Diabetes Type 2
Coping with insulin
Although many people diagnosed with type 2 diabetes will be prescribed tablets (e.g. metformin) eventually many people will be transferred to insulin. Insulin cannot cure diabetes - there is still no cure for diabetes - but it can slow the progress of the disease and make it easier for some people to control their blood glucose. Those who had changed to insulin from tablets said that they felt much better because insulin kept their blood glucose more stable.
Tina takes one long-acting insulin in the day and another (Levemir) at night which she says works...
I mean, obviously you know, what you eat affects it a lot, and I wasn't so aware at the beginning about the hidden sugars in food. So I was aware that I shouldn't have sugar in tea, and I shouldn't have treacle sponge pudding or whatever, but I wasn't so aware of the hidden sugars in food and, which, you know, I am a little bit more now. And so I think' That I, you know, I mean that was quite a long time I sort of struggled trying to get control. And sometimes, you know, some days were better than others really, but basically I would say that my sugar levels were always more than they should have been, for quite a lot of years.
Now looking back on it all, what do you think you could have done differently?
I think I should have gone on insulin earlier because as soon as I went on insulin, that my sugar levels sort of came down. And I mean even on insulin, you can still can have high sugar levels, because it does depend on what you eat and it depends on, you know, how regularly you are at making sure you do your injections and all the rest of it. So you still can have high sugar levels but not as high as they used to be on just tablets. So I think I should have gone on insulin, really. But I didn't push it and' You know, that was it.
So when did you go on insulin?
I went on insulin as soon as I had as soon as I came out of hospital after I'd had the MRSA, I went on insulin. I was put on insulin probably about within two or three weeks of me coming out of hospital. And that was obviously to get stricter control on my sugar levels, which did work more or less straightaway and I was on a combination insulin. I think it was called Nova 30, for probably about a year, 14 months maybe, and that was working okay, but then I still needed better control. And after speaking to my diabetic nurse, she said that there was an insulin which, meant that you had to inject more each day, but would give better control, and so I've just gone, well I've been on that around about, probably about a year I think I've been on that.
And that's called?
It's the night-time insulin called Levemir, [insulin detemir] and the day time one' I'm not sure.
It was quite a lot, quite a juggling act when I first went on it. More so that the one I originally went on because that was two injections a day, and although my sugar levels were higher they seemed quite stable. They didn't fluctuate that much, but on this insulin you have better control using it, but you have to be much more much more accurate with your blood sugar readings. You have to be much more aware of taking them yeah.
Shahnaz explains how she increases the amount of insulin she takes when she returns to Pakistan...
And so, a bit about, if you could talk a bit about your diabetes management in Pakistan in some detail'?
Well, when you go there then obviously among your own people there is lots of eating that goes on. So over there, basically, what I have to do for my diabetes is that I have increase my dose of insulin. Because people just insist, 'Oh please, eat this, eat that'. So even though I am careful about my diet, but I do increase my insulin dose by one or two, so that my sugar stays in control.
So this dose that you increase, is that on somebody's advice or?
Oh yes of course, I have checked with the doctors, my doctors here have said that when you look, check at night to find that your sugar is raised then take your insulin, take three or four doses. And if you find that with food as well, that you are eating the kind of food that carries the risk of raising your sugar, then also you can put two to three units [of insulin].
So the advice that the doctors give you, do you find it easy to'?
...follow it? Definitely. I find it very easy.
Most people we interviewed who were on insulin had had diabetes for five or more years and most of them had started with oral medication such as metformin (see 'Controlling diabetes with metformin and other medications'). Only a few people had been prescribed insulin directly after being diagnosed. The kind of insulin and also the dosage varied from person to person, according to their blood glucose level and their state of health; few people could recall the name of the insulin they were taking.
There are seven main types of insulin:
- Rapid-acting analogues - injected just before, with or after food and only last long enough for the meal at which they are taken.
- Long-acting analogues - injected once a day to provide background insulin.
- Very long-acting analogues – provides background insulin for 42 hours (3 days) and are normally used for people unable to inject themselves and are given by a healthcare professional.
- Short –acting insulins- injected 15-30 minutes before a meal to cover the rise in blood glucose after eating. They work for 2-6 hours but can last up to eight hours.
- Medium - and long- acting insulins – are taken twice a day to provide background insulin or in combination with short-acting insulins or rapid- acting analogues.
- Mixed insulin – a combination of medium- and short-acting insulin.
- Mixed analogue – a combination of medium-acting insulin and rapid- acting analogue.
Originally all insulins came from animal sources and were known as porcine (pork) or bovine (beef). Many of these remain available and are very inexpensive. Then it became possible to synthetically manufacture insulins that were exactly the same as the insulin we normally produce in our own pancreas: human insulins. More recently insulin manufacturers have produced insulins closely similar to the human type but slightly modified to have certain alleged benefits: the so-called "analogue" insulins and these are designed to work at different speeds and said to have a more predictable absorption rate than human or animal insulins. Most people tend to use human insulin or insulin analogues when first diagnosed but a small number of people still use animal insulins as they find it works better for them as they found they lost their hypo warning symptoms when using human or analogue insulins.
Philip has recently changed from Mixtard 20 to NovoMix 30 and says he keeps a record of his blood...
At the moment. Currently my sugar levels have been reasonably erratic, and they've gone from anything between 6 to 23, and that has caused the diabetic nurse at my practice to investigate different regimes. And at the moment we've gone from a Mixtard 20, and we changed that recently mainly because it was just about to be discontinued in manufacture. So we had to have another insulin to take. And so they recommended that I took NovoMix 30, which is long-lasting but not as long-lasting as the Mixtard 20. And I take 22 units in the mornings and take 20 units in the evenings.
I keep a record of my sugar levels on my computer, and I do a reading in the morning before breakfast and before having insulin. I have a reading at lunchtime; I have a reading before dinner when I have my second injection, and I have a reading when I go to bed. The reading when I go to bed is quite high, because I usually have a hot chocolate before I go to bed - along with the gin but I have the gin before the chocolate - and it's usually quite high in the mornings. But it's usually back down to 8 or even 6 in the mornings.
Gareth takes higher doses of insulin now than he did before and advises newly diagnosed diabetics...
Has it changed over the years?
Oh yes. When I first started on insulin I was on something like about 10/10, just to find out, it's like everything you titrate isn't it? People might not know what titrate is - you find the level of the medication that you need to keep your diabetes in control. So I started going up and then of course my sugar was rising slightly, so I increased it with telling people what I'm doing and also with the consultation with a nurse or a doctor. And I'm on this level now.
I was finding that if I was taking more units in the morning, I found that my levels the following morning would risen, so this is why I take a high dosage in the evening - two more in the evening to counteract that - so I take 44 in the evening just before my evening meal - because that is normally your biggest meal. And then, in the morning, I just take say 42, and then I'm right for the day.
The people have to take insulin or tablets at various times in the day, more than twice, so if you were logging it, [write] it down [on the] log when you're taking your tablets and what time you're taking them, and also whenever you take your reading, what time you take your readings. So if you have to go to the doctor, he can see the peaks and troughs of whatever you've got. Its important that you record when you are newly-diagnosed and I'm not saying that you shouldn't do it after, but it's more imperative that you take it when you are newly-diagnosed, so that they can see how you're reacting with your treatment.
Some experienced insulin users had developed routines that worked for them and preferred to stick to their own tried and tested methods of coping. Others valued deciding for themselves whether to raise the insulin dosage depending on what they were planning to do or eat. The 'Dosage Adjustment For Normal Eating' or DAFNE routine was thought by several people we interviewed to be a good way for very active people to manage their insulin although this system is normally for Type 1 diabetics only. This is because those with Type 2 diabetes do produce some insulin which makes carbohydrate/insulin ratios fluctuate.
Philip sticks to a particular routine with his insulin but says other kinds of routine may work...
So is your insulin, I mean the level that you take is that sort of fixed, you don't change it that much?
I don't change it that much at all. I have 26 of a morning, 18 of an evening before my evening meal and that seems to suit my lifestyle. If I am more active, if I'm going to be active, I tend to may take a little Mars Bar or something, have a chew at that. And that will raise my blood sugars to counteract the effect of the exercise that I am doing. So once again it's coming back to this self-management. To be able to look ahead and say [to yourself] 'Well' I'm going to be doing that, I'm doing this, I'll have that before I do it, and that'll balance me out while I'm doing it'.
These are suggestions that people have made you know over the years, and it suits me.
And I think everybody is an individual as far as that goes. And each person has got to adjust their regime to themselves, not to what other people are doing. They've got to adjust it for themselves I think. Trying to tell people, 'Well you should do this and you should do that, and you should do that, like I do' - that's wrong. I think there's only one person who should tell you what to do and that is the doctor, or the clinic staff.
I think you should recognise your symptoms, be able to recognise when you are going low - particularly when you are going low - look at what you are doing if you are driving and things like that; what precautions should you take if you are driving any distance. I think all these things come under your self-management. You've got to plot it ahead. You've got to look ahead at what you are going to do, how you are going to do it. You've got to be able to analyse I think your feelings to a certain degree, what's happening to you. And carry on with your normal life.
There are several other education courses that are recommend for people with Type 2 diabetes:
- Diabetes Education for Self-Management for Ongoing and Newly Diagnosed (DESMOND) for people with Type 2 diabetes
- The X-PERT Diabetes Programme for people with Type 2 diabetes and the X-PERT Insulin Programme for people with Type 1 or Type 2 diabetes
Several people said that being 'insulin-dependent' had given them an illness identity which made them feel they were defined by their diabetes. Others who were not on insulin felt that it marked a point of no return, and that they intended to resist it for as long as possible. Others not yet on insulin were simply worried by the thought of it.
Now he is insulin-dependent Darren has to carry his medication around with him and feels he is...
So there's this whole thing of you know, you bring your support equipment out with you and so now I've got this rucksack with extra pockets in it that we bought, that has everything in it, and I mean I always carry a bag with me because I have so many things to carry around with me for the job, but, I don't know... I think there is a symbolism of being read, [laughs] upon reflection. So yeah I feel like that's me now, it's on my driving licence, I'm going to have to wear it on my wrist. I'm going to, you know, I'm going to have to declare it wherever I go and whatever I do. And almost when you weren't insulin-dependent it was less of a thing but now, because you are, there is an issue.
People also talked about the practical difficulties of taking insulin during their everyday lives; how they managed their injections when they went out for meals with friends and how they had to use different parts of the body to avoid getting sore patches of skin.
Brian does 5 injections a day and explains how he remembers where to inject.
In the same place?
Well, it's about the size of a loaf of bread, small loaf of bread area, which I'll stick it in somewhere. And we're quite happy.
Several people stressed to the importance of keeping insulin cool when travelling. Insulin needs to be kept at temperatures lower than 25°C/77°F, ideally between 2 and 6°C/36 and 43°F.
Some of the people interviewed said they had not been told how they should dispose of their used needles or 'sharps'. Several people noted how important it was to keep injection sites clean and also to shake the insulin container before the injection.
Although the pros and cons of traditional forms of insulin made from animals as opposed to newer 'human' insulins manufactured synthetically have been hotly debated for years, no one we met expressed an opinion on this subject.
Last reviewed March 2016.
Last updated March 2016.