Careful, Your Prejudice is Showing

About halfway through reading the second paragraph of David Spero’s blog entry last week ("Not So Fast With the Insulin?"), I began seething. Now that a few days have passed…I’m still seething.


It’s clear to me that Dr. Roger Unger dislikes overweight people. It’s clear to me that he dislikes people who have “given themselves” Type 2 diabetes. Of course, most people with Type 2 diabetes are overweight: Excess insulin results in weight gain, and one of the cornerstones of Type 2 diabetes is excess insulin production (along with beta cell dysfunction and relative insulin deficiency). Dr. Unger, an octogenarian, obviously has his feet firmly planted in the Blame the Patient School of Medicine.

I won’t even mention that many people with Type 2 diabetes already resist taking insulin — to their detriment — and don’t need anybody, much less an acknowledged leader in the field of diabetes research, telling them insulin is the worst thing they can put into their bodies.

Did you notice the part about “relative insulin deficiency” up there? That means your body is making insulin, even too much, but it isn’t enough to keep your blood glucose in normal ranges. Are we to walk around with high glucose turning our blood flow into sludge and risking a host of diabetes-related complications just because Dr. Unger is more interested in punishment than in glucose control?

“The indication that ‘Weight-loss and major lifestyle changes may be more effective than intensive insulin therapy for overweight patients with poorly controlled, insulin-resistant Type 2 diabetes’ may be true but is highly impractical,” says Charles H. Raine III, MD, a diabetologist in Orangeburg, SC, who also has Type 2 diabetes.

“It is known that insulin resistance can be also reduced by starvation. This, of course, is impractical,” Dr. Raine says. “The low, long-term, success rate of the various dietary programs, including bariatric surgery, indicate that weight-reduction tools currently available do not offer a realistic approach to the masses of overweight, insulin resistant Type 2 diabetic patients.”

Contrary to Dr. Unger’s pronouncements, Dr. Raine says, “The fact is that the best available tool to reduce insulin resistance is indeed insulin. This has been shown in numerous clinical studies,” including a case study he did that was reported in a 1999 edition of the Journal of the National Medical Association.

That study cited the case of a woman given frequent injections of rapid-acting insulin over several days. During her 11-day stay in a hospital for the treatment, her daily insulin dose dropped from 479 units to 60 units and her mean blood glucose decreased from 274.7 mg/dl to 111 mg/dl.

High blood glucose leads to glucose toxicity. Prolonged glucose toxicity leads to decreased insulin secretion and to beta cell destruction. Glucose toxicity can be reversed, as seen in Dr. Raine’s case study, but beta cells that have been destroyed cannot be rejuvenated. Just ask anybody with Type 1.

Dr. Unger is quoted in one article as saying, “Today there are many treatment options, including bariatric surgery, if necessary, to lower the fat content in the body before you start giving insulin.”

Researchers are still puzzled as to the mechanism in bariatric surgery that results in a reversal, as it were, of Type 2 diabetes in some people who’ve undergone the procedure — even before any weight (or fat) is lost. And researchers from the Washington University School of Medicine in St. Louis reported in The New England Journal of Medicine in 2004 that abdominal liposuction, in which fat cells are removed from the body, failed to significantly alter insulin sensitivity.

So bariatric surgery works before any fat melts from the body, and sucking fat out of the body doesn’t work either. ‘Splain that, Lucy, ’cause I sure am confused.

Furthermore, in the January 5, 2009, Diabetes Flashpoints feature “Bariatric Surgery: Beware,” Dr. Nicholas Yphantides notes that up to 20% of people who have gastric bypass need follow-up surgery; the chances of dying are 1 in 200; and the resulting nutrient deficiency can lead to anemia, osteoporosis, and other bone diseases. And there’s other stuff like explosive diarrhea. Sounds great, huh?

In another area of research, Dr. Unger and colleagues found that giving leptin to terminally ill rats with Type 1 diabetes lowered their blood glucose levels. Leptin is a hormone produced by the body’s fat cells. Heck, Type 2s should be swimming in the stuff! (Then, again, many a rodent has been cured of diabetes.)

Dr. Unger may be one of the preeminent leaders in the field of diabetes research, but his prejudices are showing if he considers death, disease and explosive diarrhea as preferable to having Type 2 diabetes. I’ll take the diabetes rather than the punishment, thank you very much.

I’ll go back to my original assessment: Dr. Unger does not like overweight people and he does not like people who have Type 2 diabetes.

There is some precedence for that.

Apparently, there is so much weight bias in the health-care profession that the Yale School of Medicine has a continuing medical education course “designed to increase awareness of weight bias in health care settings and to help clinicians across a variety of practice settings to improve delivery of care for overweight and obese patients.”

(Hmmm…that sounds like a good blog topic for next week.)

Type 2 diabetes bias? That was addressed in the January 2002 issue of Southern Medical Journal, which concluded, “regardless of age, sex, or level of training, internal medicine physicians have negative attitudes toward Type 2 diabetes…”

Those negative attitudes can result in suboptimal care. I addressed a couple of those in my blog entry “Patient, Heal Thyself?” a couple of years ago.

As I’ve said before — and surely will again — we gotta watch out for ourselves. Fat chance some of the docs out there will.

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  • Jolie

    When I read that post of his, I really kind of freaked. I just switched to an all insulin regime in January. I am overweight and despite following a 1200 calorie diet, I am only losing about a pound every two weeks. I started thinking that I was doing more harm by switching to insulin. But then, I had to look at my numbers. My readings are so much better than when I was taking Metformin, Gliburide and Lantus. Though the weight loss is extremely slow going, I am not GAINING weight (as I was before). So I settled down and put his comments in the back of my mind as something to discuss with my doctor later.

  • CalgaryDiabetic

    Dear Jan

    My first reaction to David’s article was much the same as you have just written. But on futher though there is a problem with insulin. I now need 1 unit of insulin per 2 grams of carbs. This is a terminal situation as the more insulin you take the fatter you will get. This is a positive feedback loop that is certainly not positive in its results.

    I may be that his idea of a starvation diet could be the only thing left. It is true that in the beggining of the disease you can get the pancreas working again by getting the blood sugar into the normal range and then cut the external insulin dose to a sane level.

    However it is not clear what you can do once the pancreas is toast and God still blessed you with massive insulin resistance. We need much more info on how to cut insulin resistance? Loosing weight? or much more insulin to get BG in normal range? Metformin makes me really sick when taken more than 3 weeks? Taking meridia for weight loss now appears to be working however have not lost 10 lb yet so body is still not yet discovered it is starving.

    Bariatric surgery I would rather die right now!

  • siddi

    God Bless All of You!!!

    I am on Paxil, Glyburide, Metformin and Actos. I have been gaining weight and talked to my doctor and of course he declared that meds do not cause weight gain. The problem is me! Needless to say I have spent many hours upset and in tears, (which of course does not help my BG) because I feel like this is all my fault. But having read your comments I feel much better, think I need to find another doctor. Thanks again for your comments and insight, very helpful.

  • dabernethy

    Jan & David,
    I have been an avid reader of both blogs, but this is a first time comment. I am a type 1 diabetic, but also a medical resident working towards becoming an endocrinologist.

    Both of your blogs are quite long and raise several issues I hope to address, but I’ll try to be brief as well.

    I think much of this debate is needless and may have been avoided if David had provided his information source. I assume David is referring to Unger’s article in 3/12/08 JAMA issue titled “Reinventing Type 2 Diabetes” where Dr. Unger suggests an alternate theory of how Type 2 Diabetes may develop.

    I actually found this article very fascinating, but David’s presentation may have been somewhat oversimplified (no offense intended). I will try to provide a better synopsis, but I encourage all to read the article themselves (although it is quite complex for the non-medical person). When Dr. Unger suggests that increased fat leads to increased insulin resistance, he is not referring to the conventional perception of fat as abdominal obesity. Instead, he means “ectopic deposition of fat” (aka fat depositing into vital cells, leading to their destruction or impaired function). For instance, fat can deposit in pancreatic beta cells and contribute to their destruction; fat also deposits into muscle cells (the main consumers of glucose) and impairs the ability of insulin to move glucose into the cell.

    So, why should insulin be a last resort? If Dr. Unger’s “lipocentric theory” is correct, then using insulin will lower glucose levels. However, it will simultaneously stimulate excessive fat depositing into pancreatic or muscle cells, which will exacerbate insulin resistance (in the long run) and possibly lead to a “dead pancreas”. Since insulin is a driving force behind this fat deposition, most long-term management regimens should exhaust non-insulin using approaches first. However, it must strike a balance with managing blood glucose. That balance is what each of us must discuss with our doctors.

    I also wish to comment on the 1999 NMA case study “Improving Severe Insulin Resistance with frequent Lispro insulin injections”. The patient in this study had uncontrolled diabetes and the physicians suspected that she was not taking her home insulin as prescribed. This woman was in the throes of glucose toxicity. When blood glucose is extremely elevated for several days to weeks, the beta cells of the pancreas will “shut-down,” but can resume normal function once blood glucose is regained. In this context, insulin is often used in the short-term to return blood glucose levels to normal, so as beta cells turn back on insulin resistance/needs will decrease. At that time, patients can resume more reasonable regimens that hopefully do not require insulin.

    In fact, in that same article, Raine refers to an article from Diabetes Care (1997;20:1353-1356) by Ilkova H et al titled “Induction of long-term glycemic control in newly diagnosed type 2 diabetic patients by transient intensive insulin treatment” which concluded lasting improvement in beta-cell function in type 2 diabetic patients after continuous subcutaneous insulin by insulin pump for TWO WEEKS. Several patients remained in “adequate” glycemic control for 9 to more than 50 MONTHS after discontinuation of continuous subcutaneous insulin, being treated with DIET ALONE.

    So, the take-home message is that both of you are right and wrong (as in most disagreements). Insulin is still a very important means controlling blood sugar, but there are numerous lifestyle changes and medications that can lower blood glucose without increase insulin levels. Dr. Unger is encouraging an exhaustion of these options before resorting to insulin (bariatric surgery should be used more conservatively until it is perfected and better understood).

    I hope my rambling was not too long and that you found my comments helpful. If so, please feel welcome to republish my comment so that other may more easily access it.

    Thank you.

  • Kathy

    What about the Type 2 who is not overweight? My husband is far from overweight at 147 pounds. Skin and bones cannot tolerate metformin and starving to death is not an option. Takes glipizide and Actos and the numbers are still not going down like we would love to see. Has cut down on carbs more. He can’t afford to lose anymore weight on his 6′ frame. Help!!!!!!

  • seekerjohn

    I so much appreciate your thoughtful, research-based blogging. I have a short tale to tell: A year ago I was taking a lot of both Lantus (twice a day) and a bolus of Novolog based on carb. calculating before each meal. I visited a not-too-well known diabetes center in Sulphur, Ok, wher I was put on a totally vegan diet for the 19 days of my stay. I also had a C-peptide test done to measure insulin resistance and discoverd that I was able to produce about 172 per cent of expected amounts of insulin. As a result of the diet, I have been able to reduce insulin by more than half, and weight began to drop off. I stuck to a vegetable-based diet when I got home and continued to lower both insulin resistance, weight, and the amount of insulin I needed to take. Earlier A1Cs were always over 6.3 or so. Now they have been running at 5.4 and 5.5 over the past six months. I’d like to hear more about your thoughts on vegetable-based diets. The program I was on flies in the face of the ADA diet. I should add that everyone in my program (about 13 of us) had weight loss, all the Type 2s had lower insulin resistance, and everyone experience improvement in mood and general health–blood fats, etc. Blood pressures also came down for all of us. The biggest change I noticed was in my feet which changed from purple and sore to pink and white almost immediately through “contrast therapy”–a five minute soak in 104 degree water followed by three minuites in 80 degree water. It’s such an old therapy, but it truly works–and can be done in your bathtup with a couple of plastic containers and a pool thermometer.

  • Cecelia

    I resisted taking insulin for a long time by using exercise and diet to try to control my glucose levels. Then I got breast cancer, which led to congestive heart failure and a lot more meds. Since I have been on the insulin (and I have to take a lot more than most) my glucose has leveled off and 3 times I have been able to lower the amount of insulin I take. I would love to lose my extra weight, but the docs have to take in consideration that most of the meds a person takes put weight on.

  • Cathy

    I left David a message also but the short story is this. When I was diagnosed in 1995 with type II diabetes I immediately went on a food plan and walking regimen. I lost 80 pounds but my blood sugar was not where my family doctor wanted it to be. (Some people are never satisfied.) So he sent me to an endo who was an older man who believed that it was all my fault. If I came in for a check up and my numbers were not where he wanted them he would pout. I finally told him that I only needed one father and changed doctors. He had put me on Actos on my first visit to him and I quickly gained back 40 of those hard earned pounds lost. I tried everything to lose those pounds. I tried Weight Watchers where I had great success before for 6 months but could not lose even 1 pound while I took Actos. My new doctor is much younger and I feel he listens more to me and takes my issues seriously. He doesn’t give me the feeling that he knows what’s best for me. The first thing my new doctor did was take me off the Actos and add Lantus at night. I have been able to lose 20 pounds and I feel so much better. I don’t know from studys and such but I do know that I feel much better and am less depressed. My sister has had the bariatric surgery but I have no desire to try it. I have noticed that a lot of the people who have this surgery slowly regain their weight over a few years – Randy Jackson (Dawg) and Carnie Wilson are good examples of this. I don’t want any kind of surgery unless it is emergency life-saving stuff.

  • dabernethy

    Calgary Diabetic,
    As I am not your physician, my guidance is only general suggestions that you can discuss with your doctor.

    I do not know which you may have tried already, but here is a general list of how a typical management strategy may progress.

    1)Dietary and lifestyle changes.
    2)Metformin: b/c it often facilitates weight loss
    3) Historically, sulfonylureas are added next; however, these act by trying to boost your own insulin production. But, if we think increasing insulin levels is bad, then this may not be the best choice (also if your pancreas is dead, these will not work for you).
    4)Avandia/Actos are insulin sensitizers, but recent controversy about their effects on water retention and cardiac function has left many reluctant to use these. If you do, evidence is supporting actos over avandia.
    5)Byetta/Januvia – this class of meds can slow glucose absorption by your gut and even reduce hunger. Januvia is a pill and has a weaker effect than Byetta, which is an injectable. Currently, Byetta is daily injections similar to mealtime insulin; however, the FDA recently approved a once-per-week injection that should be hitting pharmacies before summer.
    The main side effect of nausea may be avoidable by starting with the weaker Januvia (max it out) then slowly transition to Byetta (if needed).
    *Currently, Byetta is not approved for use with insulin although some physicians have done so with good results. If you are on insulin, discuss Symlin with your doctor instead. Symlin is copycat of another hormone produced by beta cells that has similar effects to Byetta.

    The above are focused on glycemic control, but only some will facilitate weight loss (insulin & sulfonylureas typically do not).

    A less commonly used option is Acarbose. This is a pill that blocks your gut from ever absorbing certain types of sugars. However, some pts have GI side effects and it also impairs your ability to recover from hypoglycemia b/c you cannot absorb sugars as well. This definitely has weight-loss benefits, especially b/c the GI effects are most prominent when you eat sugary foods, so it also works to discourage consumption of these types of food.

    Xenical (or its lower dose OTC version: Alli) work similarly, but these block GI absorption of certain types of fat. These will not really help with glucose control, but again it can have GI side effects, especially when you eat fatty foods. So again its side effects will discourage people from eating unhealthy fatty-rich foods.

    Those are most of the medical options available right now, though an exciting drug class in the pipeline will act on the kidney (SGLT2 inhibitor) but are still undergoing clinical trials. It will be several years still.

    My other suggestions are helpful strategies for diet and exercise.
    1)When you are hungry, try a tall glass of ice water first. This will stretch the stomach and reduce the sensations of hunger.
    2)Eat without distractions (no TV, radio or eating on the run) The satisfaction from eating has a psychological element as well. Watching your plate go from full to empty will leave your more satiated than if you ate the same amount while your mind is elsewhere.
    3) Eat in bright lights. People tend to eat more when lighting is dim (fancy restaurant strategy to make more money – maybe not just intimacy)
    4)There is some evidence that Chromium supplements may reduce “carb-craving” Many patients also swear that tagamet (an early heartburn med) is also effective at reducing their desire to snack; however, it must be used with caution b/c it can affect the function of other meds that are processed by the liver.

    5)Insulin resistance tends to be highest in the morning, so exercise in the morning is preferable

    6)Cardio exercise may be more common and easily accessible, but there is evidence that weight-lifting or resistance training will make your muscles gobble up more blood glucose for a longer period of time
    *So weight-lifting/resistance training in the morning may be the best.

    That is all I have in me for now. I hope you found my comments helpful

  • Yes, all of the posts have their bit of truth. and the conclusion is that there is no “cookie cutter” solution that would ecomapss all of the different types of Type 2 Diabetes witha single ultima result. Bodies differ in theri fucntions and the commentators have demosnstrated that each one follows what works best for their particular circumstances. Again, also different bodies have different parameters of working and what may work for one or a few does not necessarily trasnlates that it should work for all. I am a Type 2 and am on a 5 lb overweight and excersice 6 days out of 7 with a brisk walk of at least 40 minutes daily, more when I can depending on my work schedule (I am 65 and have had Type 2 for over 10 years plus Hypertension and tachicardia for over 20 years) So I try to learn how my body reacts, works best and gives me the best results to continue my daily life. I take advantage of having meaninful discussions with my physician regarding my diabetes control, and circulatory system. We have concluded that the goal, in my particular case, is finding the range of blood glucose where it does the most good for my overall health and the east harm to my circulatory system by excersicing in a sensible manner that would provide the best results within a set range. We have also concluded that we are not to get hung a number, rather a range which may vary as time passes, but the one thing we do strongly agree is on excersice that makes sense for both of us. Insulin for me is not a problem becuase it is one of the things I recognized early on that it would have an impact on my weight and I can attest that it has helped tremndoulsy to gan control of my diabetes without ruining my gastrointestinal system with pills and in turn ruining my kidney further more than that they have.
    Sorry for being long winded, I wanted to express some of my thoughts, albeit in a random manner.

  • David Spero RN

    Your 147 pound “Type 2” husband needs to get on insulin ASAP. He also needs to be tested for LADA and/or MODY. I very much doubt he is truly a type 2. See here for more info

    Good post Jan! Reading all these stories doesn’t increase my trust in doctors, that’s for sure! Anti-fat prejudice is rampant in medicine, as it is in society. I’ve written about this a lot.


  • Calgarydiabetic

    Dear Dabernethy.

    If you are insulin resistant and your pancreas is dead what would you suggest? Metformin is toxic to me. I would rather die than have bariatric surgery. Loosing weight on a high dosage of insulin is near if not totally impossible.

    I am trying meridia to suppress the uncontrollable hunger. Cutting carbs to the bone, cutting insulin and accepting much higher BG. Cutting calories and trying to exercise one hour per day at least. Any other thoughts?

  • Rob Kimes

    Like you, when I read this, I was livid. Stupidly, I had resisted taking insulin for 7 years as I had been told a great many years before (by someone as ignorant of the facts as I was), that taking insulin caused incurable erectile dysfunction. As a result, I went through years of dry mouth/excessive thirst/frequent urgent urination, blurred vision, hypersensitive feet (what happens before they go numb, early onset of gastroparesis and ketoacidosis. I learned the truth of the line, “never stand between a diabetic and the bathroom door.” Now, I have eye floaters, leaky blood vessels in both eyes, frequent bouts with cellulitis and dermatological irritations in my legs.

    I don’t particularly enjoy all the copays from the myriad of doctors and drugs I take. Then I hear that some buffoon named Dr. Unger probably thinks I’m doing the wrong thing by taking insulin shots at all. I’m sure that my blood pressure must be hitting the ceiling often.

    The last time I was in the hospital for cellulitis, I was on an 1800 calorie ADA diet for diabetics. Not once in that week was the hospital able to get my bgs below 238. It usually hung around 350+. A new Endocrinologist came in and decided I was getting too much insulin and cut my units in half. My readings immediately went to the 450 – 480 level. I was in and out of consciousness for 3 days. My PCP came back from attending a seminar and restored my insulin levels. It took 3 more days to come back down to usual levels.

    Now, as I prepare to go in the hospital once again with cellulitis from arthritis causing an ulcer on the outside of the bottom of my right foot, I’ll need to be extra vigilent to protect myself.

  • Fred

    I think this debate shows that we have some very gross (as in broad, high-level, unrefined) tools and don’t even fully understand how to use them. We are all exchanging anecdotal data to try to figure it out and make the tools work for ourselves. The medical research is conflicting and colored by opinion, bias and ego. We are not so good at understanding systemic things as we are and single-cause / single solution problems. I bet by the time we are done and fully understand this disease there will be a dozen or more types of diabetes and we’ll all have various combos of them. My favorite example is the idea of beta cells ‘wearing out’. Lets just admit we don’t know while we’re still trying to find out. And if there’s a theory of how something works that seems to be backed up by a small study or anecdotal information, lets recognize it for what it is, and isn’t, even thought we are all desperate for good answers. We can make better decisions about our care knowing what we don’t know rather than pretending based on an instinctive theory or something that sounds good and matches our particular view of the world. We should always remember stories like what happened with our understanding of how stomach ulcers work, but not use that as a reason to believe every counter-theory until there is real proof.

  • David

    This comment is in response to Kathy (Feb.25th).
    I agree that your husband must be tested for LADA immediately. I have starred in this movie that your husband seems to be going through.
    I am 57 years old and have been an active runner and bicycle racer most of my adult life. I am 5’8″ tall and always weighed between 140 and 150lbs.
    In January of 2005 I suddenly began to lose weight, urinate constantly, and was always thirsty. My doctor diagnosed me in 5 minutes as a type 2, and started me on metformin. I ate very carefully, continued to exercise, took the metformin…and was still losing weight. My glucose levels did come down for about six months but had to keep increasing the metformin until I reached the maximum dosage. After about a year I finally convinced my doctor to give me a c-peptide test. At .3 my level was far below the low-end of normal, and I weighed 128 lbs. I felt like I was slowly dying. He immediately started me on Lantus. Kathy, it was a dramatic change. I felt like a man in the desert who was handed a cold bottle of water.
    Today I weigh 148 lbs, feel just fine and my glucose is under control.
    BTW…my diabetes counselor diagnosed me as LADA the first day she met me…took my doctor a year to give me the tests…you sometimes have to insist.