Monday, August 02, 2010

Is Insulin a "Failure" for Type 2 Diabetics?

My friend Jess asked a very interesting question on Twitter the other day. (I had requested suggestions for topics Type 1 diabetics might like to see a Type 2 address.) Why, I was asked, do many Type 2 diabetics feel that going on insulin therapy means that they've failed?

(It may be a good idea here to remind everyone that I'm not a doctor or a scientist and that the following is only my best understanding.)

It's an excellent question. First, from what I've read, it's certainly true that many Type 2's struggle when that transition becomes appropriate. It's so true, in fact, that many physicians delay making the recommendation because it's so likely to be poorly received. That's a shame, because when other therapies no longer work well, going on insulin will bring a dramatic improvement in blood glucose control and result in the patient feeling much better, immediately. I've read a couple of articles talking about how PWDs that have begun taken insulin often wish that they'd done so years before.

My speculation is that the problem is rooted in two ideas. They're both false, but they're both so seductive as to be nearly irresistible. The first of these false ideas is that insulin-dependent diabetes is "worse" than that treated in other ways. It's really hard to dismiss the notion that Type 2 "worsens" as it progresses - especially, I imagine, when it's happening to you.

The second of these false ideas is that Type 2 diabetes, its progression, and the complications we're all trying to avoid are the "fault" of the diabetic because of the lifestyle component in the development of insulin resistance. Science now knows that there's a genetic component as well - no T2 genes, no T2, no matter how many Twinkies you scarf. And, it's thought that there are other factors as well, perhaps in the environment.

But, that's not the message in the media. The bookstores are crowded with books on using a combination of diet (their special diet, of course) and a serious exercise regime will "reverse" Type 2 diabetes. As with all the best lies, there's some truth here. Many new T2s, or those with numbers that suggest a problem in the future, ARE able to use strict diet, weight loss and vigorous exercise to cause blood levels to go down and symptoms to disappear. I think (not sure here) that it's expected that this only delays full onset, but that delay may be a number of years.

Because of this partial truth, even many doctors with the best of intentions try to hammer home the notion that exercise and weight loss can "prevent" or "reverse" diabetes. But where does that leave those of us who are unable to make those changes, or whose pancreases are already too badly damaged for this approach to be effective? It leaves us feeling guilty and at fault for our diabetes. Society believes that we're diabetic because we're fat (even though many of us AREN'T fat) - our families believe that, our friends believe that, our insurance companies love to believe that, our employers believe it, and all too often WE believe it. It may even be that our doctors believe it.

So, if we accept into our hearts the lie that our diabetes is our own fault, even subconsciously or partially, then the progression of our disease also becomes our fault. Seen through that lens, the need for insulin becomes the scarlet letter "I" we wear on our inner selves that we have failed to prevent the progression of the disease.

If and when my current medications no longer work for me and I need to start climbing up the list of other available therapies, I hope very much I'm able to establish a relationship with a CDE or other medical professional that I can trust to recommend insulin therapy when it has become appropriate. I hope that I'll recognize that point myself and initiate the discussion, but the blizzard of medication options may make that tough.

I'm not afraid of insulin. I'm afraid of not knowing I need it.


  1. "I'm not afraid of insulin. I'm afraid of not knowing I need it."

    Me too.

  2. There's also the not-so-little fact that far too many doctors tend to "threaten" type 2 patients with insulin, with lines like "if we can't bring this HbA1c down, you'll have no other alternative than insulin" which is counter to the very Hippocratic Oath doctors take to "do no harm" (someone needs to remind them that also INCLUDES psychological harm). Still, the reality is that insulin is anything but a perfect therapy, and the challenge for many to get diabetes education covered is yet another obstacle in getting patients the care they really deserve.

  3. Scott, that's an excellent point, and I wish I'd thought of it. I've been threatened with an increased dose of my current med if I didn't lose weight - I never went back to that doctor.

  4. Ooh, I'm so glad you wrote this post. That makes so much sense. I'd thought it was based in fear of low blood sugars (or perhaps fear of needles), which can be pretty darn scary, and is more prevalent from taking insulin than from oral medications.

    But this (and Scott's point) make a lot of sense. And it's obvious that endos just aren't doing a good job of explaining the ins and outs of the disease to their patients. IMO, that's unforgivable.

  5. Elizabeth, I think fear of lows is part of the hesitancy also. Right now, I'd be very reluctant to wear a pump, because of the ways it can go wrong, though I imagine a couple years on MDI would fix that! :) (I DO understand that most pump wears are very happy with the tradeoffs. Just kinda scary from the outside. :/)

    It's my impression that it's rare for a T2 to have an endo...maybe more often if they're on insulin.

  6. Another great post Bob. What about the fears of GAINING weight on insulin? Is that something people worry about?

  7. Scott J - I haven't talked to other T2s about this other than at the DSMA thing and a couple articles I've read. I haven't seen the weight gain mentioned as an issue, and don't worry about it myself. However, that may be because I suspect insulin is quite a bit down the road for me, since I've got good numbers on the first stage of medication. Also, in my own particular case, I suspect that my metabolism is pretty much broken already.


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