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Sebastian Rushworth MD: “Is insulin life-saving for type 2 diabetics?”

re: diabetes
re: Sebastian Rushworth MD
re: Is the cholesterol hypothesis dead?

This is the kind of reasoning I like to see when discussing whether a medical intervention is justified.

Sebastian Rushworth MD: “Is insulin life-saving for type 2 diabetics?”

2022-02-19. By Sebastian Rushworth MD. Emphasis added.

There are two diseases that share the name “diabetes mellitus”. This is unfortunate, because the diseases have very little in common, except for the fact that both are associated with high levels of glucose in the blood stream. Type 1 diabetes is an auto-immune disease, in which the immune system destroys the insulin producing cells that reside in the pancreas. Type 1 diabetics quickly die if they aren’t treated with insulin. For them, it is immediately and dramatically life saving.

Type 2 diabetes is a lifestyle disease, caused by excessive consumption of refined carbohydrates. This results in metabolic dysfunction and “insulin resistance” (a state in which muscle cells and fat cells stop responding normally to insulin, which causes glucose levels to rise in the blood stream). While type 1 diabetics literally produce no insulin, type 2 diabetics produce plenty of insulin.

So, when a person with type 1 diabetes takes insulin, they are replacing a substance that they are lacking, and which they need to survive. When a person with type 2 diabetes takes insulin, they are taking more of a substance that they’re already producing a ton of. There is no immediate survival benefit.

So why would anyone ever come up with the idea of giving insulin to people with type 2 diabetes, who already produce lots of insulin? ...The extra insulin helps to lower the blood sugar. But does that actually matter?

Blood sugar is a surrogate marker, just like blood pressure and LDL-cholesterol. What really matters to people is whether they have a decreased risk of bad outcomes, like strokes and heart attacks, not what their specific blood sugar level happens to be. It has been assumed that the harms associated with type 2 diabetes are primarily due to the high blood sugar levels. Which is a reasonable hypothesis, but it needs to be tested. 

We don’t care about lowering blood sugar if there is no beneficial effect on survival, or heart disease risk, or risk of blindness, or something else that patients actually care about. Additionally, lowering blood sugar with insulin isn’t a harm-free intervention...

...

...An even bigger trial was published in the New England Journal of Medicine in 2012. 12,537 people over the age of 50 with type 2 diabetes or pre-diabetes and cardiovascular risk factors were randomized to receive either long-acting insulin plus “standard care” or just standard care on its own... no difference between the groups in terms of mortality, heart disease risk, stroke risk, amputation risk, or microvascular disease risk. Basically, six years of treatment with insulin provided no beneficial effect whatsoever, even though this was an older group at particularly high risk of cardiovascular complications.

What can we conclude?

The evidence that exists really doesn’t support treating type 2 diabetics with insulin. It’s questionable if insulin provides any benefit whatsoever, and if it does, then the benefit is tiny and easily outweighed by the harms. As I’ve discussed previously on this blog, type 2 diabetes can be effectively treated with a carbohydrate restricted diet. In fact, a carbohydrate restricted diet is by far the most effective treatment in existence when it comes to type 2 diabetes, and can often reverse the disease completely. That is where physicians should focus their efforts.

WIND: lots of expense based on guessing for no benefit and to maybe buy yourself other problems? That’s assembly line medicine at work. Treatment approaches for everything are driven by profit motives. That’s all you really need to know. Of course some treatments for some things have benefits, but that doesn’t mean you get the best treatment, or that the treatment nets-out as a benefit.

The comments on the surrogate markers blood pressure and LDL cholesterol are spot-on. Tens of millions of people in the US pop statins like candy and most are almost certainly netting out harm to themselves, with exceedingly few getting any benefit of any kind—but they do get a reduction in the surrogate marker of LDL cholesterol! Were it not so unscientifically absurd, it would be funny. But it’s deadly seriously unfunny.

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