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In a sense, you could look at my insulin shot before eating only the protein portion of the meal as mimicking the nondiabetic's phase II response. This is much easier to accomplish than trying to mimic phase I, because of the much lower levels of dietary carbohydrate and injected insulin.

The Type II Diabetic
Let's say Jim, a Type II diabetic, is 6 feet tall and weighs 300 pounds, much of which is centered around his midsection. Remember, at least 80 percent of Type II diabetics are obese. If Jim weighed only 150 pounds, he might well be nondiabetic, but because he's insulin-resistant, Jim's body no longer produces enough excess insulin to keep his blood sugar levels normal.

The obese tend to be insulin-resistant as a group, a condition that's not only hereditary but also directly related to the ratio of visceral fat to lean body mass (muscle). The higher this ratio, the more insulin-resistant a person will be. Whether or not an obese individual is diabetic, his weight, intake of carbohydrates, and insulin resistance all tend to make him produce considerably more insulin than a slender person of similar age and height (see Figure 1-3). Many athletes, because of their low fat mass and high percentage of muscle, tend as a group to require and make low levels of insulin. An obese Type II diabetic like Jim, on the other hand, typically makes two to three times as much insulin as the slender nondiabetic. In Jim's case, from many years of having to overcompensate, his pancreas has partially burned out, and despite the huge output of insulin, he no longer can keep his blood sugars within normal ranges. (In my medical practice, a number of patients come to me for treatment of their obesity, not diabetes. However, on examination, most of these very obese "nondiabetics" have slight elevations of their test for average blood sugar.)

Let's take another look at that mixed breakfast and see how it affects a Type II diabetic. Jim has the same toast and jelly and juice and boiled egg that Jane, our nondiabetic, and I had. Jim's blood sugar levels at waking are normal.* Since he has a bigger appetite than either Jane or I, he has two glasses of juice, four pieces of toast, and two eggs. As soon as the toast and juice hit his mouth, his blood sugar level begins to rise. Unlike mine, Jim's pancreas releases insulin, but he has very little or no stored insulin (his pancreas works hard just to keep up his basal insulin level), so he has impaired phase I secretion. His phase II insulin response, however, may be intact. So very slowly, his pancreas will struggle to produce enough insulin to bring his blood sugar down toward the normal range. Eventually it may get there, but not until hours after his meal, and hours after his body has been exposed to high blood sugars. Insulin is not only the major fat-building hormone, it also serves to stimulate the center in the brain responsible for feeding behavior. Thus, in all likelihood, Jim may well grow even more obese, as demonstrated by the cycle illustrated in Figure 1-1.

Since he's resistant to insulin, his body has to work that much harder to metabolize the carbohydrate he consumes. Because of insulin's fat-building properties, his body stores away some of his blood sugar as fat and glycogen; but his blood sugar level continues to rise, since his cells are unable to utilize adequate amounts. Jim, therefore, still feels hungry. As he eats more, his beta cells work harder to produce more insulin. The excess insulin and the "hungry" cells in his brain prompt him to want yet more food. He has just one more piece of toast with a little more jelly on it, hoping that it will be enough to get him through until lunch. Meanwhile, his blood sugar goes even higher, his beta cells work harder, and perhaps some of them burn out. Even after all this food, he still may feel many of the symptoms of hunger. His blood sugar, however, will probably not go as high as mine would if I took no insulin. In addition, his phase II insulin response could even bring his blood sugar down to normal after many hours without more food.

Postprandial blood sugar levels that I would call unacceptably high—140 mg/dl, or even 200 mg/dl—may be considered by other doctors to be unworthy of treatment because the patient still produces adequate insulin to bring them periodically down to normal, or "acceptable," ranges. If Jim, our Type II diabetic, had received intensive medical intervention before the beta cells of his pancreas began to burn out, he would have slimmed down, brought his blood sugars into line, and eased the burden on his pancreas. He might even have "cured" his diabetes by slimming down, as I've seen in several patients. But many doctors might decide such "mildly" abnormal blood sugars are only impaired glucose tolerance (IGT), and do little more than "watch" them. Again, it's my belief that aggressive treatment at an early stage can save most patients considerable lost time and personal agony by preventing complications that will occur if blood sugar levels are left unchecked. Such intervention can make subsequent treatment of what remains—a mild disease—elegantly simple.

On the Horizon

The catch here for me and other diabetics who no longer have any insulin-producing capacity is that the cells from which new beta cells would be cloned have to be your own, and I have none. Had I gone on insulin, say, a year before I was diagnosed with diabetes, or had my blood sugars been immaculately controlled immediately upon diagnosis, the injected insulin might have taken much of the strain off my remaining beta cells and allowed them to survive.

Many people (including the parents of diabetic children) view having to use insulin as a last straw, a final admission that they are (or their child is) a diabetic and seriously ill. Therefore they will try anything else—including things that will burn out their remaining beta cells—before using insulin. Many people in our culture have the notion that you cannot be well if you are using medication. This is nonsense, but some patients are so convinced that they must do things the "natural" way that I practically have to beg them to use insulin. In reality, nothing could be more natural. Diabetics who still have beta cell function left may well be carrying their own cure around with them—provided they don't burn it out with high blood sugars and the refusal to use insulin.

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