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Byline: Ibrar Ahmed

To start with I want to quote Dr. Frederik Banting "Insulin does not belong to me; it belongs to the world"1. Diabetes mellitus is one of the endocrine endemics arising in our country in recent years. According to the recent IDF Atlas 2019, Pakistan is at No. 4 in the prevalence of Diabetes2. People and physicians were thinking that diabetes is a bomb which is about to explode but the recent published data of diabetes prevalence survey of Pakistan(DPS-PAK)3 showed that it had already exploded. Therefore, we should emphasize on relevant measures that should be taken in already diagnosed diabetics. They should be treated with care and prompt action needs to be taken at proper time to prevent or delay complications. Oral hypoglycemic agents are frequently not sufficient to control glycemic status and insulin therapy is required. One of the foremost action is to start insulin at proper time; however, as health care professionals we come across a lot of hurdles in initiation of insulin.

These are many fold and vary from opinions of relatives, parents, physicians, quacks, medical store owners, lab technicians to social issues or economic burden and patient's beliefs against starting insulin4-6. Firstly, insulin is believed as last treatment resort for diabetes and if the sugar levels are not controlled adequately(even on insulin), they would have nothing left for management. So to keep their hopes alive they stress that they should remain on oral medicines and they will control their diabetes status more aggressively and resist insulin eventually. Here comes the role of physician to give them ample time and counsel them that insulin is not the last resort. It will not just improve the diabetes status but will also be of help in preventing the complications. Many landmark studies have shown reduced incidence of microvascular and macrovascular compilations in intensively controlled diabetic patients7-9. Secondly, the fear of injection and pain during injection is another big hurdle.

Now comes the role of diabetic educator who should make sure the patients see insulin as a friend rather than enemy10. The teaching of insulin injection technique, importance of site rotation as well as insulin syringe width and the availability of new less painful gadgets need to be explained to the patients. Thirdly, fear of side effects from insulin e.g. hypoglycemia. When patients get a single episode of hypoglycemia, they may leave this important remedy in future. To overcome it, patients need to be given hypoglycemia awareness before initiating insulin; insulin should be started at low doses; and titration of insulin in accordance with self-monitored blood glucose(SMBG). Lastly, the cost issue, as people are worried about the cost of insulin.

Government should look into it as a priority and take the responsibility of providing insulin free of cost so that this mode of treatment is availed by all deserving patients. A comprehensive action plan comprising of effective strategies and feasible remedies is the need of the day to address all these hurdles. "Success is determined not by whether or not you face obstacles, but by your reaction to them. And if you look at these obstacles as a containing fence, they become your excuse for failure. If you look at them as a hurdle, each one strengthens you for the next." With combined and ongoing efforts of doctors, community workers, diabetic educators, nutritionists, we can be able to stop or hold this uphill task and gigantic wave of diabetes which is hitting our community.



2. International Diabetes Federation. IDF Diabetes Atlas, 9th Ed. Brussels, Belgium; 2019. Available at:

3. Aamir AH, Haq ZU, Mahar SA, Qureshi FM, Ahmad I, Jawa A et al. Diabetes Prevalence Survey of Pakistan(DPS-PAK): prevalence of type 2 diabetes mellitus and prediabetes using HbA1c: a population-based survey from Pakistan. Br Med J Open 2019; 9:e025300.

4. Peyrot M, Rubin RR, Khunti K. Addressing barriers to initiation of insulin in patients with type 2 diabetes. Prim Care Diabetes 2010; 4:S11-8.

5. Iqbal N, Ali Z, Ullah I, Ziauddin, Awan MB, Mahmood K. Psychological barriers towards early insulin initiation in uncontrolled type 2 diabetic patients. J Postgrad Med Inst 2019; 33:13-8.

6. Lee YK, Lee PY, Ng CJ. A qualitative study on health care professionals perceived barriers to insulin initiation in a multi-ethnic population. BMC Fam Pract 2012; 13:28.

7. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes(UKPDS 33). UK Prospective Diabetes Study(UKPDS) Group. Lancet 1998; 352:837-53.

8. Nathan DM, Genuth S, Lachin J, Cleary P, Crofford O, Davis M et al. The effect of intensive treatment of diabetes on the development and progression of long term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329:977-86.

9. Patel A, McMahon S, Chalmers J, Neal B, Ballot L, Woodward M et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358:2560-72.

10. Polonsky WH, Jackson RA. What's so tough about taking insulin? Addressing the problem of psychological insulin resistance in type 2 diabetes. Clin Diabetes 2004; 22:147-50.
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Article Details
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Author:Ibrar Ahmed
Publication:Journal of Postgraduate Medical Institute
Geographic Code:9PAKI
Date:Dec 31, 2019

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