Why This Endocrinologist Hates Diabetes

 

 

[HD: The following post started out titled “Ketogenic Diet – Diabetes Cure?”  I initially intended to write a post primarily about the effects of a ketogenic diet on diabetes.  But, my preamble about why I don’t like treating diabetes turned out to be way too long (shocker, right?), so I present it to you now as a standalone post.  That means you’ll have to wait a little longer for the ketogenic diet article, which I think will be engaging for anyone with an interest in this field, even if you don’t plan to adopt that eating strategy.  At the end of the post today, I’ve included a sneak peek at Part 2.  Must have been feeling generous today…]

I’m going to share a secret with you: I do not enjoy treating diabetes.  In fact, I downright dislike it, and I’ve grown my practice in other areas of Endocrinology to the point where diabetes comprises only a small part of my practice.  Before you jump all over me about how diabetics are people too, let me make it clear that I don’t dislike my patients with diabetes.  In fact, some of my favorite patients are diabetics I’ve been treating for years.  After years of these folks dealing with the disease, I don’t always have new advice to offer at an office visit, so we’ll often spend half the time shooting the breeze about our lives.  I find that thoroughly enjoyable.

So why do I prefer to avoid treating diabetes?  I’ll get to the more substantive reasons in a moment, but first we need to talk about the logistical aspects of managing diabetes that make it difficult.  Even if diabetics comprise only 20% of one’s practice, they will consume 80% of the practice’s resources.  Again, I’m not blaming the people with diabetes, but it is what it is.  Take a look at just a slice of what goes into managing diabetes:

  • We (physician and/or clinical staff) write a prescription for a glucometer, lancets (to prick the finger), and test strips.  We need to calculate how many lancets and test strips to dispense, based on how many times per day the patient tests and/or how many times per day we want her to test.  We have to make sure that we document in the chart note how often the patient is testing, or the prescription may be denied if the insurance company requests the chart note and doesn’t see proper justification.
  • Insurance companies are constantly changing which meters and how many test strips they will cover, which means we have to rewrite and recalculate the prescriptions.
  • For patients on the newer non-insulin drugs, insurance companies frequently change what they will pay for.  80% of the prescriptions I write will come back to me, rejected, or asking for a prior authorization to be filled out.
  • In an Endocrinology practice, most of our patients will be on insulin.  With the dose of insulin changing all the time, we need to make sure the prescription is regularly updated and gives the patient enough insulin to increase the dose as needed.  Prescriptions are needed for insulin vials or pens, as well as syringes/needles or pen needles.  There are numerous kinds of syringes and needles out there, and people tend to have preferences, adding to the workload.  To top it off, insurance companies (see a theme here?) switch their “preferred” insulins on what seems like an every-few-month basis.
  • When a patient comes in to be seen, we need to download the meter so we can review the blood sugar data to make recommendations.  With all the different meters out there and all the different software to manage them, it is guaranteed that at least a few meters every day will fail to download properly due to bugs or software upgrades.
  • Patients on insulin pumps and/or continuous glucose monitors (CGMs) require an extraordinary amount of work to manage, as they have a ton of data to review every visit.  There are several variables that can be adjusted on an insulin pump (basal rates, carb ratios, correction factors, active insulin time) each time, and not all of our patients are comfortable adjusting pump settings themselves on their own time, so we need to walk them through it.  And we need to get all of this done – plus a foot exam, plus managing any diabetes related conditions (hypertension, hyperlipidemia, etc.) – in 20 minutes.  Almost impossible.
  • There are all kinds of mechanical issues with pumps and CGMs that need troubleshooting, about which I am not as knowledgeable as is my diabetes educator nurse.  But she sees her own patients by appointment and is not immediately available to come in and help.
  • Patients want to email or phone in their blood sugars (or nowadays upload their pump/CGM data to the cloud) and have us review them outside of scheduled visits and make recommendations.  We just don’t have the time to provide this free medical care.

I could go on, but I think you get the point.  A physician needs to have a real passion for diabetes in order to put up with the aforementioned workload, and I do not have that passion.  Some Endocrinologists choose the field because of diabetes, and some choose it in spite of diabetes.  I am squarely in the latter group.  Setting aside all of the logistical  management challenges, of which I was only minimally aware when I made the decision to pursue Endocrinology as a career, are there more fundamental reasons for disliking diabetes?

Why this Endocrinologist hates diabetes

To delve into this issue, we need make a clear distinction between Type 1 and Type 2 diabetes.  They are different animals and have completely different pain points.

Type 1 can be very difficult to control, in part due to the complete lack of insulin-producing ability of the pancreas.  Fluctuations in blood glucose levels tend to be extreme, as there is no pancreatic “reserve.”  So if there is no insulin on board from an injection, then there is no insulin on board at all, and blood sugars can skyrocket.  For this and other reasons, Type 1 diabetes is often associated with chasing blood sugars all over the place, trying to smooth them out as best we can.

The thing about Type 1 is that we expect it to be more labile and – to some extent – unpredictable.  Sure, there are tenets of management that guide us, but sometimes the blood sugars just do weird things in Type 1 diabetes.  So our mindset – our approach to the disease – is different than our approach to Type 2.  We learn to accept a fair amount of volatility in our toughest Type 1 patients, and we try to help them accept the concept of being “good enough.”  Once we get to “good enough,” then that has the potential to feel like a win, as opposed to focusing on all the days when they were “bad.”

In my experience, there is a “typical” Type 1 diabetic within different age ranges, which can increase or decrease the difficulty factor in managing the disease.  I’m going to make some generalizations here, recognizing that there are plenty of exceptions to the rule:

First, there are teenagers who just don’t care.  Fortunately, I stopped seeing them when I finished my fellowship; I won’t see anyone under 18 for diabetes.  I’d like to make it 25, but adding another scheduling rule to the ones that already exist would make my receptionists apoplectic.  Frankly, I just don’t know how to talk to aloof teenagers who feel no sense of urgency to get their disease under control.  The pediatric Endocrinologists do this all day, and I’m quite sure they do it better than I ever could, so I leave it to them.

When I see an 18 or 19-year-old kid who just “graduated” from pediatric Endocrinology to adult Endocrinology, I usually expect a quick visit.  They tend to be pretty healthy other than having blood sugars in the 200s-300s, so there isn’t as much to do, especially if they are still in don’t-care mode.  Sometimes, they come in realizing that it’s time to get serious, and I love those visits, as I feel like I have the potential to help them.  Occasionally I even do.  But it’s usually not until some point in their 20s that they come in and say, “OK, doc, I know I need to deal with this better.  What can we do about this?”

Next, there are Type 1 diabetics in their 30s to 50s; they are usually interested in good control and are the most likely to be on a pump +/- a continuous glucose monitor.  They may be frustrated with the disease, but unlike the teens-early 20s folks, they know that ignoring it will ultimately hurt.  These are the people I can usually help.

Finally, there are Type 1 diabetic patients in their 60s to 80s.  I find that they either have great control and I can’t tell them much that they don’t already know; or, they have poor control and I can’t tell them much that they don’t already know.  One of my octogenarians has frequent low blood sugars on a pump.  Our conversation goes the same way every time:

Me: You should really consider backing off on your basal rate before your daily walk, since you almost always seem to go low during the walk.

Her: Yeah, but I forget to turn it down.  Or after the walk, I forget to turn it back up.

Me: What about using an alarm reminder?

Her: [Shrugs and makes a constipated face]

Me: Well, maybe we should just decrease your basal permanently then, and let you run a little higher.

Her: Yeah…I don’t really want to run higher…

Me: So what would you like to do?  What do you think is the best way to handle this?

Her: [Changes the subject at this point to something only tangentially related to her blood sugars]

You would think that, after years of having this conversation with her, I would just stop trying.  But something inside compels me to give it “one more try.”  At that moment, I always get the sense that this will be the time that whatever I say will break through whatever the barrier is and make a difference.  And I’m wrong every time.  But you know what?  This woman is a tough old bird, and I like tough old birds, which somehow makes my failure less painful.

Type 2 diabetes – a lifestyle disease

This is actually the perfect segue into what really exhausts me about managing Type 2 diabetes, so let’s dive right into that.  Because Type 2 is generally associated with obesity and poor lifestyle choices, it can be quite frustrating to have the same conversations about their poor choices, especially when things are not changing much.  Then, the patient gets frustrated with me because “all you want to do is increase my medications.”  Sometimes, as with my octogenarian patient above, I feel like I can break through the wall and help the patient in front of me reach that “a-ha” moment.  So I continue to bang my head against that wall, with very little to show for it when it comes to results.

I think the medical profession has done Americans a great disservice by softening our emphasis on the fact that Type 2 diabetes is essentially a lifestyle disease.  Yes, people with Type 2 diabetes may have a genetic predisposition to developing it, but it tends to only present itself in the context of weight gain.  Yes, there are some aspects of the pathophysiology of obesity which may be beyond our control, but weight gain is – more often than not – due to poor diet and lack of exercise.  Cruel reality dictates that the absolute best treatment for Type 2 diabetes is weight loss.  Unfortunately, it’s super-easy to gain weight, but magnificently hard to lose it.

Not only is weight loss difficult under ordinary circumstances, but when we start adding medications to lower the blood sugar, it often gets even harder.  This is partly due to the fact that people with very high blood sugars are losing a lot of that sugar in the urine.  They are literally urinating out calories, which may be keeping further weight gain at bay.  When we start glucose-lowering medication, the sugar that was being lost in the urine is now being retained inside the cells of the body.  So the body is retaining glucose (calories) that it was previously urinating out, leading to weight gain.

In addition, many of the medications we use for diabetes have the potential to cause weight gain by other mechanisms, notably: insulin, sulfonylureas (glimepiride, glipizide, glyburide), and pioglitazone.  We have other medications that are weight-neutral or even weight-negative, but sometimes we just have to use some of the weight-positive meds to get the blood sugars down to normal.

So where does this leave me?  It is, after all, all about me.  I have a patient who needs to lose weight, but she also needs her blood sugar lowered yesterday.  I’m going to go out on a limb here and also state that she has tried to lose weight in the past and has been mostly unsuccessful.  What do I do, short of funneling her toward the bariatric surgeon?  I have tried weight loss medications, partial meal-replacement diets, formal weight management programs, dietician visits, counseling the patient myself…but it is rare for any of my patients to lose a significant amount of weight and keep it off.

In my experience, the problem is usually not a lack of patient education about what to do; it’s that our current strategies just don’t work very well.  It’s not that the advice to eat less and move more is bad, but people just aren’t very good at following it in a way that is sustainable, producing lasting results.  On top of that, I give them diabetes medications that may impede their progress.  Remember, Type 2 diabetes has the potential to improve significantly with simply a better lifestyle.  Eventually, this better lifestyle would lead to much happier patients and an Endocrinologist who wouldn’t cringe when she sees a morning full of diabetics on her schedule.

So, again I ask: what can we do to control blood sugar and reduce weight, which will ultimately lead to better long-term control of glucose levels by reducing insulin resistance?

 

 

[HD: Read on for a sneak peek at Part 2 of this post, “Ketogenic Diet – Diabetes Cure?”  Then come back soon for Part 2 in its entirety]

…what can we do to control blood sugar and reduce weight, which will ultimately lead to better long-term control of glucose levels by reducing insulin resistance?

Enter the Ketogenic Diet!

Those of you who are familiar with not only my writing style, but also what gets my quack-o-meter dialed up to 11, are probably thinking, “Ooh…I can’t wait to see HD rip KD a new one.  Let’s get it on!”  As much as I enjoy debunking extreme diets based on lousy/no science (hcg diet, anyone?), I also enjoy presenting ideas that are extreme, but also may have merit.  This is one of those times.

So what is a ketogenic diet (KD)?  There are plenty of sites where you can dig into the details, so I’ll present a quick overview.  In general, it’s a very low-carbohydrate diet that tends to be high in fat.  There are various iterations, but a common macronutrient percentage-of-daily-calories breakdown would be 70/20/10 fat/protein/carb.

70% fat?!  That sounds revolting!  I’m clicking back over to my Twitter feed now.  See ya!

Listen, I’m with you.  I don’t have any desire to eat ketogenically.  I trim every last bit of fat off my steak before a bite enters my mouth.  However, if I was overweight with diabetes and I had already tried “everything,” I think I would be receptive to hearing more.  So, for those of you with some residual interest, read on.  The rest of you, I hope the Kardashians did something really interesting today…

 

Hey, doctors and other health-care practitioners, do you enjoy treating diabetes?  Why or why not?  Where are your pain points?  Does the busywork with all the supplies and rejected prescriptions feel overwhelming?  People with diabetes, how do you feel about your disease?  Do you have it all figured out?  Are you burned out from having to deal with it all the time?  Does it feel like a second full-time job?  Is it surprising to learn that your doctor may not enjoy treating diabetes?  Comment below!

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Image credit: Photo by Armando Ascorve Morales on Unsplash

 

24 Replies to “Why This Endocrinologist Hates Diabetes”

  1. “In my experience, the problem is usually not a lack of patient education about what to do; it’s that our current strategies just don’t work very well. It’s not that the advice to eat less and move more is bad, but people just aren’t very good at following it in a way that is sustainable, producing lasting results.”

    You might be interested in a book called “The Beck Diet Solution.” It’s a stupid name for a good book– it’s a cognitive-behavioral book for dieters about changing mindsets that lead to failing to follow an eating plan. There’s no actual nutritional advice; it is just about building the cognitive framework so that someone can stick to a defined eating plan of their choice.

    In my opinion, as an experienced dieter, some people are blessed to have learned good eating habits early, and some of us are just going to spend our lives managing self-destructive, entrenched eating habits. Weight loss is very straightforward. Behaviour modification is hard as hell, and it’s highly individual because we aren’t all getting the same starter package in life.

    I understand patients don’t life being told they need psychological help by doctors, but there is a lot of research into habit modification and resilience that people who need to drop weight can take advantage of through CBT and other therapies. If being unable to stop medically self-destructive eating isn’t a reason to seek counseling, I don’t know what is.

    As far as lasting results– I think we need to re-frame failure. If someone drops weight but regains it, we consider that a diet failure, but it may just be part of the learning process. They met an obstacle to sticking with their diet and didn’t overcome it. Learning to evaluate mistakes, brainstorm strategies for overcoming that mistake next time, and get back on track after failure are essential dieting skills.

    1. This is the most sensible thing I’ve read about diet ever! Thank you. I’ve somehow managed to achieve this on my own, but I’m getting the book anyway just for support. I tell people all the time, when they ask how I lost (and have maintained for ten years now– 45 lbs, a quarter of my weight BTW), that it has a lot to do with changing your whole outlook about food, the culture we live in, and how you choose to deal with it on a consistent basis. I think I somehow did my own CBT.

  2. I totally get your frustration with Type II patients and weight loss. I was told numerous times in the years that I was “borderline” to lose weight. Like most people, I would lose a few lbs, then gain it right back. I just didn’t get it then, that you actually have to EAT LESS, not just switch to “healthier” food. Too much quinoa will make you fat! So will too many grapes–or “sugar bombs” as I like to call them. You have to get ANGRY at the food industry and the marketers! And the restaurants with their portions and lack of real alternatives besides salad! (This is starting to change a bit I’ve noticed recently, especially with the Obamacare calorie-posting requirements FINALLY taking effect).

    The main problem with weight loss, is that people think they are done when they reach their goal. Then the creep begins because they stop monitoring their habits. You have to make permanent changes. Ane the very first thing you must do is keep the much dreaded, (though I cannot understand the horror this seems to induce in people) food journal, so that you can get a baseline for how many calories you need. I would also love to have a dollar for every (overweight) idiot who tells me she can’t be bothered to count calories. They wonder why they fail!

    No, I am not perfect and I experience some fluctuation, but I never let this go for more than 5 lbs before I take steps–like getting back to keeping a detailed record of calories in and taking the time to measure portions. It’s so easy to take a little extra! You have to keep a mindset of the evils of our culture of abundance and marketing.

    So here’s where I tell you that I started my weight loss the same day I was diagnosed with Type II, and by my next visit I had dropped 6 lbs. I stayed on a 2 lb/week loss until I reached my target. Maintenance has been a learning curve but I mostly do it with ATTITUDE. I do not mean some kind of sunny disposition; on the contrary, I stay angry–at the food industry and at a government that refuses to even limit advertising to children. I maintain a certain smugness about not eating out much and not eating at social functions. I still see my RD regularly as she seems to be the only one who really gets it–unlike my Primary, who thinks I shouldn’t worry about a “couple of pounds here and there”. She is, shall we say, chunky and I’m searching for someone else who values my commitment.

    And–yes, I failed many times before, but something about the diagnosis hit me full force. I DID NOT WANT to have diabetes. I wish I could capture this and put it in a bottle or even on paper, to help others, but it was like some kind of religious experience I guess. I simply went home, read the materials from the dietician, cleaned out my fridge and cupboards, got out I’m continuing my replythe measuring cups, bought smaller bowls, and learned to enjoy feeling a bit hungry at times. As I lost weight I also greatly enjoyed looking better and buying ever smaller clothes! What fun after all those years of self-loathing in the dressing room!

    The only exercise I did was brisk walking, BTW. It’s mostly about the food folks, and it will be easier to maintain your loss if your exercise level is realistic for your age. I started my weight loss in late middle age, BTW, so that is even more impressive I think. I’m 68 today and it gets harder with the seeminly ever-slower metabolism, but I’m not giving in yet.

  3. Great points about treating DMII. We, as a medical community, need to emphasize the lifestyle aspect far more and downplay any genetic component. There is a sentiment that we don’t want people to fee like it is “their fault.” And to be fair, it does seem “unfair” that one person can eat pasta, bread, chips, candy and not get gain weight or get overt diabetes (Trust me, they are far from healthy, but they don’t end up in the doctor’s office with diabetes). Yet some people feel like they do everything right and can’t get rid of diabetes. I think the key is redefining what is means to do “everything right,” I am a big fan of using a very low carb diets as a means of treating DM, Insulin resistance, and for weight loss. When done well, and with good support, it can work wonders. I look forward to part two!

  4. As a physiatrist, a large percentage of my patients have diabetes–partially because it’s so prevalent, but also because it’s complications associated with diabetes that lands them in my office–stroke, amputations, diabetic amyotrophic, adhesive capsulitis, etc. etc. A lot of them are managed by their PCP and have minimal endocrinologist involvement. I always do the best I can with my motivational interviewing skills to encourage some lifestyle change, but if losing your leg doesn’t motivate you, my pep talk probably won’t either. So I just try to meet them where they’re at and do my best to make their life a little better.
    My personal least favorite consult is chronic low back pain, for many of the reasons that you don’t like diabetes. Of course, that is one of the most popular reasons to refer to a physiatrist–nobody else wants to deal with it either. Most of the interventions that would help the patient the most are lifestyle related–exercise, lose weight, stop smoking–and if the patient was going to do them, they would have already done them. Not to mention completely unrealistic expectations on the part of the patient. Plus it’s so boring! I feel like a broken record. A couple of years ago I read The Art of Communicating by Thich Nhat Hanh and it helped me change my outlook and approach on those days when my schedule is stacked with chronic low back pain. I don’t know if it’s improved my outcomes at all, but it makes me dread those days a lot less and makes the visits a lot more enjoyable, both for me and the patient.

    1. Thanks, Anne. I’m adding that book to my list. In the meanwhile, I deal with it by limiting the number of new diabetics I will see each day. But your way sounds like it is healthier for the psyche.

  5. We are fortunate to have a diabetes educator as a sort of extender in our practice who helps coordinate care for the numerous diabetics I see at my family practice. They are indeed a tougher population and unfortunately, as you have stated and as I have learned in my short career, do consume proportionately more time and effort from myself and staff. The kicker is that many of my poorly controlled ones tend to stay poorly controlled. I’ve seen the most dramatic changes happen in the first 30-60 days of diagnosis, when the motivation is strong. Beyond that it is just putting out fires and damage control for years and years until the big MI or the not necessarily unwelcome thrice weekly dialysis trips. Totals cost $1.6 million healthcare dollars per patient before sweet death. The very same ones who can be seen at Golden Corral buffet. But I digress… Great blog! I don’t understand why naturopaths are given licences by the health department. They are illegal in many other countries.

  6. On a somewhat related note, here’s a question I’ve been wondering about lately. I have mild PCOS, so my doctor monitors my blood sugar and cholesterol at an age where this might not normally be done and I eat healthy, exercise quite a bit and keep my weight in a range that works well for me (merely having a BMI below 25 isn’t enough for me to have near-normal periods). We know I need these things because I wasn’t having periods for months and was growing hair in places that shouldn’t have it — thus the diagnosis. But, as far as I understand, the underlying problem with PCOS is insulin resistance. If this is correct, what happens to men who have similar insulin resistance? They don’t have the obvious red flag of missing or irregular periods. Do they not know there’s a problem until they develop diabetes or heart disease?

    1. That’s an insightful question, and I never really thought about the issue in this way. To the best of my knowledge, there is no equivalent process to PCOS in young men. Presumably, if a young man has developed insulin resistance, it is due to weight gain, and it may go unrecognized until some routine blood work shows an elevated blood sugar level. Of course, by that time, the insulin resistance will have been present for years, and he will have lost some of the insulin-producing ability of his pancreatic beta cells, thus receiving a diagnosis of impaired glucose tolerance/prediabetes.

  7. I’m puzzled why Endocrinologists don’t view insulin in the same way all other hormones are viene de. That is, one can have a) none or not enough, b) the normal amount, or c) too much. Whether it is TSH and the Thyroxins, ACTH and Cortisol, PTH, Growth Hormone, Catecholamines, Prolactin, Estrogen, Progesterone, Testosterone and or DHEAS, an endocrinologist should be able to describe those cases for each (for some, like NO thyroxin, the outcome is death – kind of hard to treat). Usually, if “not enough” we give more. When there is “too much” we try things to reduce production, like talking out “hot” modules or giving radioactive iodide, or tamoxifen or bicalutamide. Other hormones are the plaything of psychiatrists.

    So what is the story with insulin?

    Sure, for hypoinsulinemia or aninsulinemia, which often lead to a quick-enough ketoACIDOTIC death (its the acidity not the glycemia which is deadly) we replace what lacks (and usually give too much, so the patient is told “eat ingest some glucose” and around the circle goes).

    But how about “too much” insulin. I don’t mean temporary low level overdoses causing hypoglycemia. I don’t mean the rare insulinoma. I mean “too much” as in fasting insulin of 1007 pM rather than 10 pM (both males, 57 yo FBG 5.4 mM, and 60 yo FBG 5.1 mM). In 1975 Gerald Reaven showed most NIDdm patient had HYPERinsulinemia. I was 11 years old then. I entered medical school in 1988 when he published about “Syndrome X”, or Hyperinsulinemic Metabolic Syndrome .

    It is pretty clear (except to Big Pharma) that the high insulin comes first, before the obesity, as it is the “RRSP” or “401K” or the “saving for a drought stricken ‘I wish it was raining’ famine day” hormone. Eating fish, fresh game & leafy greens in spring doesn’t require much insulin response (except to put amino acids into building muscles). Eating peas, corn, carrots, sweet potatoes, bread, grapes, apple & pumpkin pie, and bread at Thanksgiving, then Christmas, then New Years, then Super Bowl, then ….. does elicit a strong insulin response.

    Chronically elevated insulin leads to insulin resistance. No one learned to knock back a 6 pack by sharing a single can of beer with a friend. Tolerance requires increasing exposure. Increasing exposure leads to tolerance, or resistance. When cells are full of glucose they resist taking in more, and so the 6 Litres of circulating blood end up with more than the normal “one teaspoon” of glucose. Two teaspoons gets labelled “DM”, though to Willis “DM” meant glucosuria, which needs about 11 mM.

    So, why dont Endocrinologists speak about “too much insulin”. Why is “NID DM” a “metabolic” disorder, rather than a hormonal excess disorder?

    Have you diagnosed any “Cretins” lately? Is hypothyroidism ever called a “disorder of thermal regulation”? Not that I’ve ever heard.

    Time for Endocrinologists who treat Insulin Disorders to be “hormone doctors” not “metabolism” quacks.

    P.S. I liked your article. Time to read what you say of ketogenic & LCHF. Oh, and start eating the lightly crisped fat on your steaks. It’s delicious and goes straight via the Thoracic Duct to feed your heart.

    1. I’m glad you liked the article, thank you. You have made some assertions about the pathophysiology of diabetes that are a bit off-base, though. I recommend the following, continuously updated, online textbook as one of the best sources for information about Endocrinology subjects. You have to register to read the site, but it’s free. I’ve posted an excerpt below, but the whole chapter is worth a read:

      At least eight distinct pathophysiologic abnormalities have been associated with type 2 diabetes mellitus (T2DM). It is well established that decreased peripheral glucose uptake (mainly muscle) combined with augmented endogenous glucose production are characteristic features of insulin resistance. Increased lipolysis, elevated free fatty acid levels, along with accumulation of intermediary lipid metabolites contributes to further increase glucose output, reduce peripheral glucose utilization, and impair beta-cell function. Compensatory insulin secretion by the pancreatic beta-cells may at first maintain normal plasma glucose levels, but beta-cell function is already abnormal at this stage, and progressively worsens over time. Concomitantly, there is inappropriate release of glucagon from the pancreatic alpha-cells, particularly in the post-prandial period. It has been postulated that both impaired insulin and excessive glucagon secretion in type 2 diabetes are contributed to by the “incretin defect”, defined primarily as inadequate release or response to the gastrointestinal incretin hormones upon meal ingestion. Moreover, hypothalamic insulin resistance (central nervous system) also impairs the ability of circulating insulin to suppress glucose production, and renal tubular glucose reabsorption capacity may be enhanced despite hyperglycemia in T2DM. These pathophysiologic abnormalities should be considered for the treatment of hyperglycemia in patients with type 2 diabetes. For in-depth coverage of all aspects of Diabetes, visit http://www.endotext.org

      Endotext

  8. @HD:
    What do you think of the following hypothesis, that hyperinsulinemia itself causes insulin resistance?

    Quote from Dr David Ludwig: “Which comes first, insulin resistance or high insulin secretion? The answer has major implications to the prevention of obesity, diabetes and heart disease. Perhaps the traditional drug treatments for insulin resistance have missed the mark. ”

    Insulin action and resistance in obesity and type 2 diabetes
    https://www.nature.com/articles/nm.4350

    “Viewpoint: hyperinsulinemia causes insulin resistance.
    In individuals with obesity who are mildly glucose intolerant but do not have diabetes, fasting hyperinsulinemia occurs without the detectable increases in blood glucose that would theoretically be required to stimulate beta cells to secrete additional insulin. This is also true of the apparently identical increases in blood glucose concentrations that occur in people with hyperinsulinemia upon the ingestion of glucose. Such apparent uncoupling of circulating insulin levels from glucose levels is also observed after bariatric surgery in individuals with obesity. The above confounding considerations gave rise to the hypothesis (Fig. 3) that hyperinsulinemia is the initial, primary effect of HFD feeding and obesity, induced by the stimulation of beta cell insulin secretion4 and the suppression of insulin degradation. According to this viewpoint, primary hyperinsulinemia is what initially causes insulin resistance in target tissues such as liver, at least under conditions of nutrient excess.”

  9. Also, since obesity is related to diabetes, it is really difficult to understand why the simple “Calorie in / Calorie Out’ model is still defended by Academics… can’t we just all agree that food intake (quantity) and hormonal factors (food quality) are both important?

    Another interesting article, with another quote from Dr David Ludwig:

    “The ‘calorie in, calorie out’ concept of weight control seems to make sense, but doesn’t really explain why we have an obesity epidemic in the first place. An alternative explanation, with big implications to treatment, focuses on insulin secretion (aka Carbohydrate Insulin Model). This idea receives full-throated support in a new review, coauthored by a past president of The Obesity Society. Even the leaders of the field are doubting that obesity is simply a problem of “energy balance”!”

    Hyperinsulinemia: a Cause of Obesity?https://link.springer.com/article/10.1007/s13679-017-0261-z

  10. MODY2 (monogenic diabetes caused by GCK mutation) is frequently misdiagnosed as gestational diabetes or type 2 diabetes. These patients do not have insulin resistance; instead the blood glucose is regulated at an higher set point, with normal insulin levels. It is interesting that these patients have lifelong mild hyperglycemia, difficult to control with hypoglycemic agents, yet, they do not develop microvascular complications like patients with type 2 DM do. This is supporting the idea that “normoglycemia” might not be as important as avoiding “hyperinsulinemia” in patient with insulin resistance. Yet, most endocrinologist do not really try to confirm possible cases of GCK mutation (MODY2), and treat them the same as any diabetic.

    Recognition and Management of Individuals With Hyperglycemia Because of a Heterozygous Glucokinase Mutation
    http://care.diabetesjournals.org/content/38/7/1383

    Conclusion of the article:
    “Heterozygous inactivating mutations result in GCK-MODY. Those with GCK- MODY have a mild fasting hypergly- cemia (5.4–8.3 mmol/L) that does not require treatment (outside pregnancy), does not need or respond to hypoglyce- mic treatment, and does not result in the severe complications of diabetes. The fetal growth in pregnancy is dependent on whether the fetus inherits the mother’s mutation; fetal growth should be measured as a surrogate for fetal genotype and the use of insulin treatment based on this. In individuals with GCK-MODY outside pregnancy, and in line with the general population, ensuring a healthy diet and lifestyle is generally the only intervention necessary.”

  11. So you hate treating diabetes? You really dislike dealing with the capricious and ultimately time-consuming ways of insurance companies? You just can’t take the maddening non-compliance of insulin-resistant diabetics to lifestyle changes? It seems as though you have a strong aversion to several of the near-universal categories of headache triggers for practically all MDs involved in medical specialties in the modern era.

    One apparent distinction between yourself and the majority of the rank and file board-certified, well-respected medicine docs that I know (such as my board certified, 23-years-in-practice, hyper-adored by thousands of patients and doctors, MD neurologist wife who works 90-hours every week) is that you are free to choose your own patient population. I hope that you relish this uncommon freedom. With many docs, to push for patient population restrictions or quotas risks being labeled “difficult” or (gasp) “not a team player” by administration brass. Being an individual player can easily result in being unceremoniously walked out to your car by security and handed a three month severance salary. As a result, my wife unwillingly and frequently sees chronic malingerer top-risk scary sex offenders from the nearby State Security Hospital, a ridiculous number of headache patients who, like your diabetics, take up a massively disproportionate amount of office, medical records, and paperwork time, and patients with fictitious conditions like fibromyalgia and chronic fatigue syndrome who cannot be convinced to shed the sick patient persona. Meanwhile, patients who end up diagnosed by my wife with Huntington Disease, Amyotropic Lateral Sclerosis, and Glioblastoma Multiforme have had to wait five or six months of an already limited lifespan to see her.

    Working through and around insurance company mandates and their arbitrary cycling through non-equivalent formulary drugs takes up a sizable chunk of those 90 hours per week that my wife is off limits to our wonderful 14 year old mildly autistic son and myself. I have been taught that this is simply the state of medicine nowadays, and that a soul-sapping workload, zero say over one’s patient population, and not “abandoning” patients, no matter how hard they attempt to sabotage their own health (on more than one occasion, my wife has successfully administered clot-lysing agents to patients with acute stroke, only to see them choking down cigarettes the very next day, at the front door of the hospital) are non-negotiable prerequisites for the privilege of remaining an MD in good standing. Aren’t the factors that make treating diabetes so objectionable to you simply reflections of difficult issues that pervade medicine in 2018?

    1. The answer to your question is yes, mostly. The insurance company nonsense is the worst it has ever been, but the patients who are “suboptimally” compliant are probably the same as they’ve been for many years – nothing new there. When I can take care of a transgender patient who profoundly appreciates my care or a thyroid cancer patient who is grateful for my expertise in treating advanced carcinoma, it is exponentially more satisfying than chasing around blood sugars all day – especially if that particular diabetic patient doesn’t really seem to be invested in her own care.

      As for your wife’s practice, I see the tide shifting in what the upcoming millennial MDs will accept when it comes to work-life balance. Whereas docs in your wife’s generation have been conditioned to believe that medicine is your life and if you complain, you’re not a team player, the new generation of docs (if I can over-generalize) essentially want to be shift workers, clocking out at 5pm and not working nights or weekends. I have to say that I can’t blame the new generation for wanting to have a life, and I hope they can drive the conversation forward such that work-life balance for docs will become more of a given and less just lip-service from admin.

      As for cultivating the type of practice one wants, it is not that uncommon. Look at academic medicine – new hires are encouraged to develop an area of interest/specialty, even within a subspecialty. This makes sense, as a general Endo like me can’t possibly be expert at treating rare stuff like acromegaly or hypophosphatasia, because we almost never see it. So if you’re an Endo at an academic center specializing in metabolic bone disease, you’ll see enough cases of hypophosphatasia to get darn good at recognizing and treating it.

      In private practice, at least in my area, the competition for patients is fierce. Subspecialists like me are encouraged to have at least 1 or 2 things we’re known for, to draw more patients in. Over the years, I have become known for things other than diabetes, so my schedule tends to fill with other things, leaving less room for diabetes.

      Your wife sounds like a saint, but it also sounds like her good nature is being taken advantage of by an institution that rewards great work by…giving her more work. If your finances allow it, would she consider cutting back? I have found that less time in the office does wonders for my mental state, making me significantly more pleasant to be around as a husband, father, friend, etc.

      1. Thank you, doctor, for the candid reply. I very much appreciate your feat of endurance in slogging through my unnecessarily verbose prose. You made some excellent points and suggestions. My wife and I have spoken at length about her going to half or 3/4 time. The clinic is willing to accommodate this, and we could probably absorb the revenue loss.

        One big consideration is that the clinic, as you have probably apprehended, expects too much from its non-surgeon physicians, with the explicit threat of termination a constant stick, often swung. There are few carrots on offer. This will undoubtedly continue to be a thorn in Sarah’s paw, as part-time doctors at her multi-specialty, 150 doctor clinic are under extraordinary scrutiny and pressure by administration honchos to essentially work a full schedule, despite far less pay and revoked benefits. In this market, located in flyover country, this is normative behavior for clinic administrators. It is a business model.

        As well, my own episodic cluster headaches have transformed into agonizing daily chronic attacks, lasting up to two or more hours, when 15 l/min of 100% O2 via non-rebreather mask does not abort them, forcing me into current retirement from my career as a PhD clinical psychologist. Despite these issues, Kim will likely request a reduction in her hours within the very near future, in order to achieve some semblance of non-work life.

        Thanks again for the gracious and prompt reply. Thank you also for the wonderful blog that injects levity into an often dry and joyless discussion. I am a vigorous promoter of the application of the Scientific Method, the Principle of Parsimony, Karl Popper’s Falsifiability Criterion for scientific hypotheses, and the consideration of base rates in conjunction with test/assay sensitivity and specificity in both the medical and psychology fields. (My PhD program was at one of the birthplaces of Behaviorism, with B.F. Skinner a longtime professor well before my studies, and the dear, late Paul Meehl and Auke Tellegen frequent lecturers and confidantes while I progressed through the program’s seven years. I bleed scientific rigor.)

        I often feel like I am screaming in a vast, empty tundra when I attempt to tactfully enlighten professionals and laypersons about the creeping malignancies of the magical fields of chiropractic, homeopathy, and, often, naturopathy. Finding your blog has been tremendously satisfying. Please keep blogging and do continue to be fearlessly irreverent. It’s what pushes your writing from mere greatness to brilliance.

        (Incidentally, Sarah would absolutely bridle at being called a “near-saint”, although, when we are not imploring her to find a way to spend more time with us, my son and I tend toward idealizing and cannonizing her. She’s an excellent doc who simply tolerates too much boloney from some patients and all of her bosses.)

  12. I am a former Type 2 Diabetic who was on 100 units of Insulin via a pump. Mid 50’s male. Engineer so I looked around for a way to hack my diabetes. Found Intermittent Fasting and the Ketogenic diet. In 2 weeks I was off my Insulin. Been on the KD for 2 years now. Lost 115 lbs (285 to 170 lbs). Last HbA1C was 5.2. I have a new life thanks to KD + IF. Some of us T2DM folks really do want to get well but just don’t know that we can get fixed with KD. Thanks for being open to the subject.

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