Guest Post by David Mapletoft, Diabetes Educator
One of the main conclusions the United Kingdom Prospective Diabetes Study (UKPDS) investigators themselves have drawn from their findings is that combinations of treatments will routinely be needed for type 2 diabetes.
It proved that glycemic control limits retinopathy (and probably other microvascular complications) as much for type 2 diabetic patients as had previously been shown for type 1 diabetic patients.
It defined the progressive natural history of type 2 diabetes, with declining β-cell function over time and a need for progressively more active treatment to maintain glycemic control.
With this knowledge, why is the commencement of insulin therapy so often delayed in people living with type 2 diabetes?
Physiological Insulin Resistance refers to psychological barriers to insulin use on several levels:
- Emotional (e.g. anxiety about the expected impact on daily life, depression or guilt associated with needing insulin);
- Cognitive (e.g. distorted beliefs about insulin treatment);
- Behavioural (e.g. unpleasant negative consequences such as pain, bruising, hypoglycaemias, weight gain);
- Social (e.g. feeling stigmatised);
- Relational (influencing factors from the medical health team).
“….patients with type 2 diabetes were randomised to insulin therapy found that 27% of patients initially refused treatment. In a survey of 708 community patients with type 2 diabetes not taking insulin, 28.2% reported that they would not take insulin even if it were prescribed by their physician. Thus, the percentage of insulin refusal in a research setting is similar to the percentage of the reluctance to potentially start insulin therapy in community samples, suggesting that nearly one- third of patients with type 2 diabetes could be at a greater risk for living with out of target glycaemia levels.” More here
“Most subjects reported several reasons for avoiding insulin, rather than just one. The negative attitude that most strongly distinguished willing from unwilling subjects was the belief that beginning insulin therapy would indicate they had “failed” proper diabetes self-management. Patients may associate insulin therapy with a sense of personal failure due to common physician practice, where the possibility of insulin therapy may be used as a threat to motivate better patient cooperation.” More here
“Among poorly controlled patients with type 2 diabetes newly prescribed insulin, the major predictors of insulin nonadherence included plans to improve health behaviors in lieu of starting insulin, negative impact on social and work life, injection phobia, and concerns about side effects or hypoglycemia. Nonadherent patients often blamed themselves, believing prior poor self-management caused the current need for insulin and erroneously conceptualized insulin as itself the cause of future complications. These patient-level findings are consistent with previous studies of attitudes about insulin.
Not previously reported is our finding that nonadherent patients frequently felt their provider had not adequately explained the risks and benefits of insulin. The importance of provider communication is underscored by the association between insulin initiation and health literacy. Primary nonadherence likely also reflects inadequate shared decision making or lack of self-management training. Interventions for PIR need to address both provider- and system-level factors.
“….being previously threatened by a physician to initiate insulin as a punishment for low adherence, perceiving the physician as inexperienced, and believing that insulin is an incorrect medical decision for them, usually increases resistance when insulin is actually necessary.” More here
Benefits of Taking Insulin
Intensive insulin therapy can prevent or slow the progression of long-term diabetes complications.
Several studies indicate that intensive insulin therapy can:
- Reduce the risk of eye damage by more than 75 percent
- Reduce the risk of nerve damage by 60 percent
- Prevent or slow the progression of kidney disease by 50 percent
And there’s more good news. Intensive insulin therapy can boost your energy and help you feel better in general.
Newer insulin formulations can effectively improve glycemic control without significant effects on patient weight.
Risks of Taking Insulin?
Intensive insulin therapy may lead to:
- Low blood sugar. When you have tight blood sugar levels, any change in your daily routine — such as exercising more than usual or not eating enough — may cause low blood sugar (hypoglycemia).Be aware of early signs and symptoms, such as anxiety, sweating and shaking, and respond quickly. By identifying the early symptoms of hypoglycaemia you can treat immediately. Always carry hypoglycaemia treatment on your person, within arms reach.
A recent quote from one of our Facebook clients: “I would like my blood glucose level to be between 5 and 10….but was once told you shouldn’t aim for really good control because you loose the ability to recognise hypos…my goal is to be in the best possible health. I already have had 6 eye surgeries and loads of laser treatment for diabetic retinopathy and I have protein leakage….need to be healthy so I feel better and can do more”
- Weight gain. When you use insulin to lower your blood glucose, the glucose in your bloodstream enters cells in your body instead of being excreted in your urine. Your body converts the glucose your cells don’t use for energy into fat, which can lead to weight gain. To limit weight gain, closely follow your exercise and meal plans.
“We concluded that there is a great need of evidence-based interventions that help remove psychological barriers about insulin use in patients, as well as in health care providers.” more here
Is there a psychological barrier for you? Have you considered using a counsellor or a psychologist to help with this matter?
A few years ago I had the privilege of working in a hospital based diabetes education service that was progressive enough to believe that having a psychologist on staff ws a benefit to people living with diabetes. This psychologist often had people become successful at overcoming their psychological barriers to insulin.
Consider asking your GP for a mental health care plan to enable you an affordable access to overcome your psychological barrier to insulin today.
David, Diabetes Educator