by Wesley W. Wilson, M.D.
Includes Art: Medical Caduceus
NOTE: If you have any questions for "Ask the Doctor," please send them to the Voice editorial office. The only questions Dr. Wilson will be able to answer are the ones used in this column.
Wesley W. Wilson, M.D. has retired as an Internal Medicine practitioner at the Western Montana Clinic in Missoula, Montana. Dr. Wilson was diagnosed with type 1 diabetes in 1956, during his second year of medical school. He remains interested and involved in diabetes education for patients and professionals.
Question: I'm 67-years-old, and have been type 2 for more than 30 years. My diabetes educator suggests that it might be time for me to consider using some insulin at night. He says oral diabetes medications eventually fail, and he thinks I'm getting close to that point. Why would the pills I've taken for years now need to be replaced? How do I determine whether or not I need to start injecting insulin?
Answer: Type 2 diabetes is a complex disease and questions as to its cause, its course, and the best treatment remain. Despite these uncertainties, some parts of the "type 2 puzzle" are clear. Persons who are likely to develop type 2 diabetes show "insulin resistance," that is they require more than the normal amount of insulin. It's interesting that persons with risk factors for type 2 disease such as family history of type 2 and who are overweight have higher than normal levels of blood insulin. This insulin resistance puts an increased work load on the beta cells of the pancreas, which may eventually stop working. Type 2 diabetes then, seems to result from the combination of insulin resistance and a decreased ability to produce insulin. When that occurs, blood sugar rises, and that's what we call type 2 diabetes.
Big American and Danish studies have recently shown that modest reduction in diet, and modest exercise, in persons who are at high risk of diabetes, can cut the rate of diabetes by 50%. Even though genetic factors are important, our life style has a lot to do with development of type 2 disease. Exercise and weight loss reduce insulin resistance and sometimes seem able to revive the beta cells of the pancreas, or at least give them a rest.
During my years of practice, it was great to see someone with newly found diabetes and high blood sugars, drop the sugar into the "normal" range by just following their diet plan and starting a regular daily exercise program - something as simple as 30 minutes of walking daily.
Several studies, especially the United Kingdom Prospective Diabetes Study (UKPDS), have now conclusively shown that elevated blood sugar is associated with development of microvascular complications. These complications are the cause of eye, kidney and nerve problems so frequently seen in persons with diabetes. More importantly, there is now proof that reduction of blood sugar is able to prevent or delay or slow down progression of these complications. Another finding in the UKPDS was that with passage of time, type 2 diabetes is harder to control, requiring more medicine. This is probably due to the progressive failure of the beta cells--and is probably what your diabetes educator is alluding to--and sometimes the end result of this failure is the need for insulin injections.
Type 2 diabetes is not a stable disease, and therefore we must follow it and make adjustments as things change. This can mean adjusting lifestyle, adjusting medications, or even starting to use some insulin--it depends on your circumstances.
I'd advise you to be aware of your blood sugars and Hemoglobin A1c (HbA1c) and although it's easy for any of us to get in a groove, especially after 30 years, and think about the foundation of our treatment of type 2 diabetes. Can you get in some walking, gardening, or golf every day? Can your diet be "tuned up," and could you lose a little weight? Sometimes those things can make a big difference. The target should be to keep the sugar as near normal and the HbA1c below 7%. If it takes insulin to do that, it's worth the effort to stay healthy.