Insulin, sooner than later

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Diabetes is on the rise in Pakistan. According to a news report, there are around 6.7 million people with diabetes and approximately the same number of people has a high possibility of acquiring the disease. This puts Pakistan among the top countries with diabetics. The numbers are estimated to rise to 12.8 million by 2035.
Diabetes is a condition in which the body’s metabolism gets disturbed causing the blood sugar to rise above normal range. The hormone insulin in the body is like a key for glucose to enter into the various cells and be utilized for energy purposes or stored for future use. When for one reason or another, insulin is either not being produced (as in type 1) or if it is produced is unable to work normally (as in type 2) then this glucose or sugar cannot enter the cells. It piles up in the blood and damages various cells of the body.
The disease generally can be managed through lifestyle modification, oral medicines and insulin injections. According to Dr Muhammad Yaqoob Ahmedani, an endocrinologist at Baqai Medical University Karachi, insulin is the main treatment choice for type 1 and gestational diabetes (that occurs during pregnancy). While in type 2, the more common type, oral medicines are the initial way of treatment. But such patients have to switch to insulin later on to manage their disease when oral medicines stop responding or they are unable to control their sugar levels. “If blood sugar is high even after six months of intervention, patients should consider getting on insulin”, says Dr Abdul Jabbar, a diabetologist & endocrinologist based in Dubai, U.A.E.
Beenish, a house wife in her mid 30s, is diabetic since the past five years. She is unable to consistently control her sugar levels despite being on oral medicines and making occasional attempts to improve her diet and physical activity. Her physician has recommended her to manage her disease with insulin now. But she is hesitant. “Being on insulin means I will have to take it lifelong. This scares the hell out of me. I think my disease is not at such a dangerous level that I have no other option left”.
Unfortunately, patients have many reservations when it comes to insulin. Switching to insulin is their last choice. Some like Beenish think it will make them dependant while some fear the daily pricks. Little are they aware that by doing this they are compromising on their health. SNI, through this story, makes an attempt to address the misconceptions related to insulin.
The first resort
According to Dr Muhammad Yaqoob, switching to insulin does not mean the disease is at a dangerous level. Insulin is a mode of treatment which is better than oral medicines as it has better outcomes. “Insulin is not the last, but the first treatment resort”. Dr Abdul Jabbar goes on to add, “whatever the stage of disease, insulin is the best drug to control high sugar at all stages or levels.
Fear factor
Fear of the needle has been ingrained in the minds since childhood. “Parents or elders usually scare children by saying that if they do mischief, the doctor will give them an injection. So accepting it becomes difficult later in life”, says Dr Muhammad Yaqoob.
Nevertheless, new insulin pens and needles are almost painless. “They hurt less than a mosquito bite and the needle used to check your sugar at home on your fingers”, explains Dr Abdul Jabbar.
Even doctors are not far behind in instilling a similar fear in patients when it comes to insulin. Dr Muhammad Yaqoob says that physicians, especially at GP level, scare people by saying if you do not control your sugar level I will put you on insulin. “This threatening attitude is wrong. Doctors are probably hesitant because they fear the insulin will make the patient hypoglycemic (abnormally low blood sugar)”.
Educate the patient
Moreover, doctors do not give enough time to educate the patients. That is why patients do not realize the importance and benefits of controlling sugar and how insulin impacts. “They should tell the patient that diabetes is a progressive disease. If medicines fail insulin would eventually have to be given”, says Dr Muhammad Yaqoob. So, the patient should be mentally prepared and will know if he does not have good control he will have to switch to insulin. “This understanding will make him accept insulin as his need not a compulsion”. Giving time to the patient, especially during initial visits, to make him understand the importance is the key.
Dependency or need
According to Dr Abdul Jabbar, dependency and need are two different things. Dependency occurs when you cannot do without a thing that is not required. “Well, are people using glasses for weak eyesight dependent on it? Same is the case with insulin. The body needs it therefore it is not an addiction”.
Dose & frequency
The insulin dose does not depend on the type of diabetes you have. It actually depends on an individual’s weight and the amount of physical activity he does. “The dose is gradually increased depending on the sugar profile, according to which dose is adjusted. We start with a less dose which is between 0.5-1 units per kg body weight”, says Dr Muhammad Yaqoob.
Some patients take a single dose in a day while some take more. The endocrinologist says that this varies individually and depends on how good control the patient has of his disease. “It can start with a single dose at bed time and then go on to four doses a day in which an injection is taken before each meal and one at bed time”.
Dose for lifetime?
Taking insulin is all about the right dose, at the right time. An initial recommended dose of insulin is not for life time. “The dose can fluctuate depending on the patients’ intake, physical activity and stress. It needs to be adjusted throughout life”, says Dr Muhammad Yaqoob. Keeping a track of your sugar profile and meeting the targets set by your physician is necessary. There was a time when patients could not keep daily track of their sugar level and the dose was usually adjusted based on one sugar value. Now glucometers have made that possible. “Daily profile is necessary for adjusting the dose. And a doctor who adjusts it without considering the profile is doing wrong”.
Go for your follow-ups
According to Dr Muhammad Yaqoob, frequent visits are needed with poor sugar control. “Initially, a two to four week visit should be made and as the control gets better, a six weekly or three monthly visit can be made”.
Inappropriate dose
With a low dose it will be impossible to control sugar level, while a high dose can cause low sugar in a patient.
The ultimate goal of the physician should be to make the patient empowered by educating him so that he is able to adjust his doses and manage his disease on his own. “But not every patient can be trusted with this. It depends on how much understanding the patient is and how much he is learning about the disease”, says Dr Muhammad Yaqoob.
Wrong timing
Taking insulin at the wrong time can cause the sugar level to fall to a dangerously low level because its aim is to lower it. This happens if the patient delays in taking food after the insulin shot. A gap of not more than half an hour can be taken after having insulin. So, no going for a walk, exercise or chit chatting over the phone after having the shot.
In case of low sugar
Palpitations, sweating and trembling are signs of low sugar. Dr Muhammad Yaqoob advises mixing sugar or two spoons glucose in water and drinking it immediately to relieve the symptoms.
Can insulin cause weight gain
Insulin is a growth promoting hormone therefore can cause weight gain. “It can probably cause a two to four kilogram increase if the patient has started for uncontrolled blood sugar as insulin does not allow your glucose to be drained out in urine so you gain some of your lost weight back”, explains Dr Abdul Jabbar. Weight increase however, is more in those who are not careful about their physical activity and diet. “People should not think that once they are on insulin they need not care about what they eat and their activity”, says Dr Muhammad Yaqoob.
Pregnancy & diabetes
With good sugar control, pregnancy is possible. Dr Abdul Jabbar says that before planning pregnancy, women should have a good sugar control to reduce the risk of problems for herself and the baby. “In most cases, they would need insulin during pregnancy if already suffering from diabetes”.
Negligible side effects
Side effects of insulin are negligible. Repeated injections on the same place can cause bumps. Patients should therefore rotate places for injection; abdomen, thighs and outer arm. Moreover, slight weight gain and low blood sugar can be other problems. “Side effects of oral medicines are more as compared to insulin”, says Dr Muhammad Yaqoob.
Storing insulin
At home insulin should be kept in the refrigerators’ lower portion, vegetable compartment or in the door’s lower area. It should not be frozen or kept with ice as it can freeze. Keeping it in ice water is however, not a problem.
Expensive treatment
Considering the long term benefits of preventing more expensive and difficult problems like heart attack or disease, stroke, kidney failures, eye problems and many other issues with uncontrolled diabetes, Dr Abdul Jabbar says, “it is not at all expensive”. Moreover, Dr Muhammad Yaqoob says that new analog insulin is expensive but the basic type is not, “especially when divided over the month it is not that expensive as compared to the oral medicines”.
The big question – can diabetes be cured
According to Dr Muhammad Yaqoob, in some cases diabetes does get cured. For example, bariatric surgery done in some obese patients has cured their diabetes. Moreover, stem cell therapy and pancreatic transplants are being done in some countries successfully curing the disease. “Currently, these procedures are not available in Pakistan and they are really expensive”. Insulin pumps, though expensive, are now available here that saves an individual from repeated pricks. “The pump is similar to a battery that is attached or implanted to the waist and insulin keeps getting inside the body through the needle according to the need”.
To have good control of diabetes, one needs to have a healthy lifestyle along with insulin intake. Dr Abdul Jabbar recommends eating healthy and not more than your body needs (monitored by weight and certain blood tests). Stay active with regular exercise plan and healthy habits. Sleep and wake up on time, avoid smoking and any sort of addictions like gutka or sheesha.

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