This article is more than 5 years old. Information may no longer be current.
Facilitating insulin initiation in type 2 diabetes
Click Here to Manage Email Alerts
The results of the Diabetes Attitudes, Wishes and Needs (DAWN) study revealed that resistance to insulin initiation by both provider and patient is significant.
Diabetes educators can facilitate the initiation of insulin by using effective communication techniques and utilizing behavioral strategies. The health care practitioner’s rationale for starting insulin usually includes exhaustion of oral medication effectiveness, improvement in HbA1c and avoiding the long-term complications of diabetes. These may be the concerns and rationale for the health care practitioner, but are these concerns important to the patient? From personal clinical experience, I would have to say no. The beliefs and concerns most often expressed include:
- Self-blame: “My diabetes is getting worse. I must be doing something wrong.”
- Lack of confidence: “Any shot I have ever gotten was from a nurse or doctor. They are the professionals, I am not.”
- Past experience: “The last shot I got was a vaccination and that hurt for days.”
- Weight gain: “Everyone I know on insulin gains weight.”
- Fear of hypoglycemia: “I live alone. There is no one to help me if my sugar goes too low and I pass out.”
- Inconvenience: “I have a busy schedule. I can’t add one more thing I need to do every day.”
- Possible health consequences: “My father lost all his toes after starting insulin.”
|
|
From the list of concerns and beliefs, it is clear that diabetes educators deal with more than ensuring the patient has the necessary skill sets to properly self-administer insulin. It is clear from the statements above that all patients bring their own unique set of circumstances and history to an educational session. Most people live in the “here and now” and find that consciously doing something that will affect their future health status very difficult.
It is important to discern and understand the immediate concerns of the patient when proposing any therapy change, especially insulin initiation. Give patients the opportunity to articulate their concerns and help them explore more immediate personal benefits for starting insulin. Possible rationales for initiating insulin that would resonate with the “here and now” realm that most patients live in would include feeling better, having more energy and possibly saving money if the insulin replaces other expensive oral agents.
Starting the insulin conversation
Given that type 2 diabetes is now occurring at younger ages than in the past, it is reasonable to conclude that these individuals will outlive their beta cell function and at some point require insulin to manage their blood glucose levels. Discussion regarding insulin therapy needs to occur long before it is required to achieve blood glucose target goals. The health care team needs to work together to inform the patient that diabetes is a progressive disease whereby insulin may be required due to physiological reasons, not lifestyle modification failures. Diabetes educators can provide the opportunity for patients to discuss their concerns about insulin and address patient barriers. For example, there are some diabetes self-management education programs in the country that provide all type 2 patients, insulin-using or not, the opportunity to give themselves a saline injection. This activity serves many educational purposes. It allows for more open, personal and real-time discussions regarding concerns, myths and barriers to using insulin. Poking yourself with a needle is not a normal or desirable activity, but experiencing it within a group setting increases confidence in the ability to properly administer an injection and appears to reduce the fear of injection. No one is forced to participate but even the observers benefit from the experience. Injecting insulin is demystified and can potentially serve as a “positive past history” if and when insulin is required.
Words matter
The old adage, “It is not what you say, but how you say it,” is also applicable to how insulin initiation is approached. Even if you are not directly responsible for prescribing or teaching insulin injection, you can promote a “culture of insulin acceptance” by how you refer to insulin. For example, instead of saying, “You failed on oral therapy,” state, “It is time to progress therapy to match the progression of the disease.” Or, instead of saying, “You are going on insulin,” simply say, “We need to transition to insulin.” Both of the “you” statements are not neutral but imply blame, failure and provider authority. Insulin initiation should not be portrayed as a consequence of personal failure (patient or provider) or punishment.
There is no denying that legitimate concerns regarding insulin use exist, but insulin may be necessary to reach blood glucose goals. Referring to insulin in a positive vernacular is a beginning. Health care providers and diabetes educators in particular can reduce the perceived negative aspects of insulin by addressing patient concerns and barriers and providing information and opportunities to support insulin use and improve metabolic control.
Mary M. Austin, MA, RD, CDE, is Owner and President of The Austin Group, LLC in Shelby Township, Mich., and is an Endocrine Today Editorial Board member.
For more information:
- Funnell MM. Insulin. 2008;3:31-36.
- Peragallo-Dittko V. Diabetes Educ. 2007;33:60-65.
- Peyrot M. Diabetes Care. 2005;28:2673-2679.
- Polonsky W. Diabetes Educ. 2007;33:241-244.