Wil DuboisWho doesn't sometimes need a little help navigating life with diabetes? That's why we offer Ask D'Mine, our weekly advice column, hosted by longtime type 1 and diabetes author Wil Dubois.

This week, Wil's addressing the ever-daunting issue of insulin for those who've been diagnosed with type 2 diabetes but are nervous about starting on this particular medication even as blood glucose levels and A1C results creep higher.

{Got D-related questions of your own? Email us at AskDMine@diabetesmine.com}

 

David, type 2 from Arizona, writes: Hi. I have had type 2 diabetes for some five years. I’ve lost 40 pounds and weigh in at a healthy 155 lbs. I’m quite careful about my diet, except for occasional pieces of toast with breakfast, or a small bowl of cereal, or hummus on crackers, or some rice. I try to keep portions of carb-heavy foods small. I take Metformin, Tradjenta, and Glimeperide. My A1Cs have been: 7.0, 7.5, 6.9, 6.5, 6.9 recently. However, my glucose levels have been rising. The “forbidden” foods in small quantities that created readings of 180 two hours post-prandial now push me into the low 200s. My blood glucose readings range between a fasting glucose of 135 and a top number of 220. I had one reading of 270 not long ago. My doctor says I could be ready to begin insulin. Should I wait until the A1Cs are higher? Any advice? Thanks. 


Ask D'Mine 

Wil@Ask D’Mine answers: In nautical days of old, lookouts perched high on ship’s masts and scanned the distant horizon. A whaler’s lookout would shout, “Thar she blows!” when prey was spotted. An explorer’s lookout might shout, “Land ho!” after weeks or months at sea with nothing to cast his eye upon but water, water, water. And once, infamously, a lookout shouted “Iceberg! Dead ahead!”

Your doc is the lookout.

But you are the captain.

So what you do with the knowledge that there’s something off your bow is up to you, and it partly depends on your goals and personality. I’d say that right now your lookout is pretty sharp-eyed and you’ve got some options.

To extend our watery analogy, you sure as hell don’t want to wait to start insulin until there’s an iceberg or other complication dead ahead, although many people do exactly that with predictably tragic consequences. But beyond that, you have two fundamental choices: Do you want to be the explorer who slowly works his way toward a new frontier? Or do you want to be the hunter who’s going to chase down the diabetes monster, drag it from the deep, and slay it?

Now, before we either get out our compasses, or sharpen our harpoons, I want to make sure everyone understands what we’re up against when it comes to type 2 and insulin. The cold, hard fact is this: Every type 2 who lives long enough will require insulin to stay healthy. Period. End of sentence. Type 2 is a progressive disease. It gets worse every day all on its own, no matter what you are doing. At some point the insulin resistance will get so high, and the insulin production will get so low, that taking insulin is the only solution to avoid complications, and ultimately, death.

In a perfect world, instead of fearing insulin, starting it would be celebrated as a badge of honor: I lived long enough with this bitch to earn insulin! Oh yeah! But, as I’ve noted a time or two before, we aren’t living in a perfect world. Far from it.

In a perfect world, instead of fearing insulin, starting it would be celebrated as a badge of honor.
Wil Dubois of Ask D'Mine

Of course, smart diabetes and lifestyle management can push the need for insulin downstream for, in some cases, decades. In fact, you yourself have done a really amazing job over the last five years, what with the weight loss and the careful eating. You should be damn proud of yourself. Heck, I’m proud of you, just from reading your letter. Now, as you say, your A1Cs are basically fine; but you are wise in knowing that they are only part of the larger picture.

It’s a whale of a tale, but it’s all true: Back in 2004, Drs. Irl Hirsch and Michael Brownlee took the first serious look at why many times people with equalivalent A1Cs had unequal health outcomes. How could one person with an A1C of 6.5 be doing great, and another person with an A1C of 6.3 be doing worse? They knew there must be more to complications than average blood sugar. But what was it? At the time, it was generally believed that so long as your A1C was to target, it was, “Mission Accomplished.”

But now, of course, we all know that you have to be careful what banner you stand under on the deck of a ship.

Anyway, back to Hirsch and Brownlee. They suspected, or in their words, their “speculative explanation” was that “hyperglycemia-induced oxidative stress” was the “chief underling mechanism of glucose-mediated vascular damage.” In other words: Blood sugar spikes kill. But at the time, they had no real way to prove it.

Lucky for them, and us, it was the dawn of the age of Continuous Glucose Monitoring (CGM), a new technology that is letting us understand blood glucose like never before. And a mere two years later, not only were they proven right, but research showed that sugar spikes are actually more dangerous than chronically high sugar.

All of that said, your spikes aren’t exactly horrible, which is why I say that you can choose if you want to be a hunter or an explorer. If you want to be proactive and keep diabetes from getting even the smallest of footholds in your body (when it comes to damage) then now might be the time to start insulin, before it becomes fully necessary, and perhaps damaging. But if insulin freaks you out for some reason—and if so please write in again so we can examine that with you—then you can get more aggressive with minimizing the forbidden foods, and I suspect you can keep sailing for another few years without running aground.

 

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

 

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

Disclaimer

This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.