How to Know When It’s Time to Start Insulin

0:00
We’re so excited about this podcast episode because we’re going to talk about how to know when it’s time to consider insulin and what are some of the key indicators that somebody with diabetes may need to know before starting insulin therapy.

Welcome to the Diabetes Digital Podcast.

0:15
I’m Wendy.

And I’m Jess, and we’re best friends, registered dietitians and diabetes educators.

Through our telehealth platform, Diabetes digital.co, we offer accessible and personalized virtual nutrition counseling for people with diabetes and pre diabetes.

Visit diabetesdigital.co That’s Co to book your first appointment.

0:34
We accept insurance and offer affordable self pay options.

Now let’s get into today’s episode.

Welcome back to another episode of the Diabetes Digital Podcast.

We are so excited to have one of our superstar dietitians on with us.

0:53
This week we have Isabelle Rexon, who is a registered dietitian and diabetes educator.

She’s based in New York City and has a public health degree to which she obtained to promote HealthEquity.

Isabel specializes in hypertension, chronic kidney disease, and kidney stones.

1:11
She has experience in clinical, pediatric, and telehealth settings, and she prioritizes individual needs and preferences.

She’s passionate about using technology to improve diabetes management and we are just so excited to get into all the things today with her arms.

1:29
Yeah.

Today on the POD, we’re going to talk about how do you know when it’s time to start insulin.

And as we mentioned, Isabel is not only a dietitian but also a certified diabetes educator, which now I always forget the new title, but it’s certified diabetes care and education and support specialist.

1:46
Did I say that?

Right Care and education, Special or not?

Yeah, I’m like, I think she added an out of that.

Yeah.

So Isabel is that.

And we’ll focus on just the key indicators for considering insulin therapy, also the physiological reasons why our body requires insulin and diabetes management.

2:07
We’re going to talk a little bit about the stigma and resistance to insulin therapy.

I’m sure we all know someone who has been on insulin and typically people are afraid to start insulin.

And so we’re going to talk a little bit more about that.

We will get into the needs for people with type one versus type 2 and who tends to need insulin more.

2:26
And I I know a lot of people are afraid, like I mentioned of starting insulin.

So we’ll get into the fear of injections and the inconvenience and the kind of some strategies around that.

And of course we’ll talk about transitioning from insulin from other treatments and just so much more.

2:44
So definitely stay tuned until the end, especially if you are someone who has diabetes and you’re just curious about these things or you’re supporting a loved one with diabetes and you want to reduce the stigma and help to better support them with evidence based information about insulin.

3:01
So with that, we’d like to say welcome to the podcast, Isabel.

We’re so excited to have you.

Thank.

You.

I’m so excited to be here and talk about these important and ever changing topics with you both.

Love it.

Now we just want to jump right in to the topic, right?

3:17
So this episode is titled How to Know When It’s Time to Start Insulin.

What are the key indicators that someone with diabetes may need to consider starting insulin therapy?

What is your take on?

That yes, great question.

So it might not be A1 size fits all and I like to say that at first because someone’s doctor might recommend they start insulin based off their their medical history.

3:40
So for example, we tend to first start with like oral medications or other injectable medications but for some people those might not be appropriate.

It could be related to any history of heart disease or kidney disease or whatever it might be.

So it does differ a little bit, person to person in that respect. the ADA, the American Diabetes Association, does recommend starting insulin for anyone who has a A1C over 10 or a very high blood sugar, which they define as over 300.

4:10
So if someone you know might be new, diagnosed with Type 2 diabetes or type one as well, and they come in with numbers like that, they’ll generally need insulin, at least initially, to help get those blood sugars.

Down why you decided to focus on diabetes as a dietitian?

4:27
Yes, great question.

I started off my dietitian journey working in patients.

So working in a hospital, a lot of patients came in with diabetes and I saw it quite a bit and I learned how different diabetes is for each person, their experience that their own disease.

4:45
And I found it really interesting how we can make plans based on a person’s individual needs and it doesn’t have to be the same across the board.

Shortly after, I started working with people with type one diabetes and I got more into diabetes technology since it’s a since it’s been a bit more prevalent in that population.

5:07
And diabetes technology is constantly changing and there’s always new things coming out and it’s really interesting, it’s it’s amazing how technology can really improve the lives of people who have diabetes.

And so that’s kind of where that interest came in as well.

5:24
And can you talk to us about what might be going on in the body that would require someone to need insulin for diabetes management?

In diabetes, what happens is the pancreas, which is an organ in our body, either stops making insulin or isn’t able to make enough to help maintain our blood sugars where they want to be.

5:44
So in type one diabetes, the pancreas completely stops making insulin.

Insulin is a hormone we need to help sugar from our blood get into our cells to use for energy.

So in type one diabetes, somebody is no longer making insulin and they have to take it to be able to get the sugar, the food they eat into their body for energy.

6:03
In type 2 diabetes, the pancreas may stop making insulin as well.

But often what happens is it is not able to use the insulin the body makes as efficiently.

So sometimes someone might need insulin to help, or there are other medications they can take that are going to help the body better.

6:19
Use use the sugar for energy.

That’s so helpful.

Thank you for that explanation.

Now there is so much resistance when it comes to starting insulin therapy.

I’m sure we’ve all worked with people or have family members.

People feel like, Oh my gosh, I’ve failed.

6:35
How am I on insulin?

This is going to lead to amputations.

I’m curious, like in your work, have you seen this?

And why do you think that everybody is so fearful of insulin?

Or what are you hearing from your patients in terms of that?

6:51
I have seen resistance to insulin.

It’s from my point of view, a lot of people feel that it’s a last resort and that they failed other medications or lifestyle changes.

But the reality is that diabetes is a progressive disease.

So that means that it’s always changing.

7:06
So if someone starts off being able to make changes with their how they’re eating and they’re moving, and then they maybe add in a medication just because a few years later they need insulin doesn’t mean that they failed at that.

It just means that what they were doing is no longer working.

So I really like to remind clients and patients and everyone that you know, you could be doing the exact same thing and your body just says, hey, it’s time for more and that’s just how diabetes goes.

7:32
So it’s really no blame on anyone, it’s just the progression of the disease.

That’s helpful.

I’m wondering, are there any like specific conversations that you find helpful with people?

And again, even if someone is listening and they have a loved one with diabetes and they want to be more helpful and have a conversation that is more destigmatizing around insulin, is, has there been anything in your practice that you have noticed is helpful?

7:58
It’s important to remember that diabetes is not the person who has diabetes fault and that’s a great message for both the person who is experiencing it and their loved one.

So needing insulin is no sign of failure.

It’s just the progression of the disease.

And I think it can be really challenging because of how the stigmas we have in our society and even within doctors offices that you know, if we need additional medication or insulin, it’s a sign that we’re not doing something right, where in reality that’s really not the case.

8:27
So I do try to just go over that progression and talk about with with my patients and clients that if you need this, it will, there’s a reason you need it and it’ll help blood sugars which will help us use energy, make us feel better, help prevent disease and complications.

8:42
So it’s not a bad thing, it’s just where we’re at.

Yeah, I love that you say that because especially our bodies changing, you know, I think that’s something that a lot of people overlook, especially as they’re getting older.

They’re like, oh, well, you know, my body is not reacting the same way to things.

9:00
Or I’m noticing that my body is changing and the things that I was doing aren’t working anymore.

And it’s just a natural progression.

You know, as we age, our organs also change.

And so that can also affect insulin needs as well.

So it’s great that you brought that up.

9:16
Something that I also hear is insulin being tied to type one and not so much type 2.

You know, and it’s like, oh, well, I I don’t need insulin.

My diabetes is not that bad.

9:31
It’s something that I hear often that’s more so for people that have type 1.

So can you talk a little bit about just understanding insulin needs for someone that has type one versus type 2 and how insulin might be helpful for both conditions?

9:47
Yes.

So in a person without diabetes, what happens when we eat is the body naturally produces insulin, and that’s going to help get the sugars from the food we’re eating out of our blood into our cells to use for energy.

In someone who has type one diabetes, they don’t make any insulin anymore, so they do have to take insulin, generally a background insulin as well as insulin for when they do eat foods, especially carbohydrates.

10:13
In type 2 diabetes, it depends a little bit on the individual person.

There are more approved medication options that are oral, so someone might take a different medication before insulin or in conjunction with insulin, and they may only need a insulin shot once a day and not at every meal.

10:28
So the needs are a little bit different.

That being said, insulin is used widely for both type one and type 2 diabetes you mentioned.

Background insulin and I can see people who are not on insulin therapy not knowing what that means.

So can you kind of go a little bit more into like what is a background insulin versus an insulin that you might have with your meals And you kind of talked about like when people might need what, but just a little bit more detail for somebody who’s has literally no idea about insulin at all?

10:59
Yes.

So in someone who does not have diabetes, the body naturally makes a little bit of insulin all day to keep the blood sugars in range and keep your energy stable.

And then when someone eats, the body makes extra insulin.

So when we’re talking about insulin therapy, whether that’s injections or through technology, we try our best to replicate what the body naturally does.

11:22
And so somebody with diabetes may need insulin in the background, so a little bit of insulin all day and the way that we do that is by something called, it’s called basal.

It really just means background insulin like that is one shot a day that gives a little bit insulin throughout the day to help meet the base, the base needs.

11:41
Additionally, there’s another kind of insulin called rapid acting insulin.

This is a kind of insulin that works quickly in the body to to help blood sugars come down.

So that’s used more for meals and things that are going to make our blood sugars go up versus just our background needs.

11:57
OK, so let’s get into the fears, because so many people are terrified of injecting insulin.

And honestly, I get it.

Because when I was in training to become a diabetes educator myself, this was one thing that everyone in class was scared of.

12:13
And so they had us inject ourselves.

I can’t remember what we were injecting.

It wasn’t insulin.

It was something else, Maybe saline, I don’t know.

So we could just get a sense of what it felt like.

And I realized like, oh, it’s not so bad, but.

You know you as.

Someone who works with a lot of people.

12:28
I’m curious on your thoughts on this.

Like, you know, so many folks have fears it also may be inconvenient for somebody to give themselves insulin if they have a chaotic schedule.

So I know these are kind of two questions, but what do you find helpful?

12:45
A.

With addressing the fears with insulin and B addressing the inconvenience.

Of it all, yes, it’s it’s common to have a fear of giving insulin.

I do talk to a lot of people who have what they call a needle phobia and you know, the thought of injecting and the thought of needles can be can be quite scary.

13:03
I will say I work with a lot of children and they after they do it a couple times, they become pros.

Generally it should not hurt or cause pain, especially afterwards.

So if someone comes to me and they’re telling me that it’s hurting or causing pain, there may be a problem with where they’re injecting or how they’re doing their technique.

13:20
So it’s definitely scary to kind of get over that hump.

I do think that if this is something that brings a lot of fear or anxiety, it is good to talk to a mental health professional.

There are a lot of options within the diabetes community because this is something that I see often and I would and someone’s fears are very valid and so sometimes just getting over that initial hump once they start doing it can make it so much easier.

13:43
But having that support is really important.

To answer your second question about how it can be chaotic, I totally get that.

I find it the best we can be routine.

It’s going to be the most efficient for how the insulin is going to to work and also so that we’re not forgetting doses and such like that.

13:59
So phone alarms, I know that’s kind of a a basic idea but it it goes a long way.

So like phone alarms set, trying to do it at the same time every day.

For your background insulin, you want to follow what your healthcare provider recommends, whether that’s evening or morning.

14:15
But it doesn’t matter if it’s next to a meal, not next next to a meal.

So whatever makes it easiest to remember.

So maybe always at the start of breakfast or always right before bed.

That’s something that can help a little bit.

Another big fear that I’ve seen is people scared to go too low, also known as hypoglycemia, where blood sugars dip and then you start getting those unpleasant side effects, which is completely valid, especially if you don’t have a consistent routine or if you’re not eating regularly.

14:43
What are some other risks that you have seen to be associated with insulin?

Because I know for some of the other diabetes medications, whether they’re, you know, injectables not being insulin or oral, there is a very long list of side effects.

14:58
And I’m wondering like how do you think insulin compares with, you know, some of the other medications?

Do you find it to be?

Do you find it to be not as strong with the side effects associated with it?

Or do you feel like it’s just like a different list of side effects?

15:14
What are your thoughts on that?

I put insulin in its own category.

The main risk of insulin is hypoglycemia and it is a serious, it is a serious risk.

So I think it’s important to talk about and what I suggest for people on insulin is you know, making sure they are checking their blood sugars frequently, especially if they feel any kind of symptoms of hypoglycemia which may be shakiness or dizziness or hunger.

15:40
A continuous glucose monitor or CGM is a type of sensor that automatically checks our blood sugar every 5 minutes.

And so for people on insulin that can be helpful to see if we are having or going low.

I also do recommend if you are on insulin to make sure you always have treatment for a low blood sugar and the treatment is something like a fast acting carbohydrate or sugar so like juice, glucose, tabs, candy something like that.

16:04
So we do want to be prepared for for that as a risk, otherwise there are relatively low risks.

It’s in a different class of medications for some of the other injectables as well as the oral medications.

If someone’s injecting insulin in the same spot all the time, it might not be used as well.

16:24
So it is important to to examine the skin around that area to make sure they’re mixing up their spots because the skin can get tough if you keep injecting there and not really go through as much.

So you know, that’s another kind of side effect as well.

If you are on insulin and you’re noticing a lot of low blood sugars or hypoglycemia, it’s really important to reach out to your healthcare team because that is a sign that your doses most likely need to be adjusted.

16:48
Do you think it’s safe to say, I mean hypoglycemia side, do you think it’s safe to say that insulin is one of the more safer diabetes medications?

Because, you know, with some of these medications, I have patients who are like, oh, I’m seeing a, you know, a pancreatitis or like all these like big warning labels on the medication that are associated with, you know, taking it.

17:12
And with insulin, I mean, in my experience, the main thing is the hypoglycemia.

So what are your thoughts on that, ’cause I think that it’s, it’s almost the other way around in terms of how it’s perceived, like patients are like it’s the worst medication.

It it might make my kidneys fail or like there’s just a lot of misconceptions around taking it.

17:30
So what do you say I?

Agree with you Wendy.

I do think the the hypoglycemia is an acute like a short term risk and those longer term or complications from other medications don’t really come up as much with insulin.

So the the things that we might be concerned about somebody’s stomach or their heart health or their kidney health that may be a side effect of other medications is less of a concern with insulin.

17:53
So definitely, yeah.

Good point.

Another concern with people is they fear if they start insulin, they’re going to be on insulin forever.

So then they’re just like, well, I’m just not going to start it.

What do you have to say about that in your experience?

Is that always the case?

18:08
Does anyone ever get off insulin?

I have seen people stay on insulin and I have seen people come off insulin a lot of times.

When someone is newly diagnosed with diabetes, if they have very high blood sugars, like they were unaware that they have the diagnosis, they’ll need to be started on insulin.

But it can generally be titrated or tapered down a bit and they may come off of it after that.

18:29
Other times someone might just need insulin to help them get in better control, get a better blood sugar, get blood better blood sugar readings and a lower A1C.

And then after that they may able to be able to either go down on dosages or come off of that and instead do oral medications or injectables.

18:47
So it’s not a forever, you know, it’s really just dependent on how the body is responding to the insulin as well as other medications.

Yeah, something that I see too is like the A1C is consistently you know over 7 even as high as 910% which for those of you who aren’t sure what that means, A1C is average blood sugar and the recommendation is to maintain it for most people less than 7% for to be considered well managed.

19:15
And so you know, someone with a 910% is it’s extremely high and it could be associated with more risk.

And something that I’ve seen is delaying insulin when it’s clear that like oral medications might not be working because of the fear that we spoke about.

19:34
So can you talk about, you know, what some potential consequences might be to doing that and, you know, how someone can effectively transition from other medication classes into insulin therapy?

As you mentioned A1 CS over 9 are where we really start to see more complications related to diabetes and those complications could include cardiovascular.

19:55
So having to do with your heart microvascular, so that can relate to how blood flows through the body, you know our feet we can talk about our eyes, retinopathy and such.

So we do start to see these complications when blood sugars are high especially for longer periods of time.

20:11
So delaying insulin can mean blood sugars high and can increase those risk of complications.

So starting when we when we need it.

Is really important.

Everyone drop percentage in A1C can have big effects on on improving our diabetes risks and and limiting them.

20:28
So yeah, starting when we need it is really important.

Yeah, that’s a really good point.

Now, what are some advancements in insulin therapy?

Because I know there’s so much on the horizon and there even are different types of insulin, maybe even some that you don’t have to inject.

20:47
Can you talk a little bit more about that?

Definitely.

So this is where the the world of science and technology and research is so amazing.

Even in the last few years there’s been a lot of new types of insulins or changes.

So for example, recently there’s they’ve come out with an insulin that works even faster.

21:05
So that’s helpful for when someone needs insulin for meals that it will start working the body really quickly.

There’s insulins that do work in the background and last even more than 24 hours.

So that’s going to help if somebody maybe forget the dose or they just need a little extra coverage.

There are also insulins that we don’t need to inject.

21:21
So there is an insulin that can be inhaled called Afrezza and in the future they’re working on insulin pills.

So there is really a lot going on here and it’s an exciting feel to to keep our eyes open and see what comes.

A really quick follow up question on that.

So for some of these other therapies like Afreza, have you noticed that for most patients it is covered with their standard insurance or is this something that’s like really expensive and not typical care for most?

21:48
I would say with something like the inhaled insulin, it’s not the standard of care right now.

So I would assume there could be some, you know, some trouble with insurance coverage though it’s very dependent on each day and dependent on each insurance.

So it’s always good to ask if it’s an option and if your healthcare, if that’s something that you’re interested in, if your healthcare team can can try to fight for you and see what they can do there.

22:12
But yeah, right now injectable insulins are the the kind of standard of care primary in insulin.

So those are the ones that we see the best coverage with, yeah.

Absolutely.

So thank you so much, Isabel.

This was amazing.

I feel like everyone listening learned so much and I’m sure there’s a lot of people who are wondering how do they work with you?

22:32
So can you tell people how they can work with you as their dietitian?

If you’d like to work with me, I’m accepting new clients.

You can visit diabetesdigital.co slash patients and fill out an intake form and from there we’ll reach out to you.

We are in network with many insurances, so there’s a good chance we’ll be able to have you covered, so just let us know.

22:53
But we’re here to help.

We’re super excited.

So thank you again for being here, Isabel.

Thank you.

Thanks for joining us for today’s episode.

If you’re interested in nutrition counseling with one of our expert dietitians to help improve your pre diabetes or diabetes, visit us at diabetesdigital.co.

23:10
Also, if you found our conversation helpful, do us a favor and rate and review at this podcast on iTunes.

Plus, share with someone who might find this helpful.

You can also connect with us on Instagram at Diabetes Digital dot.

Co and TuneIn every Wednesday for practical, inclusive and culturally humble diabetes insights.

23:29
We’ll catch you later.

Bye.