, Les, for a day or so I will put up with a lot of readings greater than 200 to get my insulin down.

Scott King



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