This week I instructed an obese African-American 59 year old woman who has had type 2 diabetes for 3 years. Unfortunately she had never been given the skills of diabetes management and had a poor understanding of diabetes and insulin resistance. She has already lost most of her vision due to retinopathy – an eye complication of uncontrolled diabetes. She lives with her granddaughter who does the meal preparation, along with blood glucose testing and injecting of her insulin shots. After spending an hour discussing diabetes they both had a much better understanding of the basics and how to reduce future complications.
She has several relatives and friends who have type 2 diabetes, and she was curious as to why each person requires different amounts of insulin for the same disease. Many were on much less insulin and had good diabetes control. She was injecting 45 units of Levemir (basal insulin) twice a day and 12-15 units of Humalog (rapid acting insulin) prior to her meals. After additional discussion she understood why certain patients need more insulin than others; it related to her weight and insulin resistance. Never stop taking or change your insulin dosage without consulting your physician.
What is insulin resistance?
Certain patients may require more insulin than others. Insulin has many functions, but one of the most important functions is to allow glucose from digested carbohydrates into the muscle and fat cells so the body can utilize it as energy. A person without diabetes makes about 40 units of insulin a day. A patient with diabetes type 1 generally requires small amounts of insulin since they are not insulin resistant, they just lack insulin production. Patients with type 2 diabetes often require large amounts of insulin to control blood sugars. Those taking more than 50 units usually indicate that they are insulin resistant. In type 2 diabetes, the pancreas generally has enough insulin but the body can’t use it or becomes resistant to the insulin. Because of this, larger amounts of insulin must be pumped out of the pancreas to do the same job. The pancreas continues to pump out insulin until it can no longer keep up; then the blood sugar rises. Being insulin resistant (which occurs prior to diagnosis of type 2) can be connected to the Metabolic Syndrome which includes: hypertension, elevated triglycerides, elevated LDL, blood clotting abnormalities and central obesity. Insulin resistance can also include a fatty liver with high liver enzymes (fat accumulates in the liver). Other indications of insulin resistance include Acanthosis Nigricans (a dark thickened velvety patch usually behind the neck, armpits or in the groin), Polycystic Ovarian Syndrome (a reproductive issue) and an increase in skin tags. Insulin resistance often leads to diabetes type 2 and heart disease if not addressed. Insulin resistance can cause strokes, heart attacks, angina and peripheral vascular disease.
What causes insulin resistance?
Several factors create insulin resistance. They include: Obesity (a body mass index over 25, or a waist circumference of over 35 inches for a female or 40 inches for a male); Family history and genetics plays a strong role as well as being over age 40, being inactive, having gestational diabetes, stress, acute illness and taking steroid injections or oral medications; Certain ethnicities such as African-American, Hispanic, Asian American, Native American or Islanders have increased insulin resistance.
How is it diagnosed?
A healthcare provider should do a complete history and physical to assess signs and symptoms of insulin resistance. Blood work should be ordered and reviewed with the patient. A fasting blood sugar (or FBS) along with an insulin level is usually sufficient. A fasting blood sugar between 100-125 can indicate insulin resistance, along with other symptoms.
How is it treated?
By treating insulin resistance you can often lower the need for or the amount of insulin, and increase the sensitivity to the insulin already available. Often, lifestyle changes can reduce insulin resistance. Positive changes would include: weight loss and increased activity. Multiple studies have confirmed that aerobic exercise and weight training will decrease insulin resistance even without any reduction in weight. Smaller servings of carbohydrates and eliminating sugary beverages including regular soda, fruit juice, fruit punch, Kool-Aid, High C, Tang and Gatorade can lower insulin resistance. Adding low glycemic index food choices including high fiber, resistance starch and non-starchy vegetables can help lower insulin resistance. Metformin, an oral diabetes medication is often prescribed to increase the sensitivity of insulin to muscle and fat cells and decrease insulin resistance when lifestyle changes fail.
Knowing why you are required to do certain things, like taking more insulin when you have diabetes, is important. It is also necessary to ask the questions and get the right answers. This may further promote your compliance. My patient now has a better understanding of insulin resistance and why she is on a large dose of insulin. She is ready to make some needed changes which may allow her (through her physician) to lower her insulin resistance and insulin dosage along with improving blood sugar control.
NOTE: Consult your doctor first to make sure my recommendations fit your special health needs.
She is a member of the American Diabetes Association as well as the South Florida Association of Diabetes Educators. She worked with the education department of NBMC to help educate the hospital's in-patient nurses about diabetes. She practices a healthy lifestyle and has worked as a personal fitness trainer in the past.
She was one of the initiators of the North Broward Diabetes Center (NBMC) which started in 1990 and was one of the first American Diabetes Association (ADA) certified programs in Broward County, Florida for nearly two decades. Robbie has educated patients to care for themselves and has counseled them on healthy eating, heart disease, high lipids, use of glucometers, insulin and many other aspects of diabetes care. The NBMC Diabetes Center received the Valor Award from the American Diabetes Center for excellent care to their patients. Robbie has volunteered over the years as leader of many diabetes support groups.