Insulin Myths and Problems They Cause – Part 2

This is a continuation of the previous blog.

Myth 4: “If I am placed on insulin therapy, I will gain weight.”
Some people with Type 2 diabetes may gain weight after starting insulin therapy. Yes, this is true if people going in insulin do not cut the number of carbohydrates. This is because of improved blood glucose control. Uncontrolled diabetes causes people to lose weight because glucose cannot get to the cells in the body. When insulin is introduced, glucose can be absorbed from the carbohydrates eaten, leading to some of the weight that was previously lost being regained, but only if they do not reduce carbohydrates consumed.

The good news is that weight gain tends to level out as insulin therapy continues, and the weight gain may be temporary. Ultimately, the benefits of good blood glucose control will reduce the risk of complications and should take priority. By reducing carbohydrate consumption, often weight gain is stopped before too much weight is added. Adopting a low carbohydrate, high fat, medium protein meal plan, can prevent added weight gain and allow weight lost if needed.

Myth 5: “Insulin causes complications like blindness, amputations, and kidney failure.”
Part of the reason behind the “negative image” of insulin is that physicians have historically used it as a warning to keep their patients motivated and focused on oral medication therapies. It’s no wonder that people who try their best, but inevitably need insulin therapy, often feel guilty. Another reason this is believed is that many people have known people with these complications that developed before insulin, but insulin therapy is all they can remember.

Doctors commonly delay starting insulin due to their own lack of knowledge about the treatment. Some of these include a fear of causing low blood glucose or a concern that their patients will not adhere to an insulin regimen. The result is that insulin is often added to therapy too late in the course of diabetes. The reality is that people do not develop complications from being started on insulin, but rather, they develop complications from being started on insulin too late. Insulin actually reduces your risk of getting complications. Adding insulin to your treatment can improve your control and result in fewer complications than you would have had otherwise.

Hopefully, these myths about insulin will go away as doctors begin insulin therapy sooner rather than later and people with diabetes become more educated about insulin treatment. So if your physician tells you its time to add insulin to your regimen, just remember, diabetes is a chronic illness. The longer you’ve had type 2 diabetes, the more likely you are to need insulin. Insulin can provide improved blood glucose control and slow or prevent the development of complications. The following are more insulin myths.

Myth 6: “Insulin causes sterility and sexual dysfunction.”

This happens when insulin is delayed for too long and oral medications are no longer effective. Doctors need to lose their fears and become more knowledgeable.

Myth 7: “Insulin use is the beginning of the end.”

This is because doctors use insulin as treatment of last resort. People that let their doctors get away with this can fall into this myth, making it true. I have been on insulin for about 11 years and even at age 72, I feel I have many more years to look forward to and enjoy.

Myth 8: “Insulin is toxic.”

The number of people that find this true is very small. Most are allergic to something in the manufactured insulins and some are allergic to the animal insulins. Animal insulins are no longer available in the United States, but can be legally imported by doctors for those in need.

Myth 9: “Insulin use will label me as a drug addict.”

I have been questioned by the police about my use of syringes. Fortunately, I had the insulin there and the pharmacy RX on the box and after checking, the officer was very polite.

Myth 10: “Insulin use is an inconvenience.”

This is true, but only if you let be an inconvenience. Your diabetes health is too important for you to let this be a reason for avoiding insulin. In the almost 11 full years of using insulin, I have injected when in view of others, in private, and I refuse to use unsanitary bathrooms. On airplanes, I have been allowed to use the food gallery when it was not in use.

Insulin Myths and Problems They Cause – Part 1

Insulin myths are promoted by doctors that do not understand diabetes and are afraid of patients having a hypoglycemia episode. They use threats about failing when taking oral medications and the threat of insulin if they don't succeed. This atmosphere generated by doctors can lead to the following myths.

Myth 1: “It’s my fault I am being put on insulin because I didn’t do what I was supposed to do.”

No, it is not your fault! You have not received the education necessary to better manage your diabetes, and have had a threatening attitude from your medical providers. These doctors have used threats and left insulin as the medication of last resort. It is your fault that you let them do this to you and did not ask for insulin before it became necessary. This may have prevented this myth – diabetes is progressive from becoming true.

The doctors, CDE's, and others believe that diabetes is progressive because this is what they see in their daily practice. But because of their attitude and threatening ways of leaving insulin as a medication of last resort, they cannot help but see this. Their disrespect for us and treating us as people capable of making some decisions for ourselves is a disgrace to all doctors. There are a few doctors and more endocrinologists that will start us on insulin earlier before our pancreas is worn out and allow us to manage our diabetes to prevent it from becoming progressive.

It is inevitable that the insulin-producing beta cells of the pancreas will deteriorate over time, resulting in insulin deficiency. In other words, the pancreas cannot keep up with the body’s need for insulin no matter what you’ve done to manage your diabetes. Accordingly, insulin treatment is a normal and effective way of replacing the body’s insulin. Think of it as a form of 'hormone replacement therapy.' The goal of all diabetes treatment is to find the right combination of treatments to provide the best blood glucose control while minimizing side effects and insulin is the best of those options. Then remember that there are lifestyle changes that can help and for the different lifestyle changes, read my blog here.

Myth 2: “Insulin injections hurt.”
Most people are surprised by how little an insulin injection actually hurts. With the small, fine needles available today, insulin injections are virtually painless. Insulin is injected into the layer of fat below the skin where there are no pain receptors. In fact, most people feel that the finger pricks used to measure their blood glucose levels hurt much more than their insulin injections. Still more of us have learned how to prick our fingers that greatly eliminates much of this pain.

Myth 3: “Now that I am on insulin therapy, I will have more episodes of low blood glucose.”
Although some episodes of hypoglycemia, or low blood glucose (defined as a level below 70 mg/dl) may occur in people using insulin, severe hypoglycemia is rare and has been shown to affect only about 0.5% of people with Type 2 diabetes. You can learn how to prevent, recognize, and treat hypoglycemia, therefore avoiding severe hypoglycemia episodes.

Early symptoms of hypoglycemia include shakiness, nervousness, sweating, and confusion. People with diabetes should always carry glucose tablets with them, along with a blood glucose meter to check glucose levels when any of these symptoms occur. Treatment is usually 15 grams of carbohydrate, examples of which include 3 or 4 glucose tablets, 4 ounces (1/2 cup) of fruit juice or regular (non-diet) cola, or 5 or 6 pieces of hard candy.

Blood glucose levels should be checked again in 15 minutes and, if levels are still low, the steps above should be repeated until the glucose level is 70 mg/dl or higher. Strong evidence has demonstrated that the benefits of achieving good blood glucose control outweigh minor episodes of hypoglycemia as long as these episodes are not too severe or too frequent. Never allow blood glucose levels to become hypoglycemic if at all possible. Do not over consume when experiencing a low and put yourself in a yo-yo situation of highs and lows.

Doctors and Insulin Equals Fear

When it comes to insulin, is it really the patients that doctors are concerned about, or their lack of knowledge. Possibly, it could be that their ability to threaten the patient is what would be lost. I would not put much importance in a doctor survey that was conducted for this study. I have much more respect for the doctor telling a patient what this doctor did and working with the patient to find a doctor willing to do insulin therapy and in this case an endocrinologist.

The excuses presented are not laughable, but must be taken with a grain of salt. This is a small survey of only 71 primary care physicians at York Hospital in York, PA. The authors say that 66% of the doctors felt that putting a patient on insulin would be too burdensome. Too burdensome for whom, themselves or the patient. The next statement really may be true to a degree, but to say that 97% of their patients would be willing to start insulin, if it did not involve needles may be an overstatement. I could agree if the patients only had that choice and possibly were not trying to get off oral medications because of the discoveries of potentially deadly side effects.

Then add to this a Canadian study which found that doctors are more reluctant to start their patients on insulin than the patients are themselves. Read my blog here about the study. The following statements I made in that blog are very applicable here and I repeat them.

What they found is that doctor's fears of common side effects such as weight gain and low blood sugar were amplified compared to their patient's fears, and that doctors were more concerned than their patients about the possibility of injection-related pain and anxiety. They also discovered that many doctors where only familiar with the insulins of past usage and older delivery systems. They needed to be reeducated about the newer insulins and methods of delivery.

Like many of us now using insulin, we find it much easier to use, if we use care and learn to use it properly. Instead of eating to a certain amount of insulin, we need to learn to count our carbohydrates and adjust our fast acting insulin accordingly. This will prevent most of the risk of low blood glucose and by limiting our carbohydrates; we can prevent the weight gain many fear. Exercise, if medically able is another way of assisting the prevention of weight gain.

I would guess that this is what drives many primary care physicians to make the statements they did and why they don't feel insulin is right for their patients. Put this with the author's statement of 69% of doctors saying patients would perceive going on insulin as a failure to manage their disease. Is this because the doctors use this myth to keep their patients on oral medications?

I admire Yiyi Yan, MD, PhD for stating, "We know that education helps patients in their use of insulin, but our study indicates that there needs to be more education of primary care physicians on type 2 diabetes management and insulin usage as well. We think concern about how they think their patients will react is the biggest barrier to initiating insulin." This sounds very reminiscent of the Canadian study.

Other statistics given by the study include:

#1) 88% agreed that insulin therapy has better effect on glycemic control than oral diabetes drugs.

#2) 75% agreed that early initiation of insulin could prevent diabetes-related complications.

#3) 88% said they were comfortable initiating insulin therapy among their patients.

#4) 53% reported that the different types of insulin products created confusion in prescribing.

#5) About 60% thought insulin regimens were too complicated for most of their patients to understand.

#6) Only 6%% thought insulin therapy should be managed solely by endocrinologists.

#7) 16% deemed insulin therapy too expensive.

#8) 38% felt insulin therapy was too time-consuming.

Additional author comments include that those who were uncomfortable with insulin therapy believed that education was needed. Many physicians disagreed with the necessity of maintaining tight glycemic control. Although the authors state that experienced primary care physicians were more aware of guidelines and were more comfortable with insulin initiation, I am still concerned that education is needed for PCPs and especially education on the myths they still believe and follow.

Please take time to read this blog by Jan Chait at Diabetes Self Management. She uses her personal experience and the study to relay some excellent advise.

Why Doctors Fear Starting Patients on Insulin

This is a Canadian study, but is applicable to the U.S. physicians as well. The opening statement is a little surprising when the myths about insulin are considered.  For many U.S. patients, the myths are out in full force and both doctors and patients seem to believe many of them. But, I digress.

The statement that doctors are more reluctant to start their patients on insulin than the patients are themselves says volumes and must be explored. Dr. Catherine Yu, a researcher at the hospital's Keenan Research Centre and senior author of the paper states, "There are no clear recommendations on the safest and most effective way to start patients on it, and so physicians are often hesitant to do so."

“Dr. Yu and colleagues analyzed past studies to find out what barriers existed to starting patients on insulin, and how insulin compared to other blood sugar lowering medications in terms of its effect on blood sugars and weight. They then made recommendations for physicians and other health care providers based on evidence from the past studies.”

Their findings were published in the online edition of the Canadian Medical Association Journal.

What they found is that doctor's fears of common side effects such as weight gain and low blood sugar were amplified compared to their patient's fears, and that doctors were more concerned than their patients about the possibility of injection-related pain and anxiety. They also discovered that many doctors where only familiar with the insulins of past usage and older delivery systems. They needed to be reeducated about the newer insulins and methods of delivery.

Like many of us now using insulin, we find it much easier to use and if we use care and learn to use it properly. Instead of eating to a certain amount of insulin, we need to learn to count our carbohydrates and adjust our fast acting insulin accordingly. This will prevent most of the risk of low blood glucose and by limiting our carbohydrates, we can prevent the weight gain many fear. Exercise if medically able is another way of assisting the prevention of weight gain.

Although Dr. Yu's suggestion of starting patients on a once a day injection of long acting or 24 hour insulin while reducing the oral medications is good, those of us in our group all went from oral medications one day to insulin injections the next day. Granted this worked well for us and we were comfortable with this transition, some doctors are not. This is why we like our endocrinologists and the assistance they were able to give us.

When insulin myths are taken out of the equation, adapting to insulin use for most people can be efficiently accomplished. Education is required for using the best injection sites and matching rapid acting insulin to carbohydrates to be consumed. It is also wise to eat at regular times and is a person is ill and does not feel like eating, then do not inject the rapid acting insulin. More frequent testing is required and this must become a habit so that adjustments may be made for higher or lower blood glucose readings preprandial (before meals).

Complications of Using Insulin

An excellent topic came out in Joslin's blog February 6, 2012. While it does not outright list the myths that many people associate with the use of insulin, the question asked include two of the myths. The question is “Am going to lose my feet or go blind now that I am on insulin?”

Unless you have waited too long before starting insulin, and are letting your blood glucose levels remain too high, neither of these two myths need to happen. By keeping your A1c's less than 6.5, you should be able to avoid most complications. You do need to be very careful of hypoglycemia (low blood glucose below 70 mg/dl) and weight gain. If you are able to exercise, weight gain should be a minimal problem. Read my blog here on avoiding weight gain when on insulin.

Myths are the main reason many people with type 2 diabetes avoid insulin. Losing your feet is maybe one of the easiest to avoid. Have a good podiatrist that you see on a regular basis (preferably quarterly) that can check your feet. Be sure to point out any unusual bruises or cuts so the podiatrist can treat them immediately. If this is impossible, get yourself a mirror that can be used to see the bottom of your feet and talk about anything to your regular physician.

Blindness is a justifiable concern and you should have had an eye exam shortly after your diagnosis to establish a baseline for eye examinations while you have diabetes. You should have an eye exam annually to check for retinopathy, cataracts, and glaucoma.

There are other myths about insulin and you may read my blog on insulin myths here. It is important to understand that if you do not manage your diabetes and do not communicate with your doctors, complications will happen. They may be the expected complications or unexpected ones. Your doctor only has his questions and the results of lab work done, so if you do not answer his questions and remain silent about possible problems, then the complications are yours to deal with. Read my blog about who can be at fault and why.

Some doctors use the fear of insulin to keep people on oral medications and using them properly. Read my blog here about doctors using fear of insulin. If you are having success with oral medications, then continue taking them. Do not say I am doing well so I will stop the medications. Read my blog here about managing your medications. This is when the complications will develop and your diabetes may become unmanageable to the point you will need to use insulin. Some people are able to get off medications with their doctor's approval when they can show that their exercise and diet regimen is working and you are able to maintain this regimen. Yes, the doctors often need convincing.

Who Is At Fault?

I dislike preaching on a topic; however, this is one topic that I admit galls me and I have to wonder why is it that our doctors are afraid to prescribe insulin except as a medication of last resort. I have always wondered if they were not confident with prescribing insulin because they did not know enough about it to teach the patients how to use it, or if they believe some of the myths about diabetes. With the findings of this study (link is now broken), I may have to eat a little crow.

“In a current study it was found that there are certain barriers for physicians that prevent them prescribing insulin much earlier in the treatment of diabetes.... .“ The barriers are often the patients themselves. The people with type 2 diabetes are so ingrained in the myths of insulin that the patients become the barriers to improved health.

Not having been exposed to the insulin myths until several years after being on insulin has been an advantage for me. It seems that many type 2 patients really believe this gobbledygook and refuse to let their doctors prescribe insulin for them or take the prescription and do not use it. Read my blog here about the insulin myths as it shows the below reasons and needs widespread reading.

The study found that 35% of the patients believed insulin causes blindness, renal failure, amputations, heart attacks, strokes, or early death. “From the results it was concluded that 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.”

While the study found these legitimate concerns, they are myths, which the doctors need to correct. Adding more oral medications does not seem to bring about improvement in blood glucose levels. Many studies have shown more oral medications can have unhealthy effects and increase the risk of cardiovascular events.

“Not previously reported is the finding that nonadherent patients frequently felt their provider had not adequately explained the risks and benefits of insulin.” This statement saves me from having to eat too much crow. There is a lot of work that need to be done on both sides – physician and patient, to educate everyone concerned about the use and benefits of insulin.

How Doctors Use The Fear of Insulin

This is one blog that needs to be written, but not for the reasons that many want. This is about the doctors and other healthcare professionals that use insulin as a fear factor and perpetuate the insulin myths.

The insulin myths are just that – a myths. Why is this used by so many doctors? Is it to get compliance with oral medications? - yes. Do the doctors do anything to remove any of the myths and tell the patient that there is nothing to the myths? - seldom. Is it to get patients to make lifestyle changes? - maybe. Is it to get patients to educate themselves? - no.

An editorial (by David Marrero, PhD – Associate Editor) in the July 2010 issue of Diabetes Forecast, that I have a copy of, was written about a year ago and is still relevant today as it was then. The author is a Type 1 and has an excellent understanding of the problems that people with Type 2 diabetes encounter. The last paragraph in the editorial is the best.

Quote – How should you regard insulin if you have type 2 diabetes? Well, of all the treatment options currently available, insulin is the one with which we have the most experience (over 80 years), the least artificial (the human body naturally makes and needs insulin), and often the most potent. It is one of several medications, not a treatment of last resort. If you have type 2, I suggest that you discuss with your doctor whether insulin is a good choice for you now. Don't wait until you have run out of options. Unquote (emphasis is mine).

What is it going to take folks to wake you up to the advantages of insulin? No, I am not talking to those that are managing with diet and exercise, or those that have managed to maintain HbA1c's of 6.5 or less, although they should read this also and learn about insulin. I am directing this to those that consistently have A1c's of 6.6 and greater. These people are in line to develop the complications and probably already have problems with one or more of them.

If you are like me, you may have been diagnosed late, or the doctor has not tried to educate you in managing your diabetes for best management or has discouraged you from testing. These are the people that need to consider insulin for their treatment now.

Read about the myths with facts refuting them here and my blog on insulin myths here. Read what this doctor writes and draw your own conclusions.