DSI Newsletter: Insulin

DSI Newsletters, Issue 30:
Insulin: A Bad Hormone!

Insulin does more than just reduce blood sugar:

Promotes Fat Storage
Increases Salt & Water Retention
Increases Cholesterol Production
Burns the arterial wall similar to cigarettes and promotes arteriosclerosis (hardening of the arteries)
Weight Gain

So, the goal in diabetes is to have a normal blood sugar with the least amount of insulin as possible. The SU (sulfonylurea) type of diabetes drugs (Glucotrol, Glipizide) actually increase insulin production thereby promoting the five bad things listed above by raising pancreatic insulin production and placing the patient at risk for a hypoglycemic (low sugar) attack. High risk hypoglycemia.
The Meglitinides like Prandin (repaglinide) and the D-Phenylalanine derivatives like Starlix (nateglinide) make less insulin for less time thus exposing your arteries to less of the deleterious effects of insulin. Small risk hypoglycemia.
The Alpha-Glucosidase inhibitors like Glyset slow down absorption of sugars from the gut causing some of the calories from carbohydrate to go thru you unabsorbed (as if you did not eat it in the first place). Their main side effect is diarrhea. No risk hypoglycemia.
XENICAL (orlistat) works in your digestive system to block about one-third of the fat in the food you eat from being digested. Enzymes in your digestive system, called lipases, help digest (or break down) fat. When taken with meals, XENICAL attaches to the lipases and blocks them from breaking down some of the fat you have eaten. The undigested fat cannot be absorbed and is eliminated in your bowel movements. By working this way, XENICAL helps block about one-third of the fat in the foods you eat from being absorbed by your body. It promotes weight loss, lowering sugar without raising the insulin level. Its main side effect is diarrhea. No risk hypoglycemia.
The biguanides like metformin, Glucophage and Glucophage XR decrease glucose release from the liver (diminish hepatic glucose production via gluconeogenesis). So, they lower sugar without raising insulin and cause weight loss. No risk hypoglycemia. Their main side effect is diarrhea.
The TZDs (thiazolidinediones or glitazones) like Actos (pioglitazone) and Avandia (rosiglitazone) increase glucose uptake by fat and muscle cells. Lower sugar without raising insulin. Favorable effects on cholesterol. No risk of hypoglycemia. Promotes weight gain.
In summary, in type 2 diabetes, the corner stone to treatment is weight loss. As the fat cells enlarge, the insulin receptors on their surface are stretched further apart causing insulin resistance. As weight loss occurs, the receptors become closer together (denser) thus reversing the diabetic process.
When weight loss is not enough, diabetes medicines can help control sugar levels. The SUs lower sugar by raising insulin and causing weight gain. When possible, it is desirable to choose an agent that doesn't worsen weight gain or produce hyperinsulinemia.

Joseph Saponaro, MD, DABIM, FACP, CPI, CCI, CCRI, CCRC, CCRP
Board Certified Internist, JPMC
Principal Investigator, DSI
Diplomat American Board of Internal Medicine
Fellow American College of Physicians
Certified Physician Investigator by the AAPP
Certified Clinical Investigator by the DIA
Certified Clinical Research Investigator by the ACRP
Certified Clinical Research Coordinator by the ACRP
Certified Clinical Research Professional by SoCRA
Member: The American College of Preventive Medicine

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