Who with Diabetes REALLY Requires Insulin?

March 13, 2020
Diasome.comDiasome BlogWho with Diabetes REALLY Requires Insulin?
Hope Warshaw, MMSc, RD, CDE, BC-ADM
Hope Warshaw, MMSc, RD, CDE, BC-ADM, is a Registered Dietitian and Certified Diabetes Educator. Her career in delivering diabetes care and education has spanned nearly 40 years. She has owned and operated Hope Warshaw Associates, LLC, a consulting practice, about 25 years. She has been actively involved with promoting the role and value of peer support to people with diabetes, caregivers and healthcare providers for nearly a decade. She has been engaged in this work with other diabetes healthcare providers and leaders of peer support communities. She has been a longtime volunteer for several diabetes-focused organizations. She served as President of the Association of Diabetes Care and Education Specialists (ADCES) in 2016 after serving for several years on their Board of Directors. Currently serves on the Academy and Nutrition and Dietetics Foundation Board. She currently lives, plays and works in the beautiful mountains of western North Carolina in Asheville.
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Who with Diabetes REALLY Requires Insulin?

Most people know people diagnosed with type 1 diabetes (T1D) require insulin to manage their glucose levels. That’s typically due to a relatively fast and progressive loss of their body’s pancreatic islet cell’s (known as beta cells) ability to function.(1) Beta cells are responsible for creating (synthesizing) and putting out (secreting) the right amounts of insulin at the right times. T1D is caused by destruction of the pancreatic beta-cells due to an autoimmune response. Simply stated, the body’s immune system selectively destroys the insulin-making beta cells. The rate of this destruction is now thought to be quite variable. Some people with type 1 make no or very little of their own insulin at diagnosis while others may continue to produce a small amount of insulin for years.(1) 

It’s estimated that approximately 1.6 million people, roughly 5-10% of the diabetes population in the U.S., have T1D.(2,3) While T1D is often diagnosed during childhood, it can occur at any age. According to JDRF of the 1.6 million Americans with T1D diabetes, about 200,000 are younger than 20 years of age and more than 1 million are older than 20.(3) There are two reasons for this. One is better management of T1D which results in greater longevity. The second reason is that more adults are being diagnosed during adulthood. The term Latent Autoimmune Diabetes in Adults (LADA) is sometimes used to describe people who develop insulin-requiring diabetes in adulthood.(2)

Many Others with Diabetes Take Insulin

The Centers for Disease Control and Prevention (CDC) estimates that approximately 7.4 million Americans with diabetes, both people with T1D and people with type 2 diabetes (T2D), take insulin.(4) And this figure is likely an underestimation for several reasons. It’s based on 2015 data and doesn’t fully appreciate increases in the numbers of people with diabetes as well as those taking insulin.

If you do the math, about 6 million Americans diagnosed with T2D take insulin. You may find it surprising that this figure is several times higher than the entire T1D population but that’s because there are between 26 and 30 million Americans living with T2D. The CDC estimates that roughly 90-95% of people with diabetes in the U.S. have T2D.(2) Interpolating, it’s estimated that about 30% of people with T2D use insulin to manage their blood sugar.  

The Need for Insulin to Manage Type 2 Diabetes

People diagnosed with T2D have a combination of relative insulin deficiency (in contrast to the absolute insulin deficiency in T1D) and what is known as peripheral insulin resistance.(1) This means that a person with T2D is unable to make sufficient insulin to keep up with their body’s demand and therefore, cannot compensate adequately for their insulin resistance.

At diagnosis, which unfortunately is often delayed by months or years, many people with T2D can keep achieving their glucose targets with a healthy eating plan, sufficient physical activity and one or more oral or injectable glucose-lowering medications other than insulin.(5) Many people with T2D are overweight or obese. With T2D, losing weight and keeping even a small amount of lost weight off can decrease insulin resistance and allow the insulin the person still makes to work more effectively, at least for those early years.

However, T2D is now known to be a progressive disease. It doesn’t stay static. Over the years people continue to have insulin resistance and they slowly lose their ability to synthesize and secrete insulin. This dwindling supply becomes insufficient to keep up with their needs. Glucose-lowering medications other than insulin will become insufficient to manage their glucose levels. For this reason, about 10 to 15 years after being diagnosed, about 30% of people with T2D require insulin. (They may or may not continue to take other glucose-lowering medications.) Today, there are a variety of different types of insulin and insulin delivery devices people with T2D or T1D can use to take insulin, from simple patches, to pens and pumps.

It’s also common for people with T2D not yet taking insulin everyday to need it on occasion, for reasons, such as an infection, use of steroids, hospitalization for surgery and other situations that can cause a rise in glucose levels.

Beyond Two Types of Diabetes

It’s becoming old school to think that there are just two types of diabetes and to use the traditional paradigm that T1D occurs only in children and T2D occurs only in adults. Nuances exist that can lead to misdiagnosis.(2) Quite frequently, adults who actually have T1D or, as noted above, LADA, are misdiagnosed for a time with T2D. It’s anticipated that future schemes for classifying types of diabetes will focus more on the underlying reason why the person’s beta cells aren’t functioning normally.(6,7)

And let’s not forget one more type of diabetes, gestational diabetes, which can develop in women during pregnancy. It’s estimated that gestational diabetes is diagnosed in 2 – 10% of women who become pregnant each year.(8) Some women will need to take insulin to manage gestational diabetes most frequently in the second and/or third trimesters. Gestational diabetes is a caution sign about a woman’s risk for developing T2D. A staggering 50% of women who have gestational diabetes go on to develop T2D.(8) Women who’ve had gestational diabetes should be counseled after their pregnancy about actions to take to minimize their risks.

In summary, it’s clear from these numbers that while everyone with T1D takes insulin, many more people with T2D do as well. It’s also clear that the traditional classifications for diabetes are evolving. For these reasons and others, it’s important for all of us involved in diabetes care to minimize delineations between the types of diabetes and maximize engagement of people with diabetes as a whole community working on improving care, treatment, emotional wellbeing and quality of life.  

References:
  1. American DiabetesAssociation. 2. Classification and diagnosis of diabetes: Standards of MedicalCare in Diabetes -2020. Diabetes Care. 43(Supp 1):S14-S31. https://doi.org/10.2337/dc20-S002.
  2. Centers for Disease Control and Prevention. National Diabetes StatisticsReport, 2020. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed February 21, 2020.
  3. JDRF Statistics. https://www.jdrf.org/t1d-resources/about/facts/.Accessed February 21, 2020.
  4. Saydah SH. Medication use and self-carepractices in persons with diabetes. In Diabetesin America, 3rd ed. Cowie CC, Casagrande SS, Menke A, et al.,Eds. Bethesda, MD, NationalInstitutes of Health, 2017(NIHpubl. no. 17-1468)
  5. American DiabetesAssociation. 9. Pharmacological approaches to glycemic treatment: Standards ofMedical Care in Diabetes 2020. Diabetes Care. 43(Supp 1):S98-S110. https://doi.org/10.2337/dc20-S009.
  6. SkylerJS, Bakris GL, Bonifacio E, et al. Differentiation of Diabetes byPathophysiology, Natural History, and Prognosis. Diabetes. 2017;66(2):241-255.
  7. Schwartz S, EpsteinS, Corkey BE, et al: The Time Is Right for a New Classification System forDiabetes: Rationale and Implications of the b-Cell–Centric ClassificationSchema. Diabetes Care. 2016;39:179–186. http://care.diabetesjournals.org/content/39/2/179.full.pdf
  8. Centers for DiseaseControl and Prevention. Gestational diabetes. https://www.cdc.gov/diabetes/basics/gestational.html.Accessed January 14, 2020.

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