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Commentary

Improving Transition to Insulin Through Clinical Conversations

  1. Jana L. Wardian
  1. Diabetes Center of Excellence, Wilford Hall Ambulatory Surgical Center, Joint Base San Antonio, Lackland AFB, TX
  1. Corresponding author: Jana L. Wardian, Jana.L.Wardian.ctr{at}mail.mil
Clinical Diabetes 2020 Jul; 38(3): 285-286. https://doi.org/10.2337/cd19-0089
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Recent work suggests that how we talk to people with diabetes can play a role in their level of engagement and how they conceptualize diabetes management and affect both their treatment outcomes and their motivation and behavior (1,2). As we apply these concepts to transitioning to insulin therapy, clinicians may need to examine how they characterize insulin and discuss it with patients with type 2 diabetes.

Patients who perceive diabetes-related stigma are more likely to have a negative orientation to insulin (3). Thus, it is important to avoid using stigmatizing language and vilifying insulin (4). Insulin is not the “bad guy” and should not be used as a threat to reinforce the need to change behavior before it is too late. Perhaps, unwittingly, you have said one of the following to a patient.

  • “If you don’t start exercising and lose weight, I’m going to start you on insulin.”

  • “You aren’t getting good control with the oral meds you are taking. We have to put you on insulin.”

  • “If you don’t want to be on insulin, you had better lose weight!”

Without meaning to, you may have created a barrier to future insulin therapy (5). Most nurses and primary care clinicians (50–55%) delay insulin until absolutely necessary, viewing it as a last-ditch effort (6,7). However, oral or noninsulin injectable diabetes medications may not be enough over time, and a guilt-free door should be kept open for insulin therapy.

Discussing the progressive nature of diabetes early and often may prepare patients for a smoother transition should insulin therapy become the best treatment option (8). Consider the need for reading glasses in so many people who are over 40 years of age. No one says, “You should have eaten more carrots when you were younger!” They can just pull out their “readers” and use them to cope with this common aging-related deficit, without the fear of being shamed by anyone.

Insulin therapy may become necessary given the progressive nature of diabetes. Consider the following strengths-based ways of discussing insulin therapy:

  • “Diabetes is a progressive disease. Your body may require insulin at some point.”

  • “You’re working really hard on managing diabetes, and I think it’s time we add insulin therapy.”

  • “I think you would feel so much better if we add insulin to your diabetes treatment. What do you think?”

The benefits of insulin may include simplification of the medication regimen, and long-acting insulin has a relatively low risk for hypoglycemia (9). It is important to explain these benefits of insulin therapy to patients.

It is also important to be aware of personal attitudes and biases concerning insulin therapy. After you have insight about your own attitudes concerning insulin, asking patients about their understanding of insulin may help target specific fears and hesitancy. For example, for patients who fear injection pain, showing them how tiny the needles are and actually helping them self-administer a saline injection in the office may allay their fears.

Communicating positively with patients who may need insulin may reduce therapeutic inertia and even foster treatment acceptance.

Article Information

Duality of Interest

No potential conflicts of interest related to this article were reported.

Disclaimer

J.L.W. is the sole author of this commentary and is responsible for its content. The opinions expressed are those of the author and do not reflect the official policy of the Department of Defense or its components.

  • © 2020 by the American Diabetes Association
https://www.diabetesjournals.org/content/license

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at https://www.diabetesjournals.org/content/license.

References

  1. 1.↵
    1. American Association of Diabetes Educators
    . Speaking the language of diabetes: language guidance for diabetes-related research, education, and publications. Available from https://www.diabeteseducator.org/practice/practice-tools/app-resources/diabetes-language-paper. Accessed 10 February 2020
  2. 2.↵
    1. Dickinson JK,
    2. Guzman SJ,
    3. Maryniuk MD, et al
    . The use of language in diabetes care and education. Diabetes Care 2017;40:1790–1799
    OpenUrlAbstract/FREE Full Text
  3. 3.↵
    1. Holmes-Truscott E,
    2. Browne JL,
    3. Ventura AD,
    4. Pouwer F,
    5. Speight J
    . Diabetes stigma is associated with negative treatment appraisals among adults with insulin-treated type 2 diabetes: results from the second Diabetes MILES–Australia (MILES-2) survey. Diabet Med 2018;35:658–662
    OpenUrl
  4. 4.↵
    1. Liu NF,
    2. Brown AS,
    3. Folias AE, et al
    . Stigma in people with type 1 or type 2 diabetes. Clin Diabetes 2017;35:27–34
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Meece J
    . Dispelling myths and removing barriers about insulin in type 2 diabetes. Diabetes Educ 2006;32(Suppl.):9S–18S
    OpenUrlCrossRefPubMedWeb of Science
  6. 6.↵
    1. Khunti K,
    2. Millar-Jones D
    . Clinical inertia to insulin initiation and intensification in the UK: a focused literature review. Prim Care Diabetes 2017;11:3–12
    OpenUrlPubMed
  7. 7.↵
    1. Peyrot M,
    2. Rubin RR,
    3. Lauritzen T, et al.; International DAWN Advisory Panel
    . Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study. Diabetes Care 2005;28:2673–2679
    OpenUrlAbstract/FREE Full Text
  8. 8.↵
    1. Polinski JM,
    2. Smith BF,
    3. Curtis BH, et al
    . Barriers to insulin progression among patients with type 2 diabetes: a systematic review. Diabetes Educ 2013;39:53–65
    OpenUrlCrossRefPubMedWeb of Science
  9. 9.↵
    1. Nakar S,
    2. Yitzhaki G,
    3. Rosenberg R,
    4. Vinker S
    . Transition to insulin in type 2 diabetes: family physicians’ misconception of patients’ fears contributes to existing barriers. J Diabetes Complications 2007;21:220–226
    OpenUrlCrossRefPubMedWeb of Science
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Improving Transition to Insulin Through Clinical Conversations
Jana L. Wardian
Clinical Diabetes Jul 2020, 38 (3) 285-286; DOI: 10.2337/cd19-0089

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Improving Transition to Insulin Through Clinical Conversations
Jana L. Wardian
Clinical Diabetes Jul 2020, 38 (3) 285-286; DOI: 10.2337/cd19-0089
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