Does instituting insulin treatment in diabetes signal the end of the road or the beginning of a new journey in diabetes therapy?
IN 1919, Elizabeth Hughes, the 11-year-old daughter of Charles Evans Hughes, America’s distinguished jurist and politician, was diagnosed with type 1 diabetes mellitus (DM).
The only accepted form of treatment then was starvation. Elizabeth was treated with a very low-to-no carbohydrate diet daily. Her health deteriorated, with her weight dropping from 33kg to barely 20kg within two years.
She was tired and weak, and going to school was physically impossible.
In late 1922, the discovery of insulin reversed the misery of Elizabeth. She was one of the first diabetic patients put on insulin treatment.
In 1923, Elizabeth returned to school and graduated from Barnard College in 1929. In 1930, she married William T. Gossett, a lawyer who later became vice president and general counsel of the Ford Motor Company.
They had two daughters and a son. Elizabeth remained active in her work, and was the founder and president of the Supreme Court Historical Society in the United States.
She died in 1981 at the age of 73. She lived a fruitful life as a diabetic on insulin injection for 62 years.
Understanding insulin
Insulin is a natural hormone produced by the beta cells in the pancreas. It is needed to enable glucose from the blood to enter the cells in our body to be used as fuel so that these cells can function normally. Without insulin, or with insufficient insulin, glucose remains in the blood as it cannot get into cells. This is the reason why diabetics lose weight and feel weak and tired.
Type 1 DM is a condition whereby the pancreas is unable to produce any insulin at all. The condition tends to occur in younger age groups and makes up less than 5% of the diabetic population in Malaysia.
Type 2 DM is more common, where there is insufficient insulin from the pancreas to meet the extra requirements of the body, due to a condition called insulin resistance.
Generally, insulin is required in type 1 DM. On the other hand, type 2 DM can be treated with tablets, but in many instances, insulin may be needed.
However, lifestyle adjustments, which include appropriate diet and regular exercise, also play a vital role in the maintenance of good glucose levels in both types of DM.
In the longer term, high blood glucose leads to multiple complications affecting organs like the eyes, kidneys, heart, brain, legs and so on.
Reducing blood glucose levels minimises these complications, and in certain instances, can even reverse some of them.
Why insulin?
In many type 2 diabetics, good glucose level control is not achieved despite a healthy diet, regular exercise and oral medications. The pancreas is unable to secrete enough insulin in spite of getting the maximum dosage of drugs.
The only other solution to reduce blood sugar level is to use insulin. As insulin is injected directly into the body, it is more effective in bringing down blood glucose levels.
It can be used in combination with tablets or on its own. The former may require less frequent injections, whereas the latter may require up to four injections a day.
Insulin can also be delivered continuously via a portable computerised pump, which gives even more flexibility, and thus, better control.
There may be some patients who have developed side effects from medications or are in situations whereby tablets are not suitable, for instance, during pregnancy, or in those who have kidney damage from diabetes.
Whatever the reasons behind the use of insulin, the same aim remains – to control blood glucose levels so that long-term complications can be minimised or prevented.
Furthermore, there are also substantial short-term benefits with better blood glucose control. Many patients who have their diabetes control optimised feel more energetic. Their eyesight improves and the numbness they feel due to nerve damage from poor diabetes control may even recede.
Recently, many studies have showed that early use of insulin in those with very high blood glucose levels can also help the pancreas recover in a small, but substantial number of patients. In many such cases, the recovery is sufficient for these patients to stop the insulin at a later date.
What are the side effects of insulin?
Insulin is a natural hormone produced in the body. It is the lack of this insulin that causes diabetes mellitus. In fact, insulin injections are the most direct way of restoring the imbalance that causes diabetes.
There are now many types of insulin available; each has different characteristics to cater to individual lifestyles and needs.
These insulins are the same, or very close, to the insulin that our body produces. Therefore, contrary to a popular myth, insulin has very little side effects.
Given that the role of insulin is to reduce blood glucose, excessive or inappropriate insulin doses can result in low blood glucose levels (hypoglycaemia).
On the other hand, as expected, inappropriate low insulin doses can result in blood glucose levels going up.
Some insulins work quickly, thus, the dose can be adjusted from day to day, or even from meal to meal, in order to control glucose levels better. This can be done by discussing with the doctor or the diabetes educator how to adjust the insulin dose in various situations.
Patients with diabetes mellitus should test their blood sugar level regularly and keep a record of their blood sugar readings, especially those who are on insulin. The readings are helpful for both the patients, as well as the doctors, in determining the insulin dosage requirement and making adjustments accordingly.
How is insulin injected?
In 1922, insulin was injected using a glass syringe and long thick needles. The appropriate dose of insulin had to be drawn from a bottle of insulin before it was injected.
The advancement of technology has seen these glass syringes replaced by handy pen injection devices in recent years. Unlike syringes, these pen injectors are single-handed-use equipment with prefilled insulin, which simplifies the technique of injection, and thus, can be used across a wide range of patients, from children to the elderly.
The insulin dosage can be set easily and accurately, which helps to decrease the risk of giving the wrong dose of insulin.
The needle length and size of the injectors have also been reduced tremendously to minimise the pain of injection. In the past, the needle length was about 12mm long, but today, it is has been shortened to 5mm only. The thickness of the needle is now down to 31G, which is less than half the thickness of the needles used not too long ago.
In fact, injection using these small needles is almost painless.
Insulin injection may sound very complicated, but many people from all walks of life are on insulin. These include professional athletes who have physically demanding careers, to film stars who have highly variable lifestyles, requiring major adjustments to meals and activities.
The achievement of good diabetes control with insulin allows them to fully exploit their potential in their respective careers.
We have seen more ordinary people like Elizabeth Hughes managing to lead a normal life, having given birth to three children and living to the age of 73, despite being on insulin for more than 80% of her life.
There is a popular myth that the use of insulin in diabetes spells “the end”; that it means that the diabetes is so bad and so serious that the last resort, insulin, is needed.
Perhaps, this myth has spun another equally popular belief that since insulin is only used as a last resort, it must have very severe and harmful side effects.
In fact, the truth is exactly the opposite! Insulin use brings about better diabetes control, and it is this better control that reduces all the complications of diabetes.
It is definitely not the end of the road. It is, in fact, a new beginning.
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