Improving Transition to Insulin Through Clinical Conversations

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.

• © 2020 by the American Diabetes Association