Diabetes is a global epidemic and the number of people with diabetes globally is growing at an alarming rate. An estimated 463 million adults (20-79 years), or about 1 in 11 adults worldwide, are living with diabetes across the world in 2019; by 2045 this will rise to 700 million1.

Globally, the number of people with diabetes has quadrupled in the past three decades, and the condition is the ninth major cause of death. In 2019, the number of deaths resulting from diabetes and its complications is estimated to be 4.2 million1.

Diabetes is a chronic condition that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. The body’s inability to produce sufficient levels of natural insulin can lead to diabetes – both inherited Type 1 and Type 2.

Type 2 diabetes (formerly called adult-onset diabetes) results from the body’s ineffective use of insulin. Until recently, this type of diabetes was seen only in adults but it is now also occurring increasingly frequently in children.

Although genetic predisposition partly determines individual susceptibility to Type 2 diabetes, an unhealthy diet and a sedentary lifestyle are important drivers of the current global epidemic.

The proportion of people with Type 2 diabetes is increasing in most countries; an estimated 90% of people with diabetes worldwide have Type 2 diabetes. Asia is a major area of the rapidly emerging Type 2 diabetes global epidemic, with China and India the top two epicentres2.

Unchecked diabetes can be dangerous

Since the symptoms of Type 2 diabetes are often less marked, the condition may be diagnosed several years after onset, once complications have already arisen. Uncontrolled diabetes over time can lead to serious damage to many of the body’s systems, as it affects many major organs, including your heart, blood vessels, nerves, eyes and kidneys.

Although long-term complications of diabetes develop gradually, they can eventually be disabling or even life-threatening. Type 2 diabetes is associated with shortened life expectancy and decreased quality of life.  Besides a decrease in the number of years of life, the condition becomes expensive to treat when complications arise.

Cardiovascular complications are the leading cause of morbidity and mortality in patients with diabetes. Poor glycaemic control can also lead to complications like chronic kidney disease, serious eye diseases such as cataracts and glaucoma potentially leading to blindness, as well as, damage to nerves.

Controlling your blood sugar levels can help prevent these complications.

Early insulinization in Type 2 diabetes

Type 2 diabetes is characterised by progressive loss of function of beta cells, a type of cell in the pancreas that makes insulin to regulate sugar metabolism.

When diabetes is first diagnosed, current guidelines recommend diet and lifestyle modification with or without oral diabetic agents (OADs) like metformin as the first step in treating Type 2 diabetes. If these measures are inadequate, doctors will add additional OADs such as sulphonylurea, thiazolidinedione, DPP-4 inhibitor, GLP-1 receptor agonist.

Most of these OADs typically work by attempting to stimulate the beta cells in the pancreas to produce Insulin. After a while, the overworked beta cells gradually burn out and lose their ability to produce insulin and  you finally move into full-blown diabetes.

By actually giving the body insulin right in the beginning when it needs it, you can probably rest the beta cells and slow down the progression of the disease. Allowing a poorly functioning pancreas to rest can possibly help revive insulin secreting beta cells. Research has shown that lowering glycated haemoglobin is more easily achieved with insulin than with oral agents and can help to preserve beta-cell function.  The earlier the initiation of basal insulin, the greater the lowering of HbA1c and incidence of morbidity and mortality as a result of diabetes.

While early insulinization therapy is regarded as an efficient aid to improve long term control and quality of life in patients with Type 2 diabetes, intensive treatment is not advised in those over the age of 70, where there is diabetes of long duration, established cardiovascular disease and a high risk of hypoglycaemic episodes3.

Barriers to early insulinization

Though early insulinization therapy is regarded as an efficient aid to improve long term control and quality of life in patients with Type 2 diabetes, patients’ misconceptions about insulin therapy result in major barriers to early initiation of therapy.  Often clinicians are also reluctant to begin insulin treatment. Psychological insulin resistance (PIR) is most observed in insulin-naïve patients as they keep on delaying insulin use because of the fear of taking injections as well as their inability to appropriately estimate and time doses with meals. Social stigma related to taking injections and the pressure to keep injection use discreet also result in PIR.

Studies show that other common barriers to insulin initiation among insulin-naïve patients include misconceptions regarding insulin risk, beliefs that needing insulin reflects a personal failure, concerns that insulin is ineffective and that insulin injections are painful, and anxiety about long-term complications and side effects of therapy, loss of independence, and cost4.

In order to initiate insulin therapy earlier in disease process and to avoid serious complications resulting from poor glycemic control of diabetes, health education of both patients and primary healthcare physicians is warranted.

Lifestyle modification also important

Before opting for insulins, lifestyle changes can go a long way in keeping sugar levels in check. Lifestyle changes could include maintaining a healthy body weight, consuming a healthy diet, and staying physically active.

Diabetic patients need to eat a small snack between meals to help keep blood glucose levels up. Regular snacks can make it difficult to maintain a healthy weight, so checking with the diabetes team for specific advice is needed for diabetes management.

Physical activity such as walking, swimming or jogging is important for using up spare glucose in the body and making the joints and muscles sensitive.

If diet and exercise are not helping reverse diabetes then a patient needs to consult a specialist to discuss whether he or she should be initiated on insulins.

 

References:

  1. IDF Diabetes Atlas 2019
  2. Zheng, Y., Ley, S. & Hu, F. Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nat Rev Endocrinol 14, 88–98 (2018)
  3. Bolli, Geremia. Early insulinisation in Type 2 diabetes (2014)
  4. Brod, Meryl et al. “Barriers to initiating insulin in type 2 diabetes patients: development of a new patient education tool to address myths, misconceptions and clinical realities.” The patient vol. 7,4 (2014): 437-50.

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