Re: Re: Insulin and mortality

[Guest guest]

Like I said before, these studies generally seem to be designed to

promote a particular point of view. I don't trust 'em. Next week or

next year there'll be a counter point to this one.

CarolR

[Guest guest]

Do you know what kind of insulin was used? Regular or synthetic? I think

studies like this where they take people with preexsisting conditions and

come to the conclusions that it was the insulin that made them sick is silly

Marla

[Guest guest]

I thought that diabetes sufferers were at more risk from heart

conditions anyway, due to the diabetes.

So that almost sounds as though because we are more likely to have a

heart attack that you are advocating changing from insulin to some other

form of drug therapy.

Not much good if you can't survive without insulin in the first place -

depends how far the DM2 has progressed and whether you are producing any

insulin yourself at all. So that sounds like BS to me ( and I don't mean

Blood Sugar)!!!

Rob

Thornton wrote:

>

>

>

>

>>Do you know what kind of insulin was used?

>>Regular or synthetic? I think studies like this

>>where they take people with preexisting

>>conditions and come to the conclusions that

>>it was the insulin that made them sick is silly

>>

>>

>

>Nobody has suggested that " it was the insulin that

>made them sick " , I don't know where you get that

>idea from. The study established a statistical

>connection between treatment of DM2 with insulin

>and the chances of survival for more than one year

>after a heart attack, nothing more than that.

>

>There is a clear statistical connection between

>taking too long to get a heart attack patient to

>hospital and survival for more than one year after

>but that does not mean that they are suggesting

>that the delay causes the heart attack!

>

>If you are DM2, use insulin but never have a

>heart attack then you are not concerned. If you

>are DM2, use insulin and are considered to be

>at risk for a heart attack then you might want to

>reconsider returning to oral medication. That

>is the conclusion of the study, not that " the

>insulin made them sick " !

>

>Regards

>

>T

>

>

>

[Guest guest]

Hi, Rob...I REALLY object to the term " diabetes 'sufferers' -- probably

because the term is so negative - but mostly because I, for one, am not

" suffering " .

Also, because for those who have diabetes complications, it implies

permanancy, which is also not true. People with diabetes who have

complications need to understand that many of these complications CAN be

reversed, with good control of BGs. Which many did not know until they

joined this list.

Vicki, all for positive thinking and good BG control in 2006!

Re: Re: Insulin and mortality

>I thought that diabetes sufferers were at more risk from heart

> conditions anyway, due to the diabetes.

>

> So that almost sounds as though because we are more likely to have a

> heart attack that you are advocating changing from insulin to some

> other

> form of drug therapy.

>

> Not much good if you can't survive without insulin in the first

> place -

> depends how far the DM2 has progressed and whether you are producing

> any

> insulin yourself at all. So that sounds like BS to me ( and I don't

> mean

> Blood Sugar)!!!

>

> Rob

>

> Thornton wrote:

>

>>

>>

>>

>>

>>>Do you know what kind of insulin was used?

>>>Regular or synthetic? I think studies like this

>>>where they take people with preexisting

>>>conditions and come to the conclusions that

>>>it was the insulin that made them sick is silly

>>>

>>>

>>

>>Nobody has suggested that " it was the insulin that

>>made them sick " , I don't know where you get that

>>idea from. The study established a statistical

>>connection between treatment of DM2 with insulin

>>and the chances of survival for more than one year

>>after a heart attack, nothing more than that.

>>

>>There is a clear statistical connection between

>>taking too long to get a heart attack patient to

>>hospital and survival for more than one year after

>>but that does not mean that they are suggesting

>>that the delay causes the heart attack!

>>

>>If you are DM2, use insulin but never have a

>>heart attack then you are not concerned. If you

>>are DM2, use insulin and are considered to be

>>at risk for a heart attack then you might want to

>>reconsider returning to oral medication. That

>>is the conclusion of the study, not that " the

>>insulin made them sick " !

>>

>>Regards

>>

>>T

[Guest guest]

Hi and all,

>

> The study was peer-reviewed by cardiologists so

> there is no really good reason to doubt its validity.

With respect, I must disagree. Until the study has been replicated at least

once, there're lots of reasons to doubt its validity. That isn't to say the

study should be entirely ignored. But, the statistics themselves show a 5%

chance that the key result was due merely to random variation.

> Not much good if you can't survive without insulin

> > in the first place - depends how far the DM2 has

> > progressed and whether you are producing any

> > insulin yourself at all.

>

> Yeah, sure, but that is just stating the obvious!

A key point lurks here: the groups were not matched for severity of

diabetes. Other things being equal, I'd expect a patient on insulin to have

less glycemic control and more complications than a patient on oral meds,

due to physicians tending to reserve insulin for cases in which oral meds

have failed.

Fnally, as has mentioned but perhaps not emphasized, this was a

correlational study, not an experiment. It's not apppropriate to use words

like " cause " and " effect " in connection with the results of a correlational

study. We can't say whether the patients' need for insulin or the insulin

itself--or some unknown, related factor--was responsible for the adverse

outcomes. Please don't avoid or delay insulin on the basis of this study!

[You can learn more about this study at <

http://www.medscape.com/viewarticle/498487_2>. In the discussion presented

there, the authors of the study point out " There are a variety of plausible

explanations for the relationship between insulin treatment and adverse

outcomes in patients with HF observed in this study. The administration of

exogenous insulin may contribute to HF failure disease progression and

increase the mortality risk. Insulin has been associated with increased

sympathetic nervous system activation, increased vascular resistance,

increased cardiac and vascular hypertrophy, and endothelial dysfunction.

Alternately, insulin use may merely be a marker of patients with more

advanced diabetes, with a greater extent of microvascular and macrovascular

disease and a greater degree of insulin resistance. Because presence and

extent of CAD are important predictors of prognosis, it is possible that

patients with HF receiving insulin had more extensive CAD that accounts for

the worse prognosis. Patients in this study treated with insulin had

diabetes for longer duration, but insulin use remained an independent

predictor of mortality after fully adjusting for duration of diabetes. It

could be hypothesized that oral diabetes medications confer cardiovascular

benefits that reduce mortality risk in diabetic patients with HF. There are

too few patients in this study on individual oral diabetic medications to

fully explore this potential explanation. Finally, patients who fail oral

medications and are started on insulin therapy may have failed oral

medications secondary to poor compliance. These patients may also

demonstrate decreased compliance with HF medications and nonpharmacologic HF

therapy. Poor compliance may therefore be a potential explanation for the

worsened prognosis in insulin-treated patients. " ]

Cheers,

[Guest guest]

Hi and all,

>

> Thanks, Bill, that is all a great help. I was not ignoring all those

> points but adopting the position that we, as lay persons, are not in

> a good position to cast doubt on the conclusions. A panel of

> cardiologists naturally could but it is said to have been peer-

> reviewed so as a lay person, I feel that I ought to take their word

> for its validity such as it is.

The discussion section of the article is pretty good. There, the authors

explain the limitations of their study. Please note that they *don't* claim

that insulin *caused* the adverse results. Insulin was merely *associated*

with the adverse results; that is, the real cause could be some other factor

that's also associated with insulin use, such as relatively poor glycemic

control.

[some of us here are trained researchers, though not necessarily medically

trained. Fortunately for us, there's much in common between medical and

non-medical research. So, we're often able to spot problems and interpret

results with a reasonable degree of confidence. Here's the URL of a web page

that may be helpful in explaining the limitations of correlational studies:

<

http://www.une.edu.au/WebStat/unit_materials/c2_research_design/design_nonexperi\

mental.htm

>.]

I was interested to see that some people here reject the conclusions

> on the apparent grounds that they are suspicious of all studies and

> I have a vague feeling that most people are more willing to accept

> findings that confirm something that they already believed than news

> that runs contrary to it. I have to ask myself if that was not the

> reason why I was so ready to accept this one!

Yes, we all have our biases. But, science is about getting past those.

That's one reason why consensus, which transcends personal bias, is an

important element of science.

OTOH, in my own opinion, science has no monopoly on truth. After all, the

scientific consensus is that a low-fat, moderate-carb diet is appropriate

for diabetic patients .

Nevertheless, I think there's reason to have confidence that science, in the

long run, will prevail in finding truth. Other things being equal, I have

more confidence in scientific research than, say, alternative medicine, the

claims of which are not generally assessed in any systematic way.

Thank you for the Medscape reference. I read it right through and I

> understand the reservations but a glance at the two plots, Fig. 1

> and Fig. 2, convinced me as a lay person immediately, especially the

> striking difference in survival between DM+,Ins+ and the other two

> in the first 6 months.

>

> If my physician were to place those two plots in front of me and

> then ask me if I would like to switch to insulin, how could I make

> any other decision but to refuse? He wouldn't do that but do you

> know of any other investigations that are accompanied by similarly

> strong graphic arguments that would encourage a decision to switch?

>

> Put it this way, faced with those plots, I would need some very

> strong evidence before I could be convinced to disregard them. It

> would be like seeing figures showing that, adjusted for numbers

> sold, a particular car model was four times more likely to be

> involved in single-vehicle crashes than cars of any other model and

> then going out and buying one of them! No way!

Please bear in mind that the study's authors explicitly concede that the bad

results may not be due to insulin. For instance, they could be due to good

effects of oral meds. Or, they could be due to patients in the insulin group

having poorer health than patients in the oral meds group--only certain

aspects of health were statistically corrected for. I suggest that you read

the Discussion section and list the possible causes other than insulin

identified by the authors. Then, consider that the results may be due to

some cause not anticipated by the authors.

Yes, the statistics and tables strongly suggest that *something* is going

on. But, a correlational study such as this one can't tell us what that

thing is. Maybe it's insulin use. Maybe it's something else.

I didn't find any other studies that I considered on point enough to be

considered to have replicated this study, which is relatively recent. You

might find it worthwhile to chase the authors' references to studies showing

adverse effects of insulin. But, please consider that the effects of non-use

of insulin might be even more adverse than those of insulin use in any given

case .

The primary significance of this study, in my view, is that it begs

questions regarding whether insulin is really responsible for the adverse

effects and, if so, what component or aspect of insulin causes harm. I'd

anticipate that researchers will design experimental studies to address

these questions.

Here's another question to ask yourself about the study. Did the insulin and

non-insulin groups differ in *any* way other than choice of medication? That

is, were glycemic control, overall health, and complications equivalent

between the two groups (except for the handful of differences for which the

authors performed statistical adjustment)? Neither we nor the authors can

answer that question. But, the answer could shed light on the issue at hand

by showing that insulin itself was not the factor that lead to the adverse

results.

Make sense?

Cheers,

[Guest guest]

Actually, the digestive system gets into the mix if your pancreas is not

working properly or if a good part of your pancreas has been removed. In

that case I feel that digestive system disorder does have a lot to do

with diabetes since it can cause diabetes. I do not know if having only

half a pancreas can adversely affect glucose homeostasis but I know it

can sure limit the amount of insulin that your body can produce.

Barb in NH

Thornton wrote:

>

>

> > I tend to look at diabetes as a digestive

> > system disorder with total body

> > involvement... *smile*

>

> Oh. In my case, my digestion functions properly,

> it is my fat metabolism that is damaged and

> that gave me diabetes via insulin resistance, I

> believe. I don't see how the digestive system

> can adversely affect glucose homeostasis but

> I suppose everything is possible.

>

> Regards

>

> T

>

>

[Guest guest]

> Just because at one location there happens to be an accumulation of

> diabetics who it does not fit cannot, in my view, invalidate the

> worldwide medical consensus!

It's important to listen to what the mainstream medical community has to

say. It's also important to understand that they tend to support the status

quo, and many doctors know very little about nutrition.

Doctors have to worry about lawsuits, and one way to avoid them is to follow

standard procedures. So they tend to be conservative. It takes the brave

ones to buck the status quo.

The Joslin Diabetes Center has recently changed their dietary

recommendations to support fewer carbs. They're still not supporting

low-carb, but they're admitting that the ADA diet is flawed. The worldwide

medical consensus tends to follow the diabetes organization consensus.

Gretchen

[Guest guest]

> Just because at one location there happens to be an accumulation of

> diabetics who it does not fit cannot, in my view, invalidate the

> worldwide medical consensus!

It's important to listen to what the mainstream medical community has to

say. It's also important to understand that they tend to support the status

quo, and many doctors know very little about nutrition.

Doctors have to worry about lawsuits, and one way to avoid them is to follow

standard procedures. So they tend to be conservative. It takes the brave

ones to buck the status quo.

The Joslin Diabetes Center has recently changed their dietary

recommendations to support fewer carbs. They're still not supporting

low-carb, but they're admitting that the ADA diet is flawed. The worldwide

medical consensus tends to follow the diabetes organization consensus.

Gretchen

[Guest guest]

I'm pleased that Joslin now supports at least a reduced carb intake and

particularly interested in your statement that the Joslin Clinic now

admits that the ADA plan is flawed. Do they actually say this or is it

by inference only? And if they do say so, where can I read it?

Vicki

Re: Re: Insulin and mortality

>> Just because at one location there happens to be an accumulation of

>> diabetics who it does not fit cannot, in my view, invalidate the

>> worldwide medical consensus!

>

> It's important to listen to what the mainstream medical community has

> to

> say. It's also important to understand that they tend to support the

> status

> quo, and many doctors know very little about nutrition.

>

> Doctors have to worry about lawsuits, and one way to avoid them is to

> follow

> standard procedures. So they tend to be conservative. It takes the

> brave

> ones to buck the status quo.

>

> The Joslin Diabetes Center has recently changed their dietary

> recommendations to support fewer carbs. They're still not supporting

> low-carb, but they're admitting that the ADA diet is flawed. The

> worldwide

> medical consensus tends to follow the diabetes organization consensus.

>

> Gretchen

>

[Guest guest]

Hi and all,

So long as one understands the limitations of the study, as I'm convinced

you do, it makes sense to somehow incorporate the results of the study into

one's analysis of therapeutic decisions. I also agree that it's a given that

insulin has its downsides. Although I didn't bother to read them, the

authors of the study cited several articles allegedly making that point.

Exactly how much weight one gives to a non-replicated correlational study

and exactly how one interprets the results of such a study are, of course,

key open questions. My personal take is that achieving and maintaining

glycemic control is paramount and supersedes the choice of insulin versus

oral meds. Please note that this opinion flies in the face of the results of

a second correlational study I cited, performed by one of the authors of the

study under current discussion, which found, very roughly interpreted, that

bad control was associated with *better* outcomes for heart patients. At

least for the moment, I choose to (almost) entirely ignore that second

study. As someone offered earlier in this thread, you can find a study to

support almost any perspective. So, it's necessary to somehow decide which

studies to (tentatively) accept and which to (tentatively) ignore.

How do I decide which studies to accept? I tend to accept studies that

conform to my existing mental models, which I've spent time and effort

developing, and ignore those that don't conform. In other words, my decision

is based on prejudice. However, my practice isn't inconsistent with a

devotion to logic. The rule I'm following, a simple application of a

probability theorem known as Bayes Law, could be stated as follows:

surprising conclusions demand strong evidence. If enough good studies

contradict my existing mental models, I'll eventually choose to discard them

in favor of what I can hope are better models.

I suspect that a similar mechanism underlies your own chosen aversion to

insulin use. If that's the case and so long as we're conscious of our

decision process, I will insist that we're both being entirely logical

notwithstanding that we come to different conclusions. Such situations

demonstrate why scientific progress is a process of consensus, rather than

pure (mere) logic.

For what it's worth, I too would not buy the accident-prone car that you

cite . But, I see fewer downsides to avoiding a particular model car than

avoiding insulin. So, if I found myself unable to maintain glycemic control

using diet or oral meds, I'd take insulin without hesitation, even if I had

cadiac problems. But, I concede that my decision would find no support in

either of Fonarow's studies that we've discussed. It'd really be interesting

to know what Fonarow would do in that situation, wouldn't it ?

Cheers.

>

> Going back to my automobile analogy, just because a particular model

> is involved in more single-vehicle crashes than any other model does

> not mean that there is anything wrong with the vehicle. It could be

> one that is primarily bought by younger people who might be inclined

> to take more risks or it might be bought by people who prefer to

> drive on minor roads which have a higher accident rate than major

> divided highways. OK, but until that gets sorted out, I would not

> buy one of them. Similarly, I am prepared to believe that insulin as

> such is not the cause of the effect observed but I prefer to let

> them clarify that first before I decide about switching!

>

> The way I look at it, there has to be a downside to insulin use, it

> cannot possibly be all good news. Almost everything else connected

> with diabetes seems to involve a trade-off, why should insulin use

> be an exception?

>

>

[Guest guest]

Hi and all,

>

> I admit that I have never thought about it that way before but my

> physician keeps telling me not to forget " quality of life " ; he

> reminds me practically every visit when I lay out my charts and

> results that there are far, far worse things than diabetes waiting

> out there and not to lose sight of the real goal which he describes

> as living a full life in spite of diabetes and avoiding

> obsessive behavior patterns.

I entirely agree and confess that, despite generally maintaining an A1C

less than 5.0, I cheat with alacrity whenever the mood to do so strikes me.

I've eaten four homemade chocolate-chip cookies today .

The flaw to both the Bayesian and the frequentist schools of

> statistics is that neither of them hold true if there is no symmetry

> among the alternatives. According to Bayes you would confidently

> expect a coin tossed a large number of times to come down as often

> tails as heads. Try that with an ordinary US cent and you find that

> it comes down more often tails than heads which is a surprising

> conclusion to most people. I get a feeling that many of the options

> in diabetes management are just as asymmetrical as a red cent.

> Bayes defined his law nearly 250 years ago and he died before

> his work could be published so his own decisions were prima facie

> not exactly optimized!

>

I'm not an expert statistician, but I can't see any reason against a

Bayesian model assigning a prior probability other than 50% to one of two

outcomes. Indeed, I've done so; but perhaps in doing so I unknowingly did

some violence to Bayes's point of view. And, I understand Bayes as having

had in mind an idealized, rather than realistic, coin.

In any case, I'm not formally applying Bayes model in the sense of computing

actual probabilities . I'm merely assigning a little more weight to my

established mental models than to contradictory information of all but the

most persuasive sort, in order to avoid twisting in the wind of every new

finding that comes along. A little iintellectual inertia is sometimes a good

thing .

Thanks, BTW, for the link to the info on Joslin's revised dietary

recommendations.

Cheers,

[Guest guest]

I don't know why you'd think that maintaining good control WOULDN'T be

merry, .

I maintain excellent control and I don't think I spend an inordinate

amount of time or effort maintaining it. And my life is quite merry,

smile. And not short, either.

Vicki

> That would be the ultimate diabetic lifestyle choice, a short life

> and a merry one (if you can see a life spent maintaining good

> control as being " merry " ) OR a long life and being constantly

> doctored for one thing or the other until the end of your days!

Re: Insulin and mortality

>

[Guest guest]

Who is the villain or villainess who made them and/or brought them into

the house? Off with his/her head! Maybe this person is plotting your

early demise, LOL.

Sue

On Monday, January 2, 2006, at 02:59 PM, Bill McCarty wrote:

>

> I entirely agree and confess that, despite generally maintaining an

> A1C

> less than 5.0, I cheat with alacrity whenever the mood to do so

> strikes me.

> I've eaten four homemade chocolate-chip cookies today .

[Guest guest]

Hi Sue and all,

No, it's one of those YMMV things. I can cheat pretty regularly and, as long

as I watch my diet the rest of the time, my AIC comes out just fine. I do

hope this persists .

Cheers,

>

> Who is the villain or villainess who made them and/or brought them into

> the house? Off with his/her head! Maybe this person is plotting your

> early demise, LOL.

> Sue

>

> On Monday, January 2, 2006, at 02:59 PM, Bill McCarty wrote:

> >

> > I entirely agree and confess that, despite generally maintaining an

> > A1C

> > less than 5.0, I cheat with alacrity whenever the mood to do so

> > strikes me.

> > I've eaten four homemade chocolate-chip cookies today .

>