Ask D’Mine: Treating a Diabetic “Junkie,” and Considering “Insulinotropic” Foods

Need help navigating life with diabetes?  Ask D’Mine! That would be our weekly advice column, hosted by veteran type 1, diabetes author and community educator Wil Dubois. This week, Wil takes on the issues of doctors seeing “junkies” rather than patients struggling with addiction, and the insulinotropic effect of certain foods on PWDs.

{Got your own questions? Email us at AskDMine@diabetesmine.com}

Anonymous from Alabama, type 2, writes: I was diagnosed 5 months ago with type 2 diabetes. I assume I’ve had it for a few years, but I have no insurance and didn’t realize how dangerous it really is. I’m now reading a lot more and I’m terrified. My feet and hands are numb most days. Fatigue is a mild word. I finally got in a community free clinic and I’m on 2000 mg metformin a day and was on 15 units of Lantus. I had to stop taking Lantus because it seemed to be making me have withdrawals from the methadone I’ve been on for five years. Extreme diet change has lowered my numbers a lot, but the doctor seems to be not as concerned as I am, and this really bothers me. And I can’t seem to get much info about the methadone and the insulin. Any info you could give, or where or what to do next, or any insight into my situation? Thanks, I’m worried.

Wil@Ask D’Mine answers: It’s OK to be worried. Fear can be a healthy emotion, so long as it doesn’t rule the day. And, hey, I’m proud of you. You got yourself into a clinic—better late than never—you’ve made extreme diet changes, you’re reading up on your diabetes and you’re asking questions!

As to your doctor, well, I’m not so proud of him. I think you might have gotten one of the bad ones. Most docs at free clinics are pretty awesome people who are drawn to helping people in the greatest need. Let’s face it, no doc works at a free clinic for the money—this kind of work is among the lowest-paying in medicine.

That said, and there’s no delicate way to say this, so bear with me… I think he might see something different when he looks at you than what I see. I’ll go first. When I look at you (well, at your email—but I can “see” a great deal in the words people place on a page), I see someone who’s had a pretty hard road. I see someone who’s suffering a great deal, but trying to improve her lot in life. I see a fellow PWD. Hell, I just see a fellow human being.

And that’s good enough for me.

Your doc, however, sees something else. He looks at you and sees a junkie. Long-term use of methadone is sometimes used to treat chronic pain, but is usually used to treat opiate addictions. A methadone prescription is a red flag. In fact, just like your doc, I’m actually going to assume that’s why you are taking it; but unlike your doc, I’m not going to judge you for it. For some reason, some really great docs get hung up over drug use and, like the Grinch, their hearts suddenly shrink. I’ve seen some pretty open-minded providers act really strangely around IV drug users. So when I read your email I found myself wondering if your doc was really listening to you or if he’d gotten hung up over your past with his brain stuck in a stupid loop about “so she had money for heroin, but couldn’t be bothered to pay for her health care, I’m not going to waste my time…”

That’s #@$%& BS! I say to your doctor: If you can’t accept everyone, regardless of their faults, as worthy of the same treatment, then you don’t belong in medicine. The door is over there. Please leave, we have enough real challenges to solve without those kinds of attitudes. I’m sure you’ll do just fine in politics.

So I spent most of my spare time the last few weeks trying to see what’s known and not known about methadone and Lantus. The answer: not much.

In fact, about all I could find were two reports of photosensitivity in women over 50; and one report of “chills” in a 60-year-old man. Now chills might sound a bit like your “withdrawals.” And if it happened to one other person, it sure as hell could have happened to you, too.

The solution? Well, based on my field experience, I’ve found the various insulins we have to play with are a lot more different than apples and oranges. We tend to think of Lantus and Levemir like we think of Tide and Cheer: hey, the brands are different, but they both clean your clothes. And while it’s true that the glucose response profile of the two basal insulins is pretty much the same, they couldn’t be made any more differently. Hell, they aren’t apples and oranges so much as watermelons and papayas. People who have some sort of oddball trouble with one often do fine on the other. And don’t forget we have the old-fashioned NPH as an option, too.

My advice? Go back to your clinic, but ask to see another provider. Look the white coat straight in the eye and be honest about your past and passionate about your future. Be clear about your here-and-now fears. Then ask to try a different insulin, and see if it plays better with your methadone.

Oh, and don’t vote for your old doc if you see he is running for Congress.

Paul from Georgia, type 1, writes: I have recently read about foods like milk and wheat causing increased secretion of insulin (insulinotropic effect) above the insulin needed for the carbs in the food. This fact is used to conclude that products containing these ingredients be used sparingly, if at all, in an attempt to prevent obesity and type 2 diabetes. The reason being that these foods cause an overproduction of insulin that leads to storage of excessive carbs as fat.  My question is as a type 1 with a negative c-peptide is: will eating these foods have the same effect? My guess is unless they cause a glucose rise above the carb content that I gave a bolus for, there will be no extra insulin unless I give extra insulin.

Wil@Ask D’Mine answers: Well, first off, you and I must be reading different journals, because I haven’t seen nor could I find anyone worrying about insulinotropic foods causing weight gain. In fact, just the opposite may be true—they’re being heralded as the next great thing in diabetes treatment, and some people think they may even help prevent obesity.

But let’s back up and give all our readers some background. Then we’ll dissect the issue you read about a little more and I’ll take a crack at your question. As you said, insulinotropic is just a fancy-pants cocktail party word for something that causes insulin production. And it’s been a known mystery for a number of years that different proteins have different “insulinotropic properties,” meaning that they trigger insulin production independent of their glycemic index; the exact opposite of what logic would suggest. WTF?

Back in 2004, a team of Swedish researchers singled out milk as being the most unusual in this regard. After much study the smoking gun was proven to be whey protein, which makes up around 20% of milk’s protein (but a whopping 60% of the protein in human breast milk, “food” for thought). Why whey kicks the body in the pancreas more than you’d expect, given its carb count, remains a mystery to this day.

But, but, but: just because it induces the body to produce more insulin than the glycemic index would suggest, doesn’t mean it’s making your body produce more insulin than it needs. In fact, the extra squirt of insulin from whey has been shown to greatly reduce blood sugar spikes after meals. So much so, that mixing whey into high carb meals has been shown to have a medicinal effect in type 2s. In other words, a natural insulin secretagogue. (One study added whey to a meal of mashed potato and Swedish meatballs, which I find ironic given the original whey discovery came from Swedish researchers.)

Over the last few years, there has been much ongoing research that, quoting another study, “dietary interventions represent a promising therapeutic strategy to optimize postprandial glycemica.” Whey as medicine for all that ails you.

In a stretch, I suppose I could see your point about extra insulin moving the carbs into fat storage, but leaving the extra carbs in the blood moves the type 2 into the dialysis center. I don’t think these foods are likely to cause greater weight gain because of the extra insulin, nor do I think type 2s should avoid them only out of fear of weight gain. I think anyone who is worried about weight should focus more on eating less, and less on what they are eating. And just to muddy the waters, I’m seeing a lot of research actually supporting whey as an anti-obesity agent, rather than a trigger for weight gain. This has led to whey becoming a popular food supplement, especially for the for body building crowd. It’s seen as agent of muscle growth and fat reduction, but like many food supplements, we are lacking in solid science behind this particular claim.

But as to you, my insulin-deficient friend, you’re right. An insulinotropic food will not bring your dead beta cells back to life. An insulinotropic substance needs an insulin-producing body to act on.

However, your question raises another: If the “normally” functioning human body produces more insulin for whey than you’d expect it to need… why is that? Frankly, the body tends to know what it’s doing. Even though the glycemic index of foods with whey shouldn’t demand more insulin, the body provides it, and apparently with good results.

Maybe we should all consider a whey bolus.

Disclaimer: 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.