What Causes Type 2 Diabetes — and How Doctors Help Treat It

February 24, 2017 12:00 PM

Insulin therapy requires frequent dosage adjustments to maintain adequate blood glucose levels. Here’s information patients with type 2 diabetes can use.

So your doctor told you that you need insulin therapy for your type 2 diabetes. This is a common problem and is likely to grow in the coming years.

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About 29 million people in the United States have type 2 diabetes, and 86 million more have prediabetes. About 1 in 4 people with type 2 diabetes is on insulin therapy; an additional 1 in 4 probably needs to be.

What does it mean to be on insulin therapy? Could you have prevented this? Will insulin actually work?

These are frequent questions people who need insulin therapy ask. As someone who has treated people with diabetes for years and has been working to improve the treatment’s effectiveness, I will do my best to help you answer these questions. I also have been working to develop a better way to personalize dosing for insulin.

Insulin therapy for type 2 diabetes

Diabetes is a condition in which your pancreas fails to secrete a sufficient amount of insulin to help you maintain normal blood glucose, or sugar in the blood, which is transported to various parts of the body to supply energy.

There are many causes of insulin deficiency, but the most common is type 2 diabetes. The main risk factors for type 2 diabetes are family history, weight and age.

In fact, most overweight and obese people in the Western world will never develop diabetes. Weight is an important, yet misunderstood, risk factor for diabetes. The foods you eat are usually less relevant than the weight itself.

Most people in the world with type 2 diabetes do not fulfill the medical criteria of obesity; rather, their weight exceeds the capacity of their pancreas to maintain sufficient insulin secretion. Your pancreas may have less insulin-secreting capacity than your neighbor’s, making you more likely to get diabetes when you gain weight.

Type 2 diabetes is a progressive condition. Over time, the pancreas tends to secrete less and less insulin. In the early stages, when your pancreas can still secrete some level of insulin but not enough to maintain normal blood glucose, losing 5 to 10 percent of your body weight — and more important, keeping that weight off — can slow the progression of your insulin deficiency.

Even with weight loss, in the majority of cases, diabetes eventually progresses to the point where you will need to use medications. Most diabetes medications (except for insulin replacement therapy) can work only if your pancreas is still able to secrete some insulin.

Because of the progressive nature of the disease, you may require more drugs over time — and at some point, you may become so insulin-deficient that none of them is sufficient for maintaining healthy blood glucose. At that point, insulin replacement therapy is needed.

Keeping glucose levels at the therapy goal is essential

Injections of insulin become necessary for many diabetics.

The stage in which you become overtly insulin-deficient typically occurs about 10 years after the diagnosis. There is no evidence to suggest that you can totally prevent this progression.

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Although keeping a stable weight and being physically active are considered beneficial to overall health, these modalities have limited impact on advanced stages of diabetes, when your pancreas is secreting little to no insulin.

Having no insulin is damaging and dangerous. Without insulin, your body breaks down necessary fats and proteins that are important parts of your body, causing damage to many organs. The vast majority of diabetes complications occur when patients with advanced diabetes are exposed to elevated blood glucose for a considerable period of time.

If I could give you one piece of advice, it would be to avoid elevated glucose at all cost.

If you or a loved one has been diagnosed with diabetes, you are probably familiar with what we call hemoglobin A1c. It is a measure of your average recent glucose levels. Do not let it go up. If you have come to the point that insulin is needed to maintain a healthy glucose level, so be it. It is not your fault that you have arrived at this point; you simply need the correct treatment for the actual stage of your type 2 diabetes.

So even when insulin therapy is needed at a certain point in the disease’s progression, it does not solve a patient’s health problems. That’s because most patients who use insulin therapy do not achieve their treatment goals in maintaining appropriate glucose levels in the blood. This is quite surprising, given its benefits and the fact that insulin therapy has existed for almost a century.

Insulin does not have an upper dosage limit, and there is no glucose level that it cannot reduce. Unlike most other drugs, it has only one main adverse effect: hypoglycemia, which occurs when glucose levels drop too low. Further, the majority of insulin users are adherent to insulin injections and glucose measurements. Why don’t they achieve their treatment goals?

Frequent adjustments of insulin dosage are critical

The problem is not with the patient or the doctor. The problem is the therapy itself.

Unlike most other drugs, insulin requirements are dynamic and need frequent dosage adjustments to overcome constant changes in insulin needs. The range of overall insulin requirements is wide. No one knows if you need 30 units per day or 300. When your doctor gives you insulin, he or she tries to give you as much as your own pancreas used to secrete before it failed. To know how much insulin you need, your doctor typically starts with a low dose and goes up gradually.

Thus many adjustments will be required before your doctor knows how much insulin to give you.

But it doesn’t end there. Your insulin requirements constantly change. Over time, you may need a different dosage. To make insulin therapy effective and safe, you may need a dosage adjustment about every week. Unfortunately, there are so many insulin users that our doctors don’t have the time to adjust the dosage this frequently.

Please don’t despair; there is technology that can help you adjust the dosage more frequently. Companies have developed technologies that enable insulin dosage to be as dynamic as needed to make it effective for you.

In summary, it is not your fault that you need insulin therapy. It is just another mode of therapy that you need when your pancreas fails. The main challenge is to adjust your dosage frequently. Fortunately, solutions are becoming available to facilitate this.

This is an updated version of an article originally published Feb. 22, 2017, on The Conversation. You can read the original version here.