New Model in Type 2 Treatment

Finally, a treatment plan to introduce insulin to people with type 2 diabetes that is showing promise of being successful.

A new model of healthcare that focuses on a stronger role for nurses in primary care has been associated with a higher uptake of insulin treatment among patients with type 2 diabetes, reports a study published in The BMJ.

By 2030, almost 600 million people will have type 2 diabetes; therefore, innovation in delivering effective clinical care to patients with type 2 diabetes is an urgent global priority.

Guidelines in the UK, US and Europe recommend early adoption of insulin treatment to improve long-term outcomes. However, insulin initiation is often delayed, particularly in primary care, because of barriers in clinical practice.

A team of researchers, led by John Furler from the University of Melbourne, assessed the outcomes of implementing "The Stepping Up" model of care that focuses on addressing some of the barriers seen in clinical practice, by enabling nurses to lead on insulin treatment initiation among patients within the practice as a part of routine care.

By focusing on an enhanced role for the practice nurse, who is trained and mentored by a registered nurse with diabetes educator credentials, the model uses existing resources within the practice in a bid to improve outcomes.

The study compared patients enrolled in an intervention group where they had consultations with the practice nurse as part of the Stepping Up Model, with a control group where patients received usual healthcare.

In total, 266 patients took part and were based across 74 practices in Australia.

Results show the model was associated with significantly higher rates of insulin initiation 105/151 (70%) patients starting insulin, compared with 25/115 (22%) in control practices.

After 12 months, patients had significantly better HbA1c levels (an important measure of glucose in the blood), which is associated with better long term outcomes, such as reduced rates of kidney and eye disease, compared to the control group.

The authors note the study may be subject to selection bias, and the patients in the study may not be representative of all people with diabetes.

Nevertheless, they say "our results indicate that, with appropriate support and redesign of the practice system, insulin initiation can become part of routine diabetes management in primary care, obviating the need to refer to specialist services with geographical, cost, and accessibility barriers."

"Our pragmatic, translational study has important implications for policymakers, funders, and practitioners seeking innovative ways to provide the best care for people with type 2 diabetes in primary care," they conclude.

I agree with the study and think a similar study in the USA could prove useful and could be an example for doctors to allow more activity for nurse practitioners and even registered nurses.

Are Doctors the Cause of Insulin Resistance?

At least Dr. Stephen A. Brunton, executive director of the Primary Care Metabolic Group, concedes that doctors may be the cause. Dr. Jay Shubrook, family physician and diabetologist at Touro University in California, is the doctor interviewing Dr. Brunton

Dr. Brunton says that doctors have always talked about insulin resistance being something that is the result of patient resistance. However, a lot of insulin resistance comes from practitioners. We resist using insulin for many reasons, and that has an impact on getting our patients to target.

Dr. Shubrook asks, what is clinician insulin resistance?

Then to quote Dr. Brunton, “Traditionally, we have been reticent to use insulin because of the impact it would have on slowing the flow in the office, and even in terms of our feelings of expertise. When the basal insulins came out, it made things so much easier—insulin could be initiated with 10 units daily. At that dose, there is a very low risk for hypoglycemia or any other problems. With the insulin pens, it became so much easier.

Part of it, however, is that we assume that our patients do not want to start insulin. Perhaps, in the past, we used insulin as a threat: "If you do not behave, you are going to get insulin." Now we have realized that it is the most effective regimen for getting patients under control. Part of the problem is that the patients may still have some of those other considerations that we may have originally laid upon them. It is our resistance to start patients on a very therapeutic regimen.

Part of the issue of complexity is that when patients come for the management of diabetes, many don't have only diabetes. They may have eight to 10 different comorbidities. We are so busy trying to manage all of that that we tend to put off starting insulin. We may have them on three or four oral antidiabetic drugs. So, we need to look at where our patients are and how we can get them to target.

Many studies show how long it takes us to make a change. It's therapeutic inertia. It has been shown that sometimes for years, the patient is out of control, and we will give them one more chance. We will add another oral agent, but it is not going to have a benefit, particularly when these patients have glucotoxicity.

We need to recognize that we have a broad base of different therapeutic options and that today's insulin is not your grandparents' insulin. We have better analog insulins. We have pens. We have very small needles, so patients are much more likely to accept insulin than we think. Insulin resistance is really our problem. Patients are not as frightened of needles as we think.

Patients may have misconceptions about what insulin means; for example, they might have heard, "I started insulin and my leg dropped off." That, as you and other clinicians know, is not why that person lost their leg, but the patient still holds onto that, and insulin becomes a big fear. It is up to us to help them overcome that.

Dr Shubrook says: You mentioned many things that make it easier for us to overcome our resistance—insulin pens, easy-to-titrate insulins, and algorithms for treatment. How do we address the clinician resistance to using insulin that remains?

Dr Brunton answers: The issue is to try to develop a system in the office so that you do not have to do everything yourself. Educate the staff to overcome some of the barriers to implementation in the office. Introduce insulin early on in the diagnosis. With people who have type 2 diabetes, insulin seems to be far in the future, and the thinking is, "Oh my God, I hope not." I say, "I have a natural therapy that eventually you might use." We recognize that diabetes is a progressive disease and eventually a significant proportion of patients are going to need insulin. I view this as a positive and say, "This natural therapy is insulin, and we will talk about that as it gets a little closer, but let me tell you a little bit about it." I explain the pathophysiology of diabetes and where insulin fits in. Then, I also have staff who can go over injection techniques and some of the algorithms, so that it is not all laying on my shoulders.

Dr Shubrook says: Those are important points, but I can still see some of my partners being resistant to the use of insulin. Maybe it's based on a bad experience they have had in the past, maybe it's just a lack of experience, or maybe it's the math. If I wanted to talk to one of my colleagues about starting insulin more frequently, what are some steps that they can follow?

Dr Brunton answers: First, try to understand the concerns. Sometimes it relates to misconceptions. Not only do we have an easier process now with basal insulin, but show them how to titrate it. A lot of patients will start on 10 units and if they stay on that, they are not going to get the benefits. The benefit of basal insulin comes with titration. One does not have to go from a basal all the way to a basal bolus with four injections a day. We can use the basal-plus approach where you provide some short-acting insulin for the main meal. That makes things a little easier. Now we also have GLP-1 agonists that we can use in concert with insulin. There are many ways that we can use insulin to help get our patients to goal.

Dr Shubrook commented: This is really still a very important topic because we know that most of our patients with type 2 diabetes and all of our patients with type 1 are going to need insulin. If clinicians are not comfortable, these patients are certainly not going to get the treatment they need.

What I have heard you say today is:

1. Clinician insulin resistance is still an issue despite many advances, and sharing these advances with providers might be a first step;
2. Get someone in your office who can help you so that it is not on the clinician alone to have to do this; and
3. Trust some of these tools and get some positive experiences.

Dr Brunton: Yes. We have come a long way, Jay, and that is one of the exciting things about managing diabetes today. We have so many tools at our fingertips that can help our patients get to goal. We have been at a plateau—about 55% of patients are getting to goal and 45% are not. Now that clinicians have these tools, if they feel more comfortable with them, we can help our patients.

This discussion points out the problems many people new to diabetes have with doctors. This reinforces earlier blogs by David Mendosa and myself on February 24, 2017 about  starting insulin at diagnosis. Please take time to read both.

Early Insulin, Less Weight Gain for Type 2

We have seen that basal insulin causes less weight gain than other insulin regimes. In this prospective, multicenter analysis, we see data that suggests initiation of basal insulin therapy earlier on in disease duration may be beneficial for therapy on the grounds of concern over weight gain appears to be counter-productive. This is especially true given the potentially superior glycemic control also associated with early insulin initiation, further limiting weight gain. As such, prolonging the start of insulin.

Peter Bramlage, MD, of the Institute for Pharmacology and Preventive Medicine in Mahlow, Germany, and colleagues analyzed data from two groups of patients with type 2 diabetes diagnosed on or after Jan. 1, 2011, identified through the Diabetes Versorgungs-Evaluation (DIVE) registry, a German multicenter registry involving 200 physician offices specializing in type 2 diabetes. The first group included insulin-naive patients receiving basal insulin for the first time (n = 113; concomitant oral antidiabetic use was permitted); the second group included patients receiving their first oral antidiabetic therapy without simultaneous basal or short-acting insulin (n = 408).

Researchers found that, relative to baseline body weight, patients in the basal insulin group gained an average of 0.98 kg at 1 year vs. a loss of 1.52 kg for those not using insulin (P less than .001); results persisted when expressed as a proportional change from baseline (P less than .001).

In multivariable analysis, researchers observed that baseline weight (regression coefficient = 0.89; 95% CI, 0.81-0.97) and diabetes duration (regression coefficient = 2.52; 95% CI, 0.53-4.52) were the only factors that were predictors of weight gain between baseline and 1 year in the basal insulin group.

The researchers noted that the duration of diabetes before basal insulin therapy as an independent predictor of weight gain was “logical,” as early initiation would minimize HbA1c escalation and avoid the creation of a “BMI deficit.”

The researchers wrote that, “Despite disagreement over the direction of weight change, findings from prior and present studies suggest that shorter diabetes duration is associated with more favorable weight outcomes, and early initiation of basal insulin therapy may be advantageous

Many of these clinical case studies exemplify the diversity of patients who may benefit from early insulin initiation. Ultimately, it is hoped that early initiation of therapy will not only prevent weight gain and short-term complications, but also reduce long-term morbidity and mortality by getting to goal earlier and potentially alter the natural history of the disease. This latter concept is currently of intense interest. Although optimal disease management is patient-specific, achieving and maintaining tight glycemic control are the primary goals of therapy.

Because many type 2 diabetes patients will eventually require insulin therapy, overcoming fears and therapeutic barriers to initiating therapy early as needed are essential for reducing the vascular comorbidities of this highly prevalent disease in patients of all ages. Fortunately, a number of new clinical tools are available, including both prandial and basal insulin analogs, new insulin-delivery devices, and an ever-improving knowledge of the pathophysiology and natural history of diabetes.

Newly Diagnosed Type 2, Start Using Insulin

I have written about being on insulin and probably will again. It is a shame that more people do not use insulin and even more shameful that many doctors will not encourage their patients to use insulin. Probably the most disturbing is that fact that many physicians actually use insulin as a threat to keep their patients on oral medications and to get them to work harder at controlling their diabetes.

This failure as these professionals call it is of their own making and is making more patients wonder where these doctors got their medical license. When the current “pill cure” generation passes, these doctors are going to face an Internet savvy group of patients that will call them out on their threats and stop using these deadbeat doctors.

A few doctors and some endocrinologists are starting to use insulin when some patients are first diagnosed. Though not enough are doing this, this will allow the pancreas to recover or rest, and bring a greater degree of control immediately. Doing this allows stopping the progression toward complications faster and this is a valid concern. Being on insulin at the start does not mean that you have failed or that you will need to be on insulin for the rest of you life. That will depend on the stage of your diabetes when diagnosed and the lifestyle changes you make. Please read the thoughts of David Mendosa on this topic.

Many patients started on insulin are able to get off and on to oral medications. Most are encouraged to change their lifestyle and be serious from the beginning about exercise and nutrition. A number of the patients have successfully gotten off all medications and are controlling with nutrition and exercise. In talking to a few individuals, they were very concerned when started on insulin, but with the faster lowering of their A1c and stricter control of their diabetes, they are satisfied that this was a way they would not have thought about, but did work well for them. Of the three persons I have talked with, only one was still on oral medications. The other two are off all diabetes medications.

One of the individuals I was able to talk with admitted that he had to overcome his extreme dislike for needles, but since he was always going to need to test, the needles were just another hurdle he had to overcome. He also felt that since the doctor was not threatening him, but encouraging him, that maybe he should listen and learn.

They did emphasize that it was important to receive from the start, the meetings with the nutritionist or diabetes dietitian to get the lifestyle change underway. This more than anything, they felt created the success they were experiencing. They admitted that it was difficult at the start, but as more of the changes were introduced with the reasons for the change also instilled with the change, they learned how to adapt and that they did feel better and wanted to continue what they were learning.

They were also happy that they had been allowed to experiment with lower carbs and different foods. I then asked if they were they told they must eat a minimum number of carbs? All three agreed that they had been told that a number of carbs was suggested. Then all three felt that this was the last time the number of carbs was pushed. They felt that the nutritional value was more important than a set number of carbohydrates in all discussions. A balanced diet was the main topic and when a couple of them wanted to experiment with a lower carb restriction, only the nutritional values of what they wanted to eat was the topic.

Yes, the number of carbs was taken into account, but they felt that then the dietitian was more interested in teaching them the way to determine the nutritional values of the foods and where to substitute to not harm the overall nutritional value and still stay at the carbohydrate value they had chosen. This was a big eye opener for me and restores a little of my respect for some dietitians.

Just don't let a dietitian say I need a minimum number of carbohydrates, as at that point, I admit, I tune them out and forget the rest of the class. I am happy for the success these individuals were having and that they will remember what to do and the reasons for doing it. This is the place of the support people and this example should be more widespread than it is today.

Barriers to Insulin Therapy

The fear of needles or sharp objects is not that uncommon among people with diabetes. While I dislike needles, I do not have a fear, or technically – belonephobia.

Yet, I have met several people with type 2 diabetes that do have belonephobia. Two of these people need to start on insulin, but they are refusing and both are now on five different oral medications and their meter readings are still becoming higher. Both are considering insulin, but one of the two has COPD so the Afrezza is out. The other has finally accepted Afrezza.

I came across the following and found it interesting:

The Fear of Needles Has Many Names - But It Is Very Real

If you've ever tried to search for "needle phobia" or "fear of shots," you've probably come across some very odd and confusing terms. But this condition is very real, and a whopping 20 percent of people have a fear of needles. There are a lot of risks associated with the fear of needles. It can prevent people from going to the doctor, getting routine blood tests, or following prescribed treatments. Modern medicine is making increased use of blood tests and injectable medications, and forgoing medical treatment because of a fear of needles puts people at a greater risk for illness and even death. For example, diabetics who skip glucose monitoring and insulin injections can put themselves in serious danger of complications.

Here are the six medical terms that are related to fearing needles:

• 1. Aichmophobia: an intense or morbid fear of sharp or pointed objects
• 2. Algophobia: an intense or morbid fear of pain
• 3. Belonephobia: an abnormal fear of sharp pointed objects, especially needles
• 4. Enetophobia: a fear of pins
• 5. Trypanophobia: a fear of injections
• 6. Vaccinophobia: a fear of vaccines and vaccinations

Back to my thoughts -

For many people with type 2 diabetes, doctors will not prescribe insulin and will use the threat of insulin as a way to get patients to follow orders. Then when they need insulin the patient blames him/her self and feels that he/she is a failure.

I have personally seen examples of people who fear needles while in the military, out of a group of over 100 men; six went down, succumbing to trypanophobia. The way medical professional should handle type 2 patients is presented here. This article also covers other fears about insulin that many people with type 2 diabetes have and explains these.

For those people that need some encouragement about using syringes, view the following video from BD on using insulin syringes.

Insulin is necessary for many people with type 2 diabetes when their pancreas can no longer produce sufficient insulin.

Researchers May Have Way to Speed Up Insulin

In the Journal of Biological Chemistry, researchers describe how they predicted the effect with computer simulations and then confirmed it with laboratory experiments. Scientists suggest that a small chemical alteration to insulin makes the molecule act more rapidly while preserving its function in the organism.

The researchers - from Switzerland, the United States, and Australia - found that they could speed up the disassembly and release of insulin from its complex structure to its available form by replacing a single hydrogen atom with an iodine atom in its molecular structure.

Insulin is a small protein that regulates blood glucose by passing signals into cells. In the body, it exists in two forms: a complex one for storage and a simpler one for action.

In its storage form, insulin exists as a zinc-bound complex of six identical molecules called a hexamer. The simple, active form is an unbound single molecule, or monomer. When the body requires insulin to regulate blood sugar, the hexamer disassembles into monomers.

The insulin molecule then has to bind to a partner molecule - known as the insulin receptor - that sits on the surface of cells. This binding allows signals from the insulin to pass into the cell.

For some time, researchers have been experimenting with ways to control this disassembly process to improve the treatment of diabetes - a disease in which insulin production is impaired or when the body cannot use it properly.

Researchers use various approaches to explore and discover new ways to fight disease with molecules that do not exist in nature. This includes creating synthetic versions, or analogs, of naturally occurring compounds.

Protein engineering involves altering the structure and function of proteins - the chemical workhorses of the organism - using only a computer or through evolution in the laboratory.

One area of application that is showing promise is the development of designer drugs to protect against several strains of influenza virus.

In the new study, Markus Meuwly, a chemistry professor at the University of Basel in Switzerland, and colleagues experimented with various insulin analogs by strategically replacing individual atoms in the molecular structure of natural insulin.

This is a promising approach for optimizing medicinal compounds.

Computer simulations based on quantum chemistry and molecular dynamics, which model processes in the body involving insulin, allowed the team to observe the properties of the analogs.

They then carried out laboratory experiments to confirm the properties observed in the computer simulations. These experiments used methods such as crystallography and nuclear magnetic resonance.

The researchers discovered that exchanging one hydrogen atom for one iodine atom improved the availability of insulin but did not change its affinity for the insulin receptor.

It is quite conceivable, say the researchers, that their insulin analog - which differs from natural insulin by only a single atom - has clinical potential as a new drug.

The use of halogen atoms - a group that includes fluorine, chlorine, bromine, and iodine - is a promising approach for optimizing compounds in medicinal chemistry, say the researchers, who add: "Inspired by quantum chemistry and molecular dynamics, such 'halogen engineering' promises to extend principles of medicinal chemistry to proteins."

This is very interesting and practical for advancing medicine.

Insulin and Weight Gain

This blog about insulin and weight gain is one of the better blogs on the topic I have read. It is written by a certified diabetes educator (CDE), so I will need to be cautious. I do have a greater understanding of the difficulty of losing weight as a person on insulin. Would I go back to oral medications if I could – no way – the management of my diabetes as a person with type 2 diabetes is so much easier and more effective than any oral medications.

Have I had hypoglycemia from taking insulin? Yes, but very rarely. In the almost 13 full years of being on insulin, I can still count the number of episodes on ten fingers and have a couple to spare. Is my carb counting that exact – I doubt it, but I don't inject all the insulin at once and generally test to see if I might need more and how much more. In general this means keeping my blood glucose levels under 150 and closer to 120 two hours after eating. For the few times I get above 150, I immediately add the extra insulin to assure myself of bringing it back down to approximately 90 at four hours.

In a few of the author identified blogs, Nora Saul at the Joslin Diabetes Center, does an excellent job of explaining why people have such a large problem with weight gain and lays the blame squarely where it belongs, on both the patient and doctor. The patient for not wanting insulin and the doctor who encourages patients to stay on oral medications. It is this treatment of last resort that makes for problems of weight gain. It is also the myths about insulin and the fear of the patient and doctor about hypoglycemia that prevents using it early on when it would be more beneficial.

Both the patient and doctor need education in the use of insulin to make it an efficient treatment without the fear of hypoglycemia. Plus what many people forget, by starting insulin use early, this allows the pancreas some rest instead of complete burn out and not requiring the quantity of insulin when the pancreas is all but done and insulin is used as the treatment of last resort.

Also important is the consideration of nutrition and exercise, which is often easier before the weight gain. Quoting Nora Saul, “one reason people with type 2 diabetes often see the pounds pile on after they begin taking insulin is that they've waited too long to start.” I have written about this before and do believe this to be very true.

Please read the full blog by Nora Saul for her full explanation of what happens when you as the patient and your doctor avoid the use of insulin until it is absolutely necessary. You are not doing yourself any favors and only damaging your body by letting your blood glucose get too high and thereby undermining the normal metabolism of carbohydrates and fat. I have several Type 2 friends that can agree that waiting too long to start insulin is not a good idea. They will tell you it is better to start early.

Many people are not educated in counting carbs correctly and then enter the vicious cycle of hypoglycemia and eating to correct it. They often eat too many carbs for correction and then develop hyperglycemia – too high a blood glucose level. Another problem is the injected insulin (the short acting) stays in your body about twice as long than your own insulin ever did and as a result, you end up feeling hungry. This is when you need to learn that you don't need food, and must force yourself to avoid food.

Eating at regular times becomes more important to know how to gain the advantage of ignoring the hunger as too many people feed the hunger and the management of diabetes goes out the window. It does take some discipline at the start, but with time the hunger pangs will subside and become easier to manage.

She does recommend seeing a CDE for education, but I would urge you to see a good dietitian or nutritionist, specializing in diabetes, that may not push the old American Diabetes Association way (unless you are a patient at Joslin Diabetes Center), but will use the new guidelines of individual needs and desires being more important. The key here is balancing the nutritional aspects of the food you eat and learning that the old ADA way often has too many carbs which will (I mean will) help increase your weight and keep you on an upward trend. You will need to adapt to the number of carbs that works for you and does not increase your weight.

When you take insulin, glucose is able to enter your cells, and glucose levels in your blood drop. This is the desired therapeutic goal. But, if you take in more carbohydrates than you need to maintain a healthy weight — given your level of activity — your cells will get more glucose than they need. Glucose that your cells don't use accumulates as fat, hence the weight gain. Therefore to prevent weight gain, be prepared to reduce the number of carbohydrates you consume on a daily basis.

Insulin Use for Type 2

Many people with type 2 diabetes fight to avoid insulin. Yet, others cannot get their doctors to prescribe them insulin. What are the problems for these people? The first group may feel like they have failed and that the doctor is disappointed with them or a few may have a real fear of needles. Chances are they are victims of their doctor that used fear of insulin to keep them on oral medications.

The second group is battling to manage their diabetes in spite of their doctors who follow the ADA and believe they should rely on their A1c only. These patients are forced to seek out other doctors once they know that their doctor will not refer them, so they can start insulin.

Both groups are dealing with doctors that do not believe in patient centered care and may or may not have adequate knowledge of how to treat type 2 diabetes. Unfortunately, this is a fact of life for those of us with type 2 diabetes. Many of us constantly find ourselves forced to change doctors because of what the doctor says or doesn't tell us about diabetes.

A minority of doctors is willing to admit they don't know everything and do work for what is best for their patients. They refer their patients to other caring doctors if they can. If they are unable, they apply themselves and obtain advice from knowledgeable physicians and work to help their type 2 diabetes patients.

The majority of doctors bully their patients and think they are all that the patient needs. Yes, I said bully their patients. I have had a few of these doctors and will never deal with them again. They are more interested in their schedule and were determined to change my medications to what they could profit from and when I refused to take the prescription slips, told them I would not change medications or the dosage, they told me I would. I told them that I would not and walked out the door. Only one tried to get me back into his exam room, but I continued to leave and am happy I did.

On the way out, another of his patients was being taken to another exam room and he recognized me and made the signal to call him without the nurse knowing. We had a good conversation later when he asked me why I saw his doctor. He agreed the doctor was a bully and had increased the dosage of two of his medications that day. I asked him if he had a copy of his lab results and he said he never received a copy even when he asked. After some more discussion, he agreed with me and said he would change doctors.

A week later, he called and said he had changed doctors and the doctor had given him a copy of his lab results and reduced the dosage of several of his medications. When he asked the doctor why, the doctor said that the tests indicate that he was being overdosed and did not need that large a dose. The doctor continued that the next time should confirm the dosage or if it was still too large. He said the doctor showed him the test results and what the ranges were for each medication and how the lab results compared. He said this was when he was given a copy without being asked.

I told him it sounded like he made a great choice. He said he was going to ask for the lab results, but was happy that he did not need to. He said he thanked the doctor profusely, but the doctor just said he does this for all patients and he feels that he has better and more proactive patients as a result. He said that this was an eye opener for him and he is setting up a database to record each lab result and in the future to do analysis to track how he was progressing.

I said this is great and I wished him well.

Advocacy to Improve Global Access to Insulin

I say advocacy, but the title of the article is call for action. Either way this means that people around the globe often cannot get access to insulin 95 years after the discovery of insulin. This needs action to prevent this being a continuing problem when insulin reaches its century mark in 2021.

More effort needs to be devoted to ensuring people with diabetes have access to insulin. This is the finding of a new in-depth review by three public-health experts. The document was published online February 5 in Lancet Diabetes & Endocrinology by David Beran, PhD, of the division of tropical and humanitarian medicine, Geneva University Hospitals and the University of Geneva, Switzerland, and colleagues.

Much attention has been given to the access of medicines for communicable diseases, think Ebola; however, access to essential medicines for diabetes, especially insulin, has had almost no focus. Very little has been done globally to address the issue of access, despite the [United Nation's] political commitment to address noncommunicable diseases and ensure universal access to drugs for these disorders,

Insulin is essential for the survival of people with type 1 diabetes and is needed for improved management of diabetes for some people with type 2 diabetes. But, today, nearly a century after its discovery, poor access to insulin translates to a life expectancy as low as 1 year following onset of type 1 diabetes in a child in sub-Saharan Africa.

The problem isn't limited to low- and middle-income countries: even in the United States, one study found that discontinuation of insulin use due to high cost was the leading cause of diabetic ketoacidosis in people in an inner-city setting (Diabetes Care. 2011;34:1891–1896).

The new paper outlines the complexity of the problem, including the economic, regulatory, and political aspects, and provides a call to action with potential remedies. The document is aimed at all stakeholders, including professionals who care for people with diabetes, Dr Beran told Medscape Medical News.

"Healthcare workers play an essential role in ensuring that their patients have access to insulin and the necessary education for its use. I also believe that in many settings they should also help advocate for people's access to insulin where this is problematic....The call to action applies for all those who are concerned about the well-being of people with diabetes," he stressed.

In WHO and Health Action International surveys, there is a huge range in the price paid for insulin by governments — across 10 studies, for example, the cost of a range of insulin formulations varied from $2.55 to $48.25 per vial.

The experts stress that insulin also needs to be available, both at a national level, something that can be assessed by the presence of insulin on national essential-medicine lists and guidance as to where insulin should be present, for example health centers vs. hospitals, and at a global level.

The global control of the insulin market by three multinational companies means that countries have a small number of suppliers to choose from, and this has often resulted in people having to change the type of insulin they take as companies have withdrawn formulations from the market or hiked up the price of insulin analogues.

At the same time, regulatory aspects around biosimilars have limited the availability of cheaper alternatives. The shift from use of vials to the more expensive patented pen devices also plays a role, the authors note.

In linking both the availability and affordability elements, only six of the countries surveyed would meet the WHO's 80% availability target of affordable insulin in the public sector, the authors note.

They also point out that insulin alone "is not enough for proper diabetes management, which also requires syringes, blood glucose meters, education, information, and family support."

This is a complex problem that needs support.

The Problems of Hypertrophy

People using multiple daily injections of insulin often develop hypertrophy. Many people are not aware of hypertrophy. This is the enlargement of the areas that has received too many insulin injections. This enlargement is often the result of scar tissue, which causes insulin to pool in this area, and this can increase the enlargement and the scar tissue can trap the insulin and prevent it from getting into the blood stream.

This means that they often have serious blood glucose issues and are difficult to manage. To avoid this problem, many people are not taught about the areas that are useful and can be used to inject insulin. See the diagram below from BD Diabetes.

Rotating among these sites may reduce the risk of lypodystrophy, lumps of fat that develop under the skin from injecting in the same spot repeatedly. Lypodystrophy is not found in any medical dictionary I have, but the BD website uses the term.

For most of us, the stomach area works the best and the area on the arms is second best. The biggest problem many people using insulin is injecting the fast acting insulin in an area too close the long acting insulin. If you want an episode of hypoglycemia (low blood glucose below 70 mg/dl), this is how you do it. I don't recommend this, as it is dangerous and unsafe. This is the reason I use a different area for long acting insulin than I am using for fast acting insulin.

Please understand the hypertrophy is serious and can upset the best management plan. Do not inject insulin in the same spot day after day to prevent this and rotate in the selected areas. I use the different areas on a regular basis and after twelve years and four months, I have a few areas of hypertrophy. I also realize that at my age, the areas of hypertrophy may not heal as quickly so I have to be very careful.

How Long Insulin Lasts

If you are using insulin, hopefully you know about how long an insulin vial lasts based on your usage. I know and I have had CDEs tell me otherwise and I have to wonder where they received their information. A vial contains 1,000 units of insulin and one insulin lasts 10.5 days and the other insulin varies from 11 to 13 days depending on the needs and occasionally I can get 14 days.

Again, the newsletter from Diabetes-in-Control has another problem with insulin that does not make sense and in this case, we are not given all the facts and readers should be wondering where the problem lies. If the there was a problem with the amount of insulin used, no mention was made about the A1c or blood glucose levels that should have possibly accompanied the problem of insulin usage.

The patient said he used 50 units of Levemir two times per day and threw out the vial after 30 days with some insulin remaining. Granted the shelf life of Levemir is 42 days once the vial is opened. It is obvious that the insulin is not being used correctly, but as readers, we are not given information to be sure it is dose being used or whether it is half a syringe that is being mistaken for 50 units. Know the latest A1cs could have been useful.

Lessons Learned:

• Inform patient about how long an insulin vial or pen should last. Inform the patient how long an insulin vial or pen should last once opened. This stresses the importance of proper expiration once opened versus shelf life.
• Explore with the patient not only what he or she is verbally telling you, but ask how often they use a new vial or pen, and if they have extras at home. If so, how many?
• Always perform a demonstration and ask for a return demonstration, and make sure the return demonstration is done correctly before discharge.

These are all things that should be done, but seldom are done. Even I was deprived of this, but at the time, I had a neighbor that is a nurse and I did ask several questions of her for several months until I was comfortable with both the amount I was using and that I was injecting in the correct areas.

Have You Talked to Your Doctor about Insulin?

A 'Thank You' goes out to David Mendosa for his blog on December 3, which gave me a start for my own blog about people with type 2 diabetes giving insulin a fair consideration. Too many refuse to even consider insulin and as a result do not effectively manage their diabetes.

Yes, too many people with type 2 diabetes never consider insulin as the first line of treatment, but only as the last line of diabetes treatment when all else fails. The sad part of this is that they are encouraged by doctors to only use oral medications with many unpleasant side effects.

Many people with type 2 diabetes are not willing to give up their poor eating habits and as a result, the oral medications are not able to manage diabetes. Diabetes then becomes progressive and steadily becomes worse. The doctors keep adding one oral medication after another to help manage diabetes – to no avail. It is what the doctors want because they have an unhealthy fear of insulin causing a low (hypoglycemia).

That is the reason doctors keep changing and/or stacking one oral medication on top of another. They even use the threat of insulin to get you to change your eating habits and manage your diabetes more effectively. But, you are so afraid of insulin that you will not even consider it. For some it could be the fear of needles and for others it is the desire to stay on pills. For others, the insulin myths have a huge effect in scaring them away from great diabetes management.

David has some good questions to ask your doctor about insulin and I agree with most of them. The last two may get negative responses from your insurance company, Medicare will not authorize number six in his list, and even people with type 1 are denied access when they should have CGMs.

If you are a person newly diagnosed, be aware that most endocrinologists will work with you on insulin and often will prescribe insulin to help you manage diabetes effectively to give your pancreas time to recover from the strain you have given it before diagnosis.

Know that by using a low carb/high fat meal plan is also good for you and will make diabetes easier to manage and will not require a lot of insulin. I have written about making insulin the first choice for treatment of type 2 diabetes. I have also written about what to do when first diagnosed.

Type 2, Use Insulin as Another Medication Tool

When I wrote this blog, I knew then that more would be said on the topic. Insulin for most doctors is not a word they want to hear. They threaten patients with it to convince patients to stay on oral medications. Then they stack oral medication on top of oral medication. This causes many patients to conclude that when they are required to use insulin that they have failed and this is their punishment.

And many people listen to these inept doctors when they should know better. Insulin is just another tool in the arsenal for managing diabetes. Many people with type 2 diabetes do use insulin. Others feel that using insulin makes them a failure. This should never be the case, but our doctors have been behind promoting this to keep patients on oral medications and because of the fact that doctors fear hypoglycemia to the point it clouds their thinking.

Insulin is simply a necessary and beneficial addition to diabetes management. There are a few reasons why people that have not needed insulin to require it (and possibly on a temporary basis). Gestational diabetes, surgery, broken bones, cancer, and taking steroidal medicines (prednisone for example) can require some people to take insulin for a temporary period. Then some people end up needing insulin on a permanent basis as they age because the pancreas becomes unable to produce enough insulin. Sometimes they have been on oral medications that force the pancreas to produce insulin and the pancreas can no longer produce sufficient insulin.

Now back to feeling as a failure because of needing insulin. When we age, the functioning of our pancreas often decreases and becomes unable to produce the quantity of insulin necessary for our cells to function and provide the energy we need. Because we are human, we don't always maintain a healthy food plan and exercise regimen and our blood glucose levels rise dramatically to a level only insulin can control.

When the dose of insulin is discussed, I urge you to read this about the three methods of dosing. It has been the experience of our support group that most doctors, CDEs, and dietitians all prefer the fixed dose of insulin. This in turn forces us, as patients, to eat a fixed number of carbs which may not be the best solution.

Yes, we need to learn how to count carbs and know what foods are safe in a food plan. This we can use when we are not feeling like eating but a snack, are under stress, have an infection, cannot exercise, or need to avoid food. This will help in managing our blood glucose levels and prevent having an episode of hypoglycemia. The amount of insulin needed will also depend on a patient’s weight, eating habits, exercise levels, other illnesses, and level of insulin resistance.

I prefer the third dosing method and use it because I have learned how with a little help from the endocrinologist. Having insulin resistance does make the adjusting more complicated at times as the level of insulin resistance has varied for me. Just when I think I have it down, it changes. I would encourage you to read this on blood glucose variables and this on more variables.

I am happy that I am on insulin and one 500 mg dose of metformin ER. I am better able to manage my diabetes, even with all the variables. I moved from oral medications to insulin about 3 months after diagnosis. Therefore, I had none of the feelings of failure, as I was able to embrace insulin and a better tool for the management of my diabetes.

Goals for a Person with Type 2 Diabetes

Our December 6 meeting was somewhat different than most meetings. We welcomed two additional members bringing our total to 33 members. The topic of goals was our discussion for the meeting and Max and I were the leaders.

What are reasonable goals for a person with type 2 diabetes? This is a topic that has bothered me for the last few months. In our support group, we all have different goals and most seem satisfied with their goals. Do we always achieve our goals? Not even all of us achieve our goals every time we see our doctor, but for the most part, as a group we don't miss by a lot. While the average age varies every time we add to the group, the majority are now over the age of 61. However, this does not establish goals for anyone.

The first thing I want to emphasize is that there are no standard answers or rules. I did remind everyone of the rules in this blog. We all strive to maintain certain limits that we can live with or tolerate. We all agree to attempt to keep our A1c's under 6.5% and lower if possible. We have all stated that we need to keep our lipid levels in range, if possible, but we seldom discuss this part of our lives. We have also agreed that our goals are ours and not for anyone else to follow. It happens that several of us have very similar goals and we probably talk about this more than the rest. At present, none of us is limited cognitively and this is something we have agreed among ourselves to maintain a link to watch for any cognitive problems. Diabetes and cognition are two of the factors that have bound us more tightly as a group because we care about each other as individuals.

Even as individuals, it has been enlightening how we set our goals. With the current number of thirty-three members and twenty-one of us being on insulin, there is quite a bit of similarity among us. Sue is still off all medications and she is happy that we support her with her goals. She wants to keep her A1c as close to 5.5% or under if possible. Even her husband is surprised at her success as her last A1c was 5.2%. She was the youngster in our group and we did tease her about this. She replies that if the old fogies would learn from her, we could be a lot healthier.

With the A1c range for people without diabetes (normal range) according the Joslin's Diabetes Deskbook being from 4.0% to 6.0%, we have to remember that prediabetes is defined from 5.7% to 6.4%. Prediabetes is another topic that many wish would be labeled as diabetes. Because A1c values do vary quarterly, some are suggesting that we should check the A1c values monthly. For more information on this, please read this blog by David Mendosa. We used David's blog for discussion about this.

With this in mind, here are some goals for people to look at as possible goals they should consider as their own. Therefore, select realistic goals and work toward them.

Of the twenty-one members on insulin, our A1cs range from 5.2% to 6.5%, as of the latest A1c values. Some of us have the same A1c and don't get too concerned since this should be expected. Max and I are the only two that occasionally exceed 6.5% and then we have to work very diligently to make sure we get below 6.5% on the next A1c. Those on oral meds had a greater variance and are still learning to manage their diabetes after learning more on management.

We are all careful to avoid hypoglycemia and three of the individuals have never had hypoglycemia. Since I have been on insulin the longest, by about two years, I have had the most incidents of this. On several occasions, I knew as soon as I put down the syringe that I was going to need to be aware of and prevent this from happening. On two occasions, I accidentally injected my short-term insulin in the same area as the long-term injection. I stayed up late both nights and fortunately had enough test strips and glucose tablets to stay out of trouble and only get to the lower 60's for blood glucose levels.

I have had eight readings below 70 mg/dl in the ten years on insulin and the next person has had only five readings below 70. Then the numbers go to three and two. Several of the group tries to constantly remain under 125 mg/dl and above 80 mg/dl and have been very successful at it.

We are all fortunate to have the test strips we need or be able to afford more if insurance limits us. Thirteen of us do obtain our diabetes supplies and medications from the veteran’s administration (VA) and are thankful for that. Our testing supplies are very much what we need, and we make use of them.

We are now close to 2015 and have now added sixteen additional members that are very happy to have us helping them. Brenda and Sue are probably the most pleased, as six of them are women and are happy to have others to talk with. Of the eight, four are on insulin and three are on oral medications, with Sue on no medications. The ones new to the group were very curious as to why so many of us were on insulin. Brenda was happy to say “Greater ease of management.” Many questions were answered about multiple daily injections and testing. They were surprised at our relaxed attitude about this and that fact that most of us did not think anything about the extra testing and multiple injections.

They were all surprised that we used our arms and different parts of our bodies for injecting insulin. They were very interested in why and Brenda was happy to answer that we needed to prevent insulin absorption and utilization problems and avoid creating scar tissue under our skin. This in turn would affect the insulin utilization and cause insulin waste if scar tissue caused the insulin not to disperse from the injection site. Some may escape, but not the full amount injected.

Then the question was asked about alternate site testing. We all stated that we used our fingers and not alternate sites because we wanted the “now” reading for accurate correction data and needed to know this. If we were going up or down was also mentioned. Then Tim said that for those on oral medications other than sulfonylureas, alternate site testing would work if their readings were fairly consistent.

The meeting ended and there was some intense discussion.

Managing Diabetes When Pills Aren't Working

Sometimes, articles are published just when you need them. When wrote my blog on May 8, 2013, about helping a veteran get assistance and get on insulin, I was feeling great. She is happy to be on insulin and says her last A1c was 5.8%. Since then I have corresponded via email with two doctors that are against insulin use for type 2 diabetes until it becomes necessary. They have their reasons and it is not what I usually hear – the fear of hypoglycemia. They have told me that as long as a person with type 2 diabetes is producing insulin, they need oral medication to help in the utilization of that insulin and not additional insulin.

We have agreed to disagree because they are not afraid of insulin and do not wait until it is too late to prescribe insulin. They also agree that insulin should never be the medication of last resort, but they do agree that the tests of A1c and insulin produced do need to be done when the A1c gets above a certain point. They claim this should also be age dependent, but agree that there are individual variances.

We have discussed using insulin at diagnosis to help the pancreas recover, but they say that is not proven. I also say that the side effects of many oral medications are unacceptable and still questionable. Claim and counter-claim is the reason we have agreed to disagree. All three of us were in agreement that much information has been deleted from the National Diabetes Information Clearinghouse and even they are suspicious about what has been deleted and not added. All of the warnings required in the product packages have been removed and several products that had warnings, but are still on the market like Victoza that is no longer on the site.

The correspondence has been open and they appreciated that I was giving URLs for information on my side. We had some good discussions about a few studies and when they referenced one study, I asked why they would rely on junk science. I sent the URL to my blog on the study and another blog by someone else calling this junk science. Just testing was the response and then the discussions got serious. When I did not have access to a study, but only the abstract, I told them this. Occasionally, I was able to provide other blogs on the topic.

Rather than make this a very long blog, read this article in WebMD about overcoming objections to injections.

Type 2 Diabetes Turmoil in Treatments

Yes, there is a lot of turmoil in the type 2 medications treatment arena because of poor science like this article. The headline of the article in Medscape is “Deaths Higher When Insulin Is Second-Line Treatment for Type 2 Diabetes.” The title for the WebMD article is “Insulin-Metformin Combo Tied to Poorer Survival” and subtitled, “Other experts dispute the study's conclusions.” This blogger, Jenny Ruhl has a better title - “Why Insulin Plus Metformin May be Associated with Higher Mortality.”

I find it very hard to believe that Medscape and WebMD are related companies because of the two varied titles. I can believe the Medscape article headline is true because too often insulin in the second or even up to the fourth line of treatment. In reality, insulin should be the first line of treatment. David Mendosa writes an excellent blog here about the benefits of insulin being a short first-line of treatment.

I am in disagreement with the lead author of the research, Christianne L. Roumie, MD, associate professor of internal medicine and pediatrics at Vanderbilt University, Nashville, Tennessee. She states it is better to use two oral medications before progressing to insulin use for people with type 2 diabetes. The preferred second drug is a sulfonylurea and her study claims that this combination causes less death than metformin and insulin combination.

What she seems to forget is that the sulfonylureas have come under investigation as causing cardiovascular deaths as well. Read my blog about this here.

Most family doctors or primary care doctors know so little about dosing insulin that they stack oral medication on top of oral medication until insulin is required. They also attempt to keep type 2 patients on oral medications until it is too late for insulin to really help the way it should have if used earlier. In addition, general practitioners are afraid of hypoglycemia and this also drives them to want to keep type 2 patients on oral medications.

Then the author all but negates the study by making the following statement. “She also cautioned that findings from work such as this can create uncertainty. The complex statistical methods needed to overcome the various sources of bias and confounding that are inherent in observational research and the fact that this is a comparative-effectiveness study make it difficult for clinicians to interpret the data, she noted. "Given these caveats, many clinicians will probably refrain from making practice changes based on this study."”

Insulin Medications Very Prone to Error

As much as I advocate for insulin use,this study from the Pennsylvania Patient Safety Authority (PPSA) does explain some problems many diabetes patients encounter. The Institute For Safe Medication Practices states that insulin accounts for more than 10% of all drug mistakes. Even scarier is this drug class has been rated as having the most mistakes every year for the last 20 years.

The PPSA did their study of state hospitals focusing on medication errors. Dispensing insulin was the most frequent of all medication mistakes made.

1. 20 percent of patients were given the wrong kind of insulin from the pharmacy.
2. 18.4 percent of patients were supplied with the wrong mix of insulins.
3. 17.4 percent of mistakes were due to misreading of prescriptions.

Obviously one of the reasons for the error rate seems to be due to simple confusion – with 13 different types of insulin available in five different categories and four similar names. The five categories are:

• Premixed
• Long-Lasting
• Intermediate Acting
• Short Acting
• Rapid Acting

The similar names are:

• Humalog
• Humulin
• Novolog
• Novolin

See the chart here for the types of insulin. Now consider that in the next few years we can expect to see at least 3 to 6 more unique insulins that could be slower in action, more rapid onset, longer acting, and many more combinations. The number of mistakes can be expected to increase when the medication is insulin.

Many of the insulin medication errors can be very dangerous and cause death. This can lead to legal action and higher insurance rates. If you are hospitalized and you are able, always be prepared to check and recheck that you are getting the same insulin you use and check the carb count to be sure that you are not overdosed in the process.

I have had problems and the hospital wanted to give me Levemir only, but I use Lantus and Novolog. Since I had my own insulin and they did not have either, I politely refused and used my own. The second time I had just had an operation and was only allowed broth so I did not need insulin and politely declined other foods and knew I would be home before I would have reading near 140 mg/dl. The nurses did test my blood glucose and were surprised I knew what my readings would be (always within 5 points) and upon arriving home, my reading was only 132 mg/dl.

Are Non-Insulin Type 2's Over Medicated?

I ask this question because I feel that the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) are over medicating people with type 2 diabetes that are not on insulin. They are doing this because many doctors do not stay current with insulin and many doctors are afraid of insulin.

This is why many patients are complaining about their doctors stacking one oral medication on top of another oral medication. Some doctors will prescribe up to four or more different oral medications. Many doctors don't even realize the side effects of doing this and many just follow the ADA and AACE and continue adding oral medications.

It is true that some individuals are able to do this without medical drug conflicts, but many become confused and even have episodes of hypoglycemia and other health problems because of this uninformed stacking of oral medications.

Another aspect that concerns me is the fact that the Food and Drug Administration (FDA) has not approved many of the oral diabetes drugs to be used in some combinations. Some combinations are relatively safe for many individuals, but unsafe for other individuals. Yet doctors continue to prescribe these unproved combinations willy-nilly and when patients have problems, blame the patients.

Even the AACE algorithm shows adding medication on top of medication. All show oral medications and recommend them before insulin for type 2. Some recommendation is made for insulin when HbA1c is above a certain level. However, many doctors do not even consider this.

The doctors do not know insulin or how to administer it. They are literally afraid of hypoglycemia and therefore keep pushing oral medications. Some doctors will use insulin as a threat and tell the patient they are failing to manage their diabetes on oral drugs. Most patients realize the need for insulin before their doctors do and are castigated for asking about or for insulin.

What are patients to do? Under the new insurance, if you can call it that, the number of doctors is limited and finding another doctor that knows insulin is very tricky. This said, I would still recommend trying to find another doctor that will work with insulin. Even a doctor that is some distance away may be a better choice for your diabetes health. Talking to your insurance company for a recommendation is still a good policy.

Do You Love Insulin?

Type 2 diabetes and insulin go well together when needed, but I certainly do not love insulin. Yes, I advocate for insulin use because it is generally not prescribed except as the medication of last resort. Many doctors also use insulin as a threat telling their patients that they have failed in their management of type 2 diabetes. The last time I had a doctor tell me that he wanted me to go back on oral medications, I said no way doc and left.

In the months since, I have talked to two other people with type 2 diabetes and both have similar experiences of having been intimidated by their doctor to stay on oral medications. The one woman was beside herself because she had lost weight and increased her exercise regimen, but her blood glucose levels continued to rise. When I met her, she was having trouble obtaining readings below 200 mg/dl. As we were talking, I saw Brenda and asked her to come over.

After introductions, I had the person tell Brenda what had happened. Brenda spoke up as I knew she would and was very explicit about her feelings toward some doctors. Brenda asked where she was seeing her doctor and asked if she would consider changing as she felt her doctor was good and that the endocrinologist I was seeing would be a good fit for her. After finding out where each doctor was located, she decided to start with the doctor Brenda was seeing.

Brenda said she had one more thing to purchase and then she would accompany her to her doctor and attempt to get her an appointment as soon as possible. I said good, as she needed to get her blood glucose levels down quickly. We continued to talk while Brenda finished her errand. I told her to make sure she obtained her telephone number to ask her questions. I said she may also give you her email address and information about our support group and I gave her some information about that.

When Brenda was finished, she asked where the person was parked and said since it was close she could ride with her and after she had obtained an appointment, she would bring her back to her car.

About 15 minutes later, I received a call from Brenda to inform me that the doctor was seeing her then. Later Brenda called again and said she had Allen and several others meeting them where I had introduced the person to Brenda and I was invited. We had an hour of discussion about insulin and she had had an injection while seeing the doctor and would wait without food for four hours and take another reading to see what her blood glucose level was. Then she would call the doctor. She would then be given another dose to inject herself. She would also be given an insulin to carb ratio to start with.

Allen said good, this was a good way to learn what her ratio was and not to have a snack while she was waiting. We nicknamed her Susan after Brenda said she would be at our next meeting. Susan said she was fairly proficient with carb counting and this would help in getting used to insulin.

Tim arrived then and after introductions set his laptop up and asked for her email address. Susan looked alarmed and Brenda said it was okay as this was the way we stayed in touch and it was only for our use and not for sale. If she joined our group, she would be given notice of all meetings and if she could not attend one meeting, she would receive a summary of the meeting. Those were normally done anyhow, but it was one thing that seemed a good reminder of the discussion.

Then Brenda said you would also be given the emails for all members and the URLs for good reading about diabetes, if you are interested. Then Brenda pointed at me and said this is the blogger of our group and you will be given the URL for his site. Brenda then said I don't read every blog, but I do read more than I tell him. Susan asked, you write about diabetes? I said yes, and related topics you may or may not have an interest in exploring.

At that point, Susan asked if anyone read the blogs by Tom Ross and Tim said most of us do and Bob also has lists of other type two bloggers and pulled up the first list and then the second and rest of the lists. Then Susan asked why she had not seen one blogger, and Brenda stated because she has type 1 diabetes. Brenda continued that we read many other blogs, but Bob only lists type 2 bloggers. Susan asked if we participated on any of the diabetes forums. I said we have, and once I have your email I can send you a list of those that I am aware are active.

Susan said that was not necessary as she had five currently. Brenda and Susan both said they needed to head home and Brenda said to call after she had talked to the doctor and that once she had the list of members with emails and phone numbers, any of us could also answer questions. Brenda thanked me for having brought her into the discussion with Susan and Susan echoed that. Tim, Allen, Barry, and I talked a little longer and then headed for home.

Is There A Best Way for Type 2 To Bolus?

Everyone seems to recommend something different when type 2 people are put on insulin. I know that everyone is afraid of insulin and doctors and others are all worried about people not injecting their insulin. This is discussed at great length in this Joslin blog, but I wonder if this is the best way. I dislike that the blog author is giving many of the insulin myths credit without giving them the recognition and doing something to disprove them.

It is as if the author believes the myths and it reads as if this is why they need to find new ways to ease patients new to insulin into injecting. I realize that some people start out with basal insulin (long acting) before bed and this is reasonable if they need help with the oral medication.

A little background here. I went from two oral medications to basal (Lantus – long acting) and bolus (Novolog – rapid acting) insulin during the day and have never looked back. I knew that I needed insulin for better diabetes health and I was ready for it. I have not regretted the decision and I have been better off as a result. I was working part-time and my boss knew that I had diabetes when I was in the hospital for a heart problem. There was never any problem with finding time for injecting and taking care of my diabetes.

I know not everyone is given the latitude by their employer to take care of their diabetes like I was, but the Americans with Disabilities Act can be used if there are problems. Yes, diabetes falls within the disabilities and provides some protection at your job. And, yes, I admit to being a trifle callous after having a great boss and other employees to protect me. At least he knew about the Americans with Disabilities Act and made sure all employees knew something about it.

As a result, I find that too many people -

1. Want to keep diabetes a secret.
2. Are afraid to inject insulin without complete privacy.
3. Let their fears overcome their health needs.
4. Cling to diabetes myths because they don't understand insulin.

The above reasons are bad enough, but then add to this the fear of what the doctor is saying about insulin being a punishment and common sense health care goes out the window. Then when bloggers on the Joslin diabetes blog have to use words like – too burdensome and overwhelming, and more cumbersome, people have to wonder if there is something wrong with insulin.

I have a fear that too many diabetes care professionals are not using positive thinking about insulin and the benefits of insulin, but are letting people with type 2 diabetes dictate the necessity of avoiding insulin. Yes, they want adherence to insulin and are therefore trying to baby step patients into insulin. This is unfortunate for many people that need insulin to better manage their diabetes.

If it seems like I am saying to push insulin all at once, yes, I am because then you adjust and should take it in stride. I know many people that have done this and most of the members of our support group started insulin in one day and are all happy they did and were able to improve their diabetes management. I can feel for those that do not have a family support structure, workplace support structure, or support group for support, but the quicker they move away from oral medications to the full insulin regimen, the better they will be.