Stuart Weiss, MD, is a clinical assistant professor of endocrinology, diabetes, and metabolism at New York University's Department of Medicine, NYU Medical Center, in New York City.
Q: I have type 2 diabetes. Do I have to take insulin?
A: For people with type 2 diabetes, insulin is a very nice tool that's better if used sooner rather than later. (Unlike in type 2 diabetes, in type 1 diabetes insulin is a requirement, not an option.) What happens in type 2 diabetes is that physicians may use insulin as a threat, an “if you” thing—if you don't lose some weight, if you don't do some exercise, if you don't follow the diet, then you're going to wind up on insulin. That's really not how people with type 2 diabetes should view insulin—as a punishment. Insulin is a very, very safe therapy, and people should not hesitate to use it if needed.
The people with type 2 diabetes who must take insulin are those who are unable to control their blood sugar even while on several different oral medications. But if you start using insulin before you reach that point, you can help preserve the function of your insulin-producing pancreatic cells for a longer time. And the longer you continue to make your own natural insulin, the longer you can get by with a less complicated insulin regimen, possibly taking just one shot a day.
Q: But I'm afraid of shots!
A: You don't need to be, if you're talking about insulin. If you're picturing big syringes that you have to boil and sterilize, think again. Modern insulin needles are very thin and disposable—no sterilizing necessary. There are also insulin pens equipped with an insulin cartridge and disposable needles that are so simple even a child can use them. Either type of delivery system makes using insulin very easy and virtually painless—really.
If you pinch the injection site before giving yourself a shot, it will hurt even less. Still, the needles are so small these days that pain is not really an issue any more.
Q: Won't too much insulin cause me to go into a coma?
A: Theoretically yes, if you take lots and lots of insulin. But in reality, the kind of severe hypoglycemia (low blood sugar) that would cause someone to go into a coma is extremely rare in people with type 2 diabetes. Hypoglycemia is a bigger risk for those with type 1 diabetes.
Q: Will I have to take insulin forever?
A: It depends. Many people can eliminate their need for insulin if they eat less, exercise more, and lose weight, and if their beta cells (which make insulin in the body) are still functioning adequately. But if your doctor has waited to prescribe insulin until you can no longer make this hormone on your own, then yes, you will have to be on insulin for the rest of your life.
Q: Why can't I just take a pill?
A: Some diabetes medications aren't great to use long-term, while insulin is extremely safe. Rather than waiting to take insulin until you're on several different oral agents—none of which are working any more—it's better to start well before you've added a second or even a third medication.
Q: How many times a day do I have to take insulin?
A: If you can start insulin really early in the course of the disease, one shot a day may do the trick. People whose disease has progressed further may need to take it several times a day, typically with each meal.
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Q: Won't I gain weight?
A: Weight gain is the first sign that your diabetes is under control, whether it's with oral agents or insulin, because your body starts being able to process sugar again. But the weight is typically gained in a healthier pattern; you may notice that your clothes fit you differently. I tell patients to pay more attention to how their clothes fit than to what their weight is.
Q: Will I ever be able to get on a plane with needles?
A: Airport security employees are pretty familiar and comfortable with diabetic fliers bringing their equipment with them. First, you should notify the security officer that you have diabetes and are carrying supplies with you. As long as any insulin you bring with you has a professionally printed label identifying the medication (the original box it came in usually carries this labeling), you'll be fine.
You are allowed to take insulin, insulin-loaded dispensing products, unused syringes, and other supplies through the checkpoint once they have been screened. You may want to bring a note from your doctor stating that you have diabetes and need insulin treatment, just to be sure. But nobody has ever come to me and told me that they've had trouble bringing their insulin and other supplies on a plane.
Q: How do I prevent hypoglycemia?
A: Hypoglycemia occurs when you have too much insulin in the body, so blood sugar drops too low. Symptoms include anxiety and confusion, sweating, hunger, and, in rare cases, seizures and coma. To prevent this, make sure to match your insulin intake to your food intake, which can take some trial and error. And you should always have a sugar source on hand; eating some will quickly reverse hypoglycemia advise patients to buy glucose tablets. While candy can work too, you'll be less tempted to snack on the tablets, which aren't all that tasty.
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Q: How can I exercise while taking insulin?
A: Exercise is great because it's a natural way to lower your blood sugar. However, if you're taking insulin you need to take this into account when planning your day. You may experience low blood sugar during exercise, or afterward. Again, having a sugar source handy—watered-down Gatorade, glucose tablets, candy—is important, and can quickly reverse blood sugar that is too low.
Q: What kind of food can I eat while taking insulin?
A: You will still have to eat a healthy diet. You can eat as much fish, poultry, and green vegetables (with the exception of peas) as you like, as these are less likely to affect blood sugar as much as carbohydrate-rich food. You'll need to match your insulin to the amount of carbohydrates you eat in a meal. However, some foods can make it harder for the insulin to control your rise in blood sugar.
You should limit starchy vegetables like potatoes, corn, and peas, which can cause blood sugar to rise. With fruit you also need to be careful. Berries are okay, but pineapples and grapes and cherries are tough.
Eating a piece of fruit as an afternoon snack is a very reasonable thing to do, but not as a before-bed snack or first time in the morning, which can make it harder for insulin to control blood sugar.(That is because hormones that are associated with waking up make it more difficult for insulin to work, and when you're asleep, your sugar will rise because you're burning fewer calories.) It can take some trial and error to figure out what food you can eat while keeping blood sugar in the safe zone.
Q: How do I store insulin?
A: Once insulin has been opened, for pretty much all types of insulin you can store it at room temperature for about six weeks. It doesn't have to be refrigerated. However, you should keep it in a relatively cool place, especially if the room temperature in your home is 85° or more.
Q: What IS insulin? Is it a drug or a hormone?
A: In a way, it's both. But first and foremost, insulin is a hormone. The beta cells of the pancreas make insulin and release it when you eat a meal. It lowers the blood sugar by multiple mechanisms, but basically by causing cells to take the sugar out of the blood. And for people who aren't making enough insulin on their own, and must take it to treat their diabetes, insulin is, technically, a drug.
Q: What exactly is insulin resistance?
A: Insulin resistance occurs when a person becomes less sensitive to the hormone and he or she needs to release more and more insulin to lower the blood sugar by the same amount. Insulin resistance further depletes the insulin-producing cells of the pancreas and leads to progression of diabetes. Obesity is a major contributor to insulin resistance, while a healthy diet and physical activity can help improve insulin sensitivity.
Q: Can insulin prevent diabetes complications, like nerve damage, heart disease, and blindness?
A: There is evidence to suggest that if taking insulin leads to better blood sugar control, people are less likely to develop complications. And the earlier you are able to get your blood sugar under tight control, the better your chance of avoiding these complications.
Q: What if I skip my insulin? Could I die?
A: Odds are you won't. But it depends on how often or for how long you skip your insulin. I tell my patients who use insulin multiple times a day that if they miss a shot, they need to cut the carbohydrate content of the food they eat that day, drink more water to counter the dehydration associated with higher blood sugar, and eat more green vegetables and less starch.
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Q: What is an insulin pump? Do I need one?
A: Probably not. An insulin pump is basically a system for delivering the hormone to your body. It can be adjusted to release different amounts throughout the day. While these devices can be helpful for people with type 1 diabetes, for most type 2 diabetics they're not necessary.
Q: Can I get addicted to insulin?
A: If you're asking whether your body can become dependent on insulin, it depends. If your body is still producing some insulin on its own, there's a chance you could reduce your need for extra insulin by eating healthier, becoming more active, and losing weight. However, if your body can no longer produce any insulin on its own, you will indeed be dependent on it, but not because you're taking insulin as a drug. In type 2 diabetes, insulin resistance damages your natural insulin-producing cells and this may increase your need for taking insulin as a drug. Disease progression can leave you dependent on insulin—not the insulin itself.