Why Insulin, Not Glucose, Matters Most for Type 2 Diabetes

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“Giving insulin to a patient with Type 2 diabetes is similar to giving an alcoholic another glass of wine and hoping that will solve the problem.”

Dr. Benjamin Bikman made this forceful comparison during the second annual Metabolix conference. The conference is online this year, but is otherwise based in Israel; it is dedicated to fixing global metabolic health.

Benjamin Bikman
Dr. Benjamin Bikman

Dr. Bikman is a widely recognized expert on insulin resistance. He is a professor of Physiology & Developmental Biology at Brigham Young University. His talk at Metabolix 2021—“Flipping the Switch: From Insulin Resistance to Diabetes”—discussed the precise changes that occur during the transition from mere insulin resistance and pre-diabetes to fully fledged Type 2 diabetes.

He is not the first expert to question the use of exogenous insulin in patients with T2D—Dr. Mariela Glandt, an ASweetLife contributor and one of the organizers of the Metabolix conference, has raised similar questions. Dr. Bikman’s stature in the field, and the boldness of his delivery, make his claim especially notable.

 

The Glucocentric Paradigm

Dr. Bikman described Type 2 diabetes as “a disease of insulin resistance” that is unfortunately defined and diagnosed by measuring blood glucose instead of insulin resistance itself. As a result, the entire condition is typically viewed through a “glucocentric paradigm,” an erroneous perspective that has unfortunate consequences for the millions of people living with it.

“The problem is that the true lethality of diabetes is not based on the glucose. I’m not saying the glucose isn’t relevant… But the true killers are really derivative of insulin.”

Insulin resistance, the fundamental root cause of Type 2 diabetes, is less frequently considered than blood glucose. Blood sugar is quick and easy to measure, and is almost universally used to evaluate the progression of the disease and the effectiveness of its treatment. Many doctors therefore incorrectly target reductions in blood glucose as the ultimate goal of therapy, and prioritize a lower glucose “at any cost.” By far the most powerful glucose-lowering remedy is insulin. Inevitably, doctors end up “increasing insulin to superphysiological levels,” which will lower glucose in the short term, but significantly exacerbate the fundamental dysfunction that led to diabetes in the first place.

“Insulin therapy in a diabetic makes insulin resistance worse. When we give a patient with Type 2 diabetes insulin, we are making them fatter and sicker than they were before.”

 

Insulin Resistance & Pre-Diabetes 

Unfortunately, the glucocentric paradigm has consequences in the very first stages of the progression of Type 2 diabetes: “our failure to measure insulin itself means that we fail to detect insulin resistance in its earliest stages.”

Type 2 diabetes is ultimately diagnosed after glucose levels have become persistently elevated. This may be the first moment that a doctor notices a patient’s metabolic issues, but in fact rising blood glucose is only one of the later stages of a long disease progression. The average patient newly diagnosed with T2D has probably already been suffering from growing insulin resistance, and its cascading effects, for years.

Even before a person has identifiable pre-diabetes, they may have higher insulin levels than normal, a condition that is almost never identified during a routine checkup. While at this early stage the body is able to make extra insulin to compensate for insulin resistance, those elevated insulin levels will simply accelerate the decline of insulin sensitivity. “Any incessant stimulus to a cell will result in resistance to that stimulus.”

Dr. Bikman contends that insulin resistance starts in the fat cells. Insulin-resistant fat cells become enlarged and overstuffed, and begin to leak cytokines and other inflammatory substances throughout the body. Insulin resistance spreads. By the time that blood glucose levels have started to rise, “insulin resistance has spilled into three other tissues: the muscle, liver and pancreas.”

When these new tissues begin to develop insulin resistance, the disease progression really snowballs. The muscles, “the main consumer of glucose,” lose their ability to take up glucose in the bloodstream. The liver, which typically stores glucose in the form of glycogen, begins to do the very opposite, releasing glycogen when it’s not needed. And in the pancreas, when Alpha cells become insulin resistant, they release another form of stored glucose, glucagon. All of these dysfunctions have the same effect: to raise blood glucose.

This summary barely scratches the surface of what’s going on. “Literally every cell has an insulin receptor,” and a great many more than the tissues mentioned above will begin to malfunction when touched by insulin resistance. The bottom line, in Dr. Bikman’s view, is that the primary cause of Type 2 diabetes—the one necessary condition that sets off this long and incredibly complicated chain reaction—is heightened levels of insulin.

 

How to Fix Insulin Resistance

“I strongly believe that the best way to lower insulin resistance is to lower insulin itself.”

Dr. Bikman advocates for the use of a low-carbohydrate diet to naturally lower the levels of insulin in the body. Carbohydrates are by far the one stimulus that most reliably and dramatically sparks insulin production. Eating fewer carbohydrates simply and immediately reduces insulin levels throughout the body.

He shared the results of several studies pitting low-carb diets against traditional low-fat or calorie restricted diets. In these experiments, the low-carb diet resulted in marvelous improvements in both fasting insulin level and insulin resistance. The low-fat diet showed no such success, and sometimes quite the opposite: “We’ve known for 30+ years that the conventional dietary advice for diabetics may make the situation worse.”

Dr. Bikman is doubtful about the use of pharmaceuticals for Type 2 diabetes: “We should never look to a drug to solve insulin resistance or Type 2 diabetes, in my mind.” Metformin and low-dose anti-inflammatory pills (such as aspirin) can help with Type 2 diabetes, as well, but “metformin is only half as effective as even modest lifestyle strategies.”

We were lucky enough to interview Dr. Bikman last year upon the release of his book, Why We Get Sick, and can recommend his book for more detail on how insulin resistance affects our health, and how to avoid it.

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