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Question: If my doctor increases my insulin, will it correct my high sugars from diabetes?
A dilemma that comes up frequently in the clinic is whether to increase the dose of insulin for patients with uncontrolled diabetes In the modern information era, many people are familiar with this principle hormone for glucose metabolism. But is diabetes just a problem with its dose?
25 million people have diabetes in the US; 50 million people in the US have pre-diabetes, a condition where there is a 15% risk of developing diabetes (CDC). Between 30 percent of commercial population to 50 percent of medicare population have uncontrolled diabetes on therapy.
Here are the two sides of the paradox:
- Since insulin drives glucose metabolism, why not increase insulin to lower blood glucose and reduce further damage?
- Why does replacing insulin lead to weight gain and require further increases of insulin?
Carbohydrate Digestion and Metabolism
To get a good idea on how to answer this question, here is a brief summary on the way the body breaks down carbohydrates (carbs.)
- The body begins working on dietary carbs (DC) as soon as they enter the mouth. The saliva contains a chemical amylase, which splits DC into shorter chains or polysaccharides.
- These sugar groups are broken down in the small intestine by pancreatic amylase to form monosaccharides like glucose.
- Now in the form of simple sugars, they cross the intestinal wall and transit to the portal venous system to the liver.
- Glucose enters the bloodstream of the portal vein. The pancreas lets out insulin pulses and begins the process of glucose metabolism.
Diabetes: impaired insulin secretion and resistance.
A diet high in carbs needs more insulin from the pancreas. This hormone prevents high glucoses in the bloodstream by shifting them into tissues, either as immediate fuel or stored as glycogen (liver and muscle) and fat (adipose and other tissues.) Increased fat stores, particularly as measured by increased waist circumference, impair the its normal function. One of the earliest problems in people at risk for type 2 diabetes is the loss of pulsatile insulin secretion.
Measurements of diabetes, such as hemoglobin A1c, remain normal in someone with obesity. However, insulin levels are higher, indicating the setting of resistance. Here is a YHF link. Insulin resistance (IR) likely originates in the pancreas, contributing to defects in its function. Fatty tissue in the liver and pancreas blunt its usual action, leading to higher insulin levels.
Insulin shifts glucose out of the bloodstream to protect the blood from inflammation. There is an increase in appetite. It might be because of lower blood glucose and some fat signaling changes. If the diet is the same, there will be weight gain.
Higher levels of insulin, both natural and therapy, drive weight gain. In diabetes, long-acting therapy can drop the A1c by 2.5 points. However, weight gain, as much as 4 kg results (1).
It all starts with the foods we eat.
What comes first: high levels of insulin from high blood glucose or insulin resistance which leads to high levels of this hormone? Studies support that the driving force of the dysfunction, beginning with high levels of insulin, comes from the diet.
A diet high in carbohydrates leads to a greater hormonal response from the body. Insulin drives glucose metabolism to increase adipose stores; this includes fatty deposits in the viscera (pancreas, liver, and intestinal adipose stores) and muscles. Fat tissue leads to tissue stress, hypoxia, and inflammatory response. These factors contribute to a blunting it action.
A high dietary intake of sugars contributes to adipose stores, which cause inflammation and decrease the potency of insulin.
Behavior and Diet
Obesity is like a gravitational pull. I like to visualize a newborn’s world. Most of the driving force is food and comfort. One of the first things an infant does after its born is feed. This illustrates how eating is a behavior. Importantly, the way the newborn manages the balance of desire and satiety is a reflection on its developing behavior and the environment.
- Food preference is a behavior. Dopamine drives craving for foods which lead to greater satisfaction and then greater dopamine deficiency. Think of the natural sugars and fat in mother’s milk as the first food source.
- Behaviors lead to a pull toward consistency, as the brain manages stressors. The greater the stress response, the greater the pull toward satisfying foods.
- Processed and high carb food fuel the cycle, eventually leading to obesity. Food actively turns on genes that produce hormones, including insulin, and this drives glucose metabolism.
So, back to the question, can diabetes be treated by increasing insulin?
The answer is no, because it just fuels the fire of a feedback loop. Increasing insulin pushes glucose into adipose tissue, causing more tissue inflammation and IR. This leads to increases of the hormone and causes weight gain and high glucose and the need to escalate therapy.
When diabetes is not controlled on current therapy, revisit the diet, rather than reflexively increasing doses.
Included in Links
- Hedrington M, Pulliam L, Davis S. Basal Insulin Treatment in Type 2 Diabetes. Diabetes Technol Ther. 2011. 13(Suppl 1):S-33-S-42.