Type 2 diabetes is a progressive condition characterised by initial insulin resistance followed by gradual loss of beta-cell insulin secretary ability. The UK Prospective Diabetes Study (UKPDS) confirmed that improving glycaemic control and reducing HbA1c by 1% can effectively reduce the relative risk of microvascular complications by 37% in those with the condition.¹

In patients with type 2 diabetes, achieving and maintaining this level of glycaemic control over time will generally require multiple therapies, including insulin.^2,3 Another publication from the UKPDS reported that 53% of patients with newly diagnosed type 2 diabetes treated with sulphonylurea monotherapy required the addition of insulin therapy within six years to maintain fasting plasma glucose levels of 6.0mmol/l.³ Similarly, another UKPDS publication found that 50% of patients with newly diagnosed type 2 diabetes required multiple therapies after three years to maintain HbA1c levels of less than 53mmol/mol (7%), a proportion that increased to 75% of patients after nine years.²

Historically, insulin has been an under-utilised ‘last resort’ option in diabetes management. Unfortunately, many patients with type 2 diabetes who could benefit from insulin therapy do not receive it or do not receive it in a timely manner.^2-5 Part of this gap appears to be attributive to resistance to taking insulin among patients and resistance to prescribe insulin among healthcare providers. As insulin therapy is likely to be ultimately required in many people with type 2 diabetes, it should be discussed early after diagnosis so that, when it is needed, it is not seen as failure of self-management or a punishment for non-adherence. 

The initiation of insulin therapy is often one of the most difficult and important choices that individuals with diabetes have to make. Because insulin use often involves negative perceptions, both the decision and the therapy may present an emotional and logistical hurdle, leading to patient resistance to treatment.^6-8 This has been coined in the literature as psychological insulin resistance (PIR) and defined as psychological opposition towards insulin use in both people with diabetes and their prescribers. 

What do healthcare professionals really know about such cases of psychological insulin resistance? How often do they occur, why do patients harbour such powerful misgivings and how can busy clinicians respond most effectively?

Barriers to insulin initiation often vary from client to client and may even change over time in an individual client. It is crucial, therefore, to identify the root reasons for a client’s apprehension regarding insulin when talking about options for intensifying treatment.

Patient barriers to insulin therapy

Numerous factors have been identified as impeding patients’ willingness to initiate insulin therapy (see Table 1).^9-13

Many people with type 2 diabetes facing the possibility of insulin being added to their treatment regimens express concerns and fears about its effect on their quality of life.¹³ In a study by Hunt et al to review patients fears and hopes of insulin therapy, when asked to identify their reasons for insulin therapy reluctance, 61.4% of patients agreed that, “Once I start insulin, I can never stop,”¹³ and in a study by Polonsky et al, 50.6% believed that insulin therapy would restrict their lives.¹⁴

Data from the DAWN (Diabetes Attitudes, Wishes, and Needs) study¹⁵ points to similar concerns as one patient explained, “Taking insulin would mean no more spontaneous adventures for me. It would make it too hard to travel or eat out or even have a life!”. 

In the days before glargine, lispro, and aspart insulins became available, it was true that insulin therapy often required significant vigilance and changes to one’s lifestyle, but in the vast majority of cases, this no longer needs to occur. Diabetes care providers need to make clients more aware of the new insulin therapies available and the flexibility they bring to reduce the perceived loss of control over one’s life. 

Self-efficacy has an important role to play in the initiation of insulin therapy for patients with type 2 diabetes. Approximately 40-50% of patients do not feel confident that they could handle the demands of insulin therapy, such as determining the proper timing and dosages.^15,16

Without proper care and explanation, insulin therapy can at first seem much too complicated and overwhelming; and when patients do not have confidence in their ability to perform particular self-care behaviour, it is unlikely that they will follow recommendations to do so.¹⁷

This reluctance can lead to delays in the initiation of insulin therapy, contributing to prolonged periods of poor glycaemic control. 

A study by Jenkins et al assessed the factors associated with psychological insulin resistance in individuals with type 2 diabetes.¹⁸ Results showed that women and ethnic minorities have more psychological barriers to insulin treatment. Individuals who believed in the value of tight glucose control, had strong self-efficacy and had better interpersonal processes with their healthcare providers were less reluctant to use insulin treatment.¹⁸

As many as 50% of patients associate insulin therapy with personal failure.^18, 19 In other words, insulin is viewed as a well-deserved punishment for one’s own gluttony, sloth, or negligence in some other area of diabetes self-care. As one patient described it: “If I have to take insulin, it means that I have messed up, and that I haven’t done a good enough job taking care of my diabetes”.¹⁹

One factor that may contribute to these negative feelings is repeated experiences of failing to achieve satisfactory glycaemic control with oral glucose-lowering agents. There is a belief that they will be unable to control the condition in the future, regardless of treatment, and that insulin will not be effective and will not make a positive difference to their overall health.^20-24

Conversely, those who have experienced improved glycaemic control with intensification of prior glucose-lowering therapy may be more accepting of initiating insulin therapy.¹⁸ Similarly, results from the DAWN study showed that patients rate the clinical efficacy of insulin as low and would blame themselves if they had to start insulin therapy. Self-blame is significantly lower among those who have better diet and exercise adherence and less diabetes-related distress.¹⁵

For many patients, insulin therapy signifies that their diabetes is now suddenly ‘more serious and more dangerous’ in contrast to ‘mild diabetes’ controlled by diet and medication. Many patients are concerned that insulin therapy may cause further health problems such as hypoglycaemia, weight gain and complications.¹⁸

This may be partially true with an increased chance of hypoglycaemia in certain client groups such as those living alone or during times of change such as shift work, extensive travel and high intensity physical activity. Not surprisingly, if people are convinced that insulin will worsen their health, they may be very resistant to begin insulin therapy.

Injection related anxiety is another contributing factor to resistance to insulin initiation with type 2 diabetes. 

Approximately 50% of patients report being fearful of injections.¹⁷ True injection phobia is rare, even among insulin-using patients with diabetes.¹⁹ Clients frequently express anxiety about the pain of injections and concerns about proper technique associated with insulin therapy²¹ as well as a general lack of confidence regarding the ability to handle the demands of insulin therapy/regimen.^22,23

A study by Larkin et al reviewed barriers to insulin use and found that 33% of patients with type 2 diabetes were unwilling to take insulin.²⁵ The most commonly expressed negative attitudes were concern regarding hypoglycaemia, permanent need for insulin therapy, less flexibility and feelings of failure. Less than 40% expressed fear of self-injection or thought that injections were painful. 

However, compared with willing subjects, unwilling subjects were more likely to fear injections and thought injections would be painful, life would be less flexible, and that taking insulin meant health would deteriorate.²⁵ Many patients are not aware that insulin pens are now more discreet, more user-friendly and have devices to conceal the needle. When patients report that they “could never give an injection”, this may often represent a broader reluctance to consider insulin therapy. 

Assessment of patient barriers

The importance of individualising therapy in a way that allows clients with type 2 diabetes to effectively self-manage their condition cannot be overstated. The specific treatment approach must be individualised based on client-specific factors such as age, comorbidities and tolerance of hypoglycaemia. For general strategies for initiating insulin therapy, see Table 2.

When clinicians are faced with patient’s barriers to initiating insulin therapy or psychological insulin resistance, Polonsky and Jackson suggest that the following practical intervention strategies should be considered²⁷:

• Identify the patient’s personal obstacles

• Frame the insulin message properly

• Restore the patient’s sense of personal control and enhance self-efficacy as quickly as possible

• Discuss the real risk of hypoglycaemia

• Tackle injection phobias.

Identify the patient’s personal obstacles 

Considering that most people with type 2 diabetes will eventually use insulin, the issues concerning insulin should be given special attention. Patients may be unable to appreciate any reassurances or additional information until their personal beliefs about insulin are recognised and discussed. Consider simple open-ended questions such as ‘What are your greatest concerns about starting insulin?’ 

Addressing specific concerns and highlighting the advantages of controlled blood glucose levels (for example, more energy, less complications and less trips to the bathroom at night) as well as pointing out the advantages of modern insulin delivery systems, can greatly reduce the degree of psychological insulin resistance.

Frame the insulin message properly

When talking about the need for insulin, stay focused on glycaemic outcomes by sharing the patient’s HbA1c results with them. Removing the patient’s sense of personal guilt is critical. 

Time should be taken to explain that diabetes is known to be a progressive condition and therefore more or stronger medications may be needed over time to achieve or maintain glycaemic targets. The goal is to prevent complications and have a good quality of life through the achievement of glycaemic targets.

Restore the patient’s sense of personal control and enhance self-efficacy as quickly as possible 

Consider introducing insulin therapy as a trial for a month and then review to see how it has impacted on the person’s sense of control of their life. When insulin is first introduced, demonstrations with practice of insulin administration should be carried out with support and encouragement. 

With practice, the patient will master the skill and this will boost self confidence. Additional behaviour changes should be kept to a minimum so that any reluctant individuals do not become overwhelmed and thus even more resistant to initiating insulin therapy.

Discuss the real risk of hypoglycaemia.

The worry of hypoglycaemia for people with type 2 diabetes can often be traced back to an event that occurred with a relative, neighbour or friend where the person needed assistance. Patients should be reassured that severe hypoglycaemia (where help from another person is required) is quite rare in type 2 diabetes, even among those on insulin. 

In the UKPDS study,¹ for example, the annual incidence of severe hypoglycaemia in people treated with insulin was less than 3%. More awareness of the early recognition and treatment of hypoglycaemia can reduce the risk of potential problems. 

Tackle injection phobias

 In cases where patients are truly fearful of needles to begin insulin therapy, clinicians may want to consider referral to a mental health provider familiar with cognitive behavioural therapy. Needle phobias can usually be resolved quite rapidly.²⁸

Conclusion

As insulin therapy is likely to be ultimately required in many people with type 2 diabetes, it should be discussed early after diagnosis so that, when it is needed, it is not seen as failure of self-management or a punishment for non-adherence.

Barriers to insulin initiation often vary from client to client and it is crucial, therefore, to identify the root reasons for a client’s apprehension regarding insulin when talking about options for intensifying treatment. These barriers include patients’ beliefs and knowledge about diabetes and insulin, negative self-perceptions and self-efficacy, fear of side-effects and complications from insulin use, as well as lifestyle adaptations, restrictions required by insulin use and social stigma. 

The good news is that patients can overcome personal obstacles to insulin therapy by recognising and addressing them with support from their healthcare team. The focus should be on helping people with diabetes see that starting insulin is not necessarily the result of poor self-care, but rather an effective therapeutic tool for the treatment of type 2 diabetes.

Elaine Newell is a diabetes development officer with Diabetes Ireland

References

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