Test Your Knowledge Answer #394

The correct answer is (D).

Key Point:

• Many patients with type 2 diabetes are hesitant to initiate insulin therapy. Much of this resistance derives from fears or beliefs about insulin and its impact on lives.

Although this patient's statement regarding her fear of needles is important, it is equally important to ascertain the exact nature of her fear in order to respond appropriately. Often what patients first identify as their concern is not the real problem. Therefore, solutions developed to address the initial statement will be ineffective because the underlying issue is not addressed. For example, a morbid fear of needles may refer to injection pain, a concern that taking insulin will affect her independence or lifestyle, misinformation about insulin being a cause of complications, or the fear of being mistaken for a drug addict; the strategies to address these specific fears differ. For example, if her fear is painful injections, showing her the needle size and/or asking her to experience an injection may be appropriate. If, on the other hand, her concern is the need to carry syringes, the impact of injections on her lifestyle, or the possibility of being mistaken for a drug user, showing her an insulin pen may help allay her fear.

A discussion of her fears may lead to a completely different and often unrelated cause for her hesitation. Patients who have diabetes very commonly view the need for insulin as a failure if they have heard statements such as “You've failed oral agents” or are promised that insulin can be avoided with weight loss and exercise. Using the need for insulin as a threat to induce weight loss and exercise is counterproductive. Presenting insulin as the next step in the treatment of a progressive disease early in the type 2 diabetes care and educational process will help pave the way for initiation of insulin. This approach also helps address another common mistaken belief that insulin is not effective for treating type 2 diabetes. Because type 2 diabetes is a progressive disease and this patient already pays attention to her food intake and exercise, additional weight loss and exercise are highly unlikely to be effective at this point. Telling her that the newer needles are less painful than the older ones or providing information about the safety of insulin may become appropriate responses once the basis of her fears is known but are premature as the initial response. In addition, providing facts often is of limited value for alleviating fear.

Bibliography

1. Funnell MM, Kruger DF, Spencer M. Self-management support for insulin therapy in type 2 diabetes. Diabetes Educ. 2004;30:274-80. [PMID: 15095517] [PubMed]
2. Funnell MM, Kruger DF. Type 2 diabetes: treat to target. Nurse Pract. 2004;29:11-5, 19-23; quiz 23-5. [PMID: 14726786] [PubMed]
3. Peyrot M, Rubin RR, Lauritzen T, Skovlund SE, Snoek FJ, Matthews DR, et al; The International DAWN Advisory Panel. Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study. Diabetes Care. 2005;28:2673-9. [PMID: 16249538] [PubMed]

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