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A Battle For Control

October 26, 2009|Marni Jameson

Simply put, diabetes is a contest between people and their blood. For people whose bodies don't produce enough insulin to manage their blood sugar, the goal is a normal blood score, achieved through a balancing act of lifestyle and medication.

"Eventually most patients will follow a course of lifestyle, medications, then insulin," said Dr. Enrico Cagliero, referring to people diagnosed with the most common form of diabetes, known as Type 2. He's an endocrinologist at Massachusetts General Hospital and associate professor of medicine at Harvard Medical School. "Overall about 30% of all diabetics are on insulin, but, given the progressive nature of the disease, close to 60% can expect to be on it eventually."

To buck that trend, some of these diabetics, with the help of physicians who share their mission, are adopting rigorous diet and exercise regimens to get off insulin, or never have to go on it. Unlike Type 1 diabetics, who have no choice but to take insulin, Type 2 diabetics still produce some of the hormone -- and more than a few are determined to make the most of it.

Dr. Wei-An "Andy" Lee, an endocrinologist and assistant professor at USC's Keck School of Medicine, is a firm supporter of this approach. He's among a handful of physicians using radical lifestyle changes to get insulin-dependent patients off insulin.

"I wish more doctors and patients would not assume insulin injections are their only option," he said. "I don't see why more don't give lifestyle a try. It's better for the patient, costs less than medications or surgery, and is better for the country."

Newer non-insulin medications, specifically ones that boost incretins (hormones found in the digestive tract), along with strict diets can help patients actually reverse their disease and ditch the insulin, he says. Lee presented two such case studies to the Endocrine Society in Washington, D.C., last summer, and points to dozens of individual success stories.

He prescribes incretin medications and a very low-calorie diet (600 to 800 calories a day). Once off insulin and stabilized, patients can maintain normal blood levels through lifestyle alone, he says: a low-calorie diet (1,000 to 1,200 calories a day), weight loss, moderate daily exercise and regular eating and sleeping schedules.

Other doctors say this approach misses the point.

They agree that controlling blood sugar is crucial. Not doing so can lead to blindness, kidney failure, loss of limbs, heart disease and stroke. And they agree that lifestyle changes are the first and best line of defense against Type 2 diabetes.

But avoiding or getting off insulin shouldn't be the focus, said Dr. David Nathan, director of the diabetes center at Massachusetts General Hospital, and editor of the Harvard Medical School Special Health Report on Type 2 diabetes. Maintaining glucose levels that in the long-term will prevent kidney and eye disease should be the focus instead, he insists. "If you can achieve good numbers without medication, you have my blessing," Nathan says. "But if you need insulin, you'll be much healthier with it than without it."

Still, many patients don't want to be on insulin. Apart from being inconvenient, the drug contributes to weight gain, which exacerbates diabetes. Patients have a lot of psychological resistance to insulin, Cagliero adds. "Doctors sometimes use insulin as a scare tactic and tell patients that if they don't lose weight and get their lifestyles under control, they will have to go on insulin. So people associate insulin with guilt," he says. "They feel like a failure, as if they didn't do their job."

Lee's approach "is a little on the odd side," he says. "I worry that these people will have wonderful reversals initially, then slide back and feel like failures."

Further, controlling diabetes, even with insulin and even for the most committed patient, can be difficult.

Richard Jackson, an endocrinologist, founder and medical director of the Joslin Diabetes Center's Outpatient Intensive Treatment program and an assistant professor of medicine at Harvard Medical School, puts it more vehemently and bluntly:

"Telling people who have diabetes that their goal is to get off medications is the dumbest thing you can do. Putting patients on a low-calorie diet is among the least successful approaches for the long term. It's not a new idea. You can take almost anyone with Type 2 diabetes and fast them, and in one day they will have a normal blood sugar. The goal shouldn't be to get people with Type 2 diabetes off medications, but to get their [glucose] and other numbers, specifically blood pressure and blood lipids, in a healthy range. Our goal is to help people live a long healthy life, not a life with the fewest medications."

What no one disputes is the positive effect of a controlled diet, weight loss and regular exercise on diabetes.

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