Psychological Insulin Resistance in Patients With

Type 2 Diabetes
The scope of the problem
1. William H. Polonsky, PHD, CDE12,
2. Lawrence Fisher, PHD3,
3. Susan Guzman, PHD2,
4. Leonel Villa-Caballero, MD4 and
5. Steven V. Edelman, MD56
+Author Affiliations
1. 1
Department of Psychiatry, University of California, San Diego, San Diego,
California
2. 2
Behavioral Diabetes Institute, San Diego, California
3. 3
Department of Family and Community Medicine, University of California, San
Francisco, San Francisco, California
4. 4
Department of Family and Preventive Medicine, University of California, San
Diego, San Diego, California
5. 5
Division of Endocrinology and Metabolism, University of California, San Diego,
San Diego, California
6. 6
Veterans Affairs Medical Center, San Diego, California
1. Address correspondence and reprint requests to William H. Polonsky, PhD, CDE, P.O.
Box 2148, Del Mar, CA 92014. Email: whp@behavioraldiabetes.org
• PIR, psychological insulin resistance

To achieve tight glycemic control in type 2 diabetic patients, it may be advantageous to

introduce insulin therapy much earlier in the disease course (1). Unfortunately, many
patients are reluctant to begin insulin and may delay starting insulin therapy for significant
periods of time (2,3). Recent evidence suggests that more than one-quarter of patients may
refuse insulin therapy once it is prescribed (4). Little is actually known about this
phenomenon, often termed “psychological insulin resistance” (PIR), how common it may be,
or why patients feel this way. Therefore, we developed and distributed a PIR self-report
survey to a large multicity sample of patients with type 2 diabetes who were not taking
insulin. The survey examined their willingness to take insulin if it was prescribed and to
identify perceived attitudinal barriers to insulin therapy.

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RESEARCH DESIGN AND METHODS

Participants at several 1-day conferences for people with diabetes (Taking Control of Your
Diabetes) conducted in San Diego, California; Raleigh, North Carolina; Portland, Oregon;
Minneapolis, Minnesota; Philadelphia, Pennsylvania; and Honolulu and Hilo, Hawaii
completed an anonymous one-page survey concerning insulin attitudes. At the beginning of
each conference, an announcement to all participants explained the study, directed them to
the questionnaire in their conference syllabus, and asked them to return completed surveys
before the conference’s conclusion. The study was approved by the Committee on Human
Research at the University of California, San Francisco.

An initial questionnaire item assessed willingness to begin insulin therapy, rated from very
willing to not unwilling. Patients also rated on a six-point Likert scale how strongly they
agreed or disagreed with each of nine items that might explain reluctance to begin insulin
therapy. These attitudinal items, drawn from recent descriptive studies (5–7), as well as
patient reports, are listed in Table 1.

We examined willingness as a discrete variable, comparing those who reported any degree
of willingness (slightly, moderately, or very) with those who were unwilling. This reflects the
clinical reality: the patient is either willing or not, and the gradations of willingness are often
not of critical concern. The nine attitudinal items were scored in a similar manner, with any
degree of agreement considered to be an endorsement of that item.

Stepwise logistic regression was used to assess the impact of patient sex, ethnicity, age,
and diabetes duration on insulin therapy willingness. The variables were entered into step 1
of the equation, followed by an ethnicity × sex interaction term in step 2. Next, we
combined the responses on each of the nine attitudinal items to create a total “negative
beliefs” score (representing the number of items to which the subject agreed at least mildly)
and included it in an equation to predict willingness. A similar series of logistic regressions,
one for each of the belief items, was then used to examine how strongly each of the beliefs
was associated with insulin therapy willingness. Finally, to assess the influence of patient
demographics on the belief items, a series of nine ANCOVAs was used, one for each belief
item.

Because there were relatively few African Americans and Hispanics in the sample, we
focused the ethnicity variable on non-Hispanic whites (NHWs) versus all ethnic minorities
combined (Asians, African Americans, and Hispanics).

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RESULTS

Of an estimated 3,833 diabetic patients attending the nine conferences, 1,267 returned
completed questionnaires (33.1%); of these, 708 were type 2 diabetic patients not taking
insulin. The mean age was 57.4 years, and the average diabetes duration was 6.9 years. The
majority were female (65.8%) and NHWs (53.7%).

Insulin therapy unwillingness was common: 28.2% reported being unwilling to take insulin if
prescribed, and the remainder indicated some degree of willingness (slightly willing, 24.0%;
moderately willing, 23.3%; and very willing, 24.4%). More females (32.0%) were unwilling
than males (21.1%) (P < 0.001), and more ethnic minorities (35.1%) were unwilling than
NHWs (22.4%) (P < 0.01). There were no significant differences by sex across ethnic groups.

Negative attitudes toward insulin were common across the entire sample, with a mean of
3.1 negative beliefs identified per subject. Patients most frequently endorsed beliefs about
insulin therapy permanence (45.0%), restrictiveness (45.2%), problematic hypoglycemia
(43.3%), personal failure, and low self-efficacy (43.3%) as reasons to avoid insulin therapy.

Unwilling subjects reported significantly more negative insulin therapy beliefs (4.0 ± 2.6)
than willing subjects (2.8 ± 2.5) after controlling for ethnicity, sex, age, and diabetes
duration (P < 0.001). Indeed, unwilling subjects reported greater agreement than willing
subjects on all nine belief items (in all cases, P < 0.001). The most pronounced differences
were the items associated with personal failure, low self-efficacy, anticipated pain, and lack
of fairness. Of note, the beliefs were not independent of each other; the median
intercorrelation was 0.46.
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CONCLUSIONS
In this relatively large multicity sample, we found that PIR is common. Similar to other
reports (4), ∼28% of insulin-naïve type 2 diabetic patients reported they were unwilling to begin insulin if
prescribed, and a substantial number of the remaining sample expressed significant degrees of reluctance.
Because ours was a relatively motivated sample, we suspect that the true prevalence of PIR
is significantly higher.
Most subjects reported several reasons for avoiding insulin, rather than just one. The
negative attitude that most strongly distinguished willing from unwilling subjects was the
belief that beginning insulin therapy would indicate they had “failed” proper diabetes self-
management. Patients may associate insulin therapy with a sense of personal failure due to
common physician practice, where the possibility of insulin therapy may be used as a threat
to motivate better patient cooperation (8).

Limitations to this study are apparent. First, the measure of PIR was a single self-reported
item that reflected beliefs or expectations, not actual behavior. Without further study, we
cannot know whether this translates into true resistance and/or refusal to take insulin once
the recommendation is made. Second, the pool of attitudinal items was necessarily limited,
and there may be other important contributors to PIR that were not assessed. Third, the
sample consisted of a relatively motivated group of patients, which may not be
representative of the insulin-naïve type 2 diabetic population as a whole.

These data lead to several implications for clinical practice. Although a patient’s clinical
presentation of PIR may point to a single issue (e.g., fear of needles), PIR typically
represents a complex of beliefs about the meaning of insulin therapy, poor self-efficacy
concerning the skills needed for insulin therapy, and a lack of accurate information. Patients
may be unable to overcome their insulin therapy reluctance until their personal concerns are
recognized and addressed. Therefore, when patients express discomfort with starting
insulin, providers might begin by questioning patients about their knowledge of insulin
therapy and their underlying beliefs. Brief, personalized interventions that address the
unique insulin therapy concerns of patients need to be developed and implemented (8,9).
These may include a more proper framing of the insulin therapy message and assuring
patients that the need for insulin does not indicate personal failure. Finally, although PIR was
seen among patients from all demographic groups, there was significantly greater insulin
therapy reluctance among females and ethnic minorities. Clarifying these differences in PIR
deserves further study.
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Table 1—

Attitudes about insulin therapy, unwilling vs. willing subjects

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Acknowledgments

This study was supported by an unrestricted educational grant from Aventis

Pharmaceuticals.

We thank the hard-working Take Care of Your Diabetes staff and the conference leaders,
volunteers, and patients at all of the participating Take Care of Your Diabetes events
nationwide.

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Footnotes
• A table elsewhere in this issue shows conventional and Système International (SI)
units and conversion factors for many substances.

Overcoming Barriers to the Initiation of Insulin

Therapy
1. Martha M. Funnell, MS, RN, CDE

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New recommendations for the management of type 2 diabetes call for more rapid initiation
of both oral medications and insulin therapy.1 Although most providers agree that insulin is
an efficacious approach to the management of type 2 diabetes, many still consider insulin
therapy as the last resort and indicate that their patients are hesitant to take insulin.2 In
addition, the initiation of insulin therapy is difficult in the confines of a 10-minute office visit.
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Assessment of Barriers
The first step is to determine the patient's view of insulin therapy and correctly identify
barriers from the patient's perspective. The discussion about the need for insulin therapy
affects people differently. Some may feel angry or betrayed, others fear that insulin will add
to the burden and stress of managing diabetes, and still others may feel overwhelmed or
frightened.3

To determine a patient's concerns, ask questions such as:

1. What do you need to know to consider insulin therapy?

2. What problems do you think you will encounter?

3. What do you see as the biggest negative of insulin? The greatest benefit?

4. What would help you overcome your concerns?

 5. Are you willing to try insulin? If not, what would cause you to consider
insulin?

The first response to such questions is very rarely a full accounting of the patients' true
concerns. Continuing to ask questions, such as “Why do you think that is?” or “Can you tell
me more about that?” will help both you and the patient better understand the existing
barriers so that you can best support patients in the decision-making process.

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Patient-Identified Barriers to Insulin Therapy

The decision to initiate insulin therapy ultimately belongs to the patient with type 2
diabetes. Common barriers among patients include beliefs that insulin is a personal failure,
that insulin is not effective, that insulin causes complications or even death, or that insulin
injections are painful, as well as fear of hypoglycemia, loss of independence, weight gain,
and cost. There are, however, strategies providers can use to decrease patient barriers to
insulin therapy and assist patients with the decision-making process.4
Insulin as a personal failure
A common belief among patients is that the need for insulin therapy is indicative of a
personal failure to manage their diabetes appropriately.2 Explaining type 2 diabetes as a
progressive disease of insulin resistance and β-cell failure from the onset will help to
diminish or even prevent this erroneous belief. Point out to patients that they have not failed
but that the other treatment options have failed them. Although many providers use insulin
as a “threat” to promote meal planning and exercise behaviors,2 this strategy ultimately
backfires when the patient does need insulin, despite having made recommended mealtime
and physical activity changes. Instead, describe insulin as a logical step in the continuum of
treatment.
Insulin is not effective
A surprising number of patients who participated in the Diabetes Attitudes, Wishes, and
Needs study indicated that they did not believe insulin was effective for treating
diabetes.2 Although the reasons behind this lack of belief were not assessed, this barrier
could stem from personal experiences in which friends or family members were prescribed
insulin in doses insufficient to lower blood glucose levels, but still resulting in side effects
such as weight gain or hypoglycemia. Although most patients think of diabetes as a “sugar”
problem, pointing out to them that diabetes is actually an insulin problem and that the
insulins used in therapy today are very similar to the insulin that the body naturally makes
may be helpful.
In addition, providers tend to base the decision to recommend insulin on hemoglobin
A1c levels, whereas patients are often more concerned about the effects of diabetes and its
treatment on their current lives. Assessing patients' concerns and goals is necessary to
frame the messages about insulin to match their goals beyond glucose control. For example,
patients who want more flexibility in their lives or more energy for activities they enjoy may
be more amenable to insulin therapy if they are taught how it can be used to achieve those
goals.
Insulin causes complications or death

Many patients with type 2 diabetes have had experiences with diabetes through relatives or
friends. The belief that diabetes causes complications or death often stems from these
experiences. Although it is more likely that insulin might have delayed or prevented these
complications, their beliefs about insulin in terms of its cause of and effect on these events
continues. Although it is tempting to provide information about insulin to counteract these
beliefs, facts alone often do very little to allay patients' fears. It is generally more helpful to
respond by acknowledging the patient's fears and then providing information about the
provider's experiences. For example, “I understand your concern, but would it help to know
that I have cared for many patients with type 2 diabetes, and I have never known anyone
who became impotent as a result of insulin therapy?”

Insulin injections are painful

Many patients equate insulin injections with inoculations or injections of antibiotics that they
have experienced in the past. Point out that insulin needles are smaller and thinner than
ever before and that most patients find it less painful than testing their blood glucose levels.
Other strategies that educators often use to overcome this barrier are to give a dry injection
to themselves in front of the patient or to ask patients to give a dry injection to themselves
at the time of the initial education, regardless of whether insulin is indicated. Insulin pens
can also be helpful for patients who are concerned about the pain of injections. Although
these patients are often described as “needle phobic,” very few patients have true needle
phobias. For those who do, psychological counseling is often needed and effective.

Fear of hypoglycemia

The fear of hypoglycemia often stems from observing people with diabetes who take insulin.
Assessing what they have observed and the outcome of the hypoglycemic event is needed
to address the patient's specific fear. Point out that with the use of newer rapid-acting and
long-acting insulins, hypoglycemia is less likely to occur and that very few patients with type
2 diabetes actually have severe hypoglycemia. Reassure patients that you can teach them
strategies so that they can prevent, recognize, and treat hypoglycemia and thus avoid
severe events.

Change in lifestyle

A concern among older adults or patients who live alone is that once they begin insulin
therapy, it will adversely affect their independence, either because of hypoglycemia or
because they fear they will not be able to draw up or administer their own injections.
Providing information about insulin pens or other devices to increase accuracy and ease of
administration and about local home-care resources may help to diminish these barriers.
Teaching patients to correctly identify symptoms of hypoglycemia and strategies to facilitate
insulin use is also often helpful.

Other lifestyle concerns are related to timing, difficulty in traveling, and loss of spontaneity
and flexibility. If patients identify these concerns, provide information about insulin regimens
that offer maximum flexibility, strategies for traveling with insulin, or other identified
lifestyle barriers.

Some of these barriers result from concerns about injecting insulin away from home, for
example in public places or at work. Some patients worry that if they inject in public places
they will be perceived as injecting illegal drugs. Insulin pens can be very helpful for
overcoming this barrier by increasing patients' ability to inject discretely. Using only morning
and/or bedtime insulin regimens can also eliminate this barrier for some patients.

Some patients have justifiable concerns about the loss of their jobs if they need to begin
insulin therapy. Although there are some occupations for which this is true, the Americans
With Disabilities Act requires employers to make reasonable accommodations for patients
with diabetes, including those who take insulin. In addition, the regimen may be adjusted to
allow for insulin injections to be given while patients are at home instead of at work.
Insulin causes weight gain

It is true that many patients who begin insulin therapy gain weight with improved glycemia
and greater meal plan flexibility. If this is a barrier, offer to arrange a meeting with a
dietitian before the initiation of insulin to identify strategies to prevent weight gain.

Insulin is too expensive

There is no question that diabetes is expensive, particularly for patients who have limited
drug coverage or no insurance at all. Generally, however, insulin is less expensive than
using multiple oral medications to produce the same glycemic outcomes. The regimen may
also be adjusted to decrease this barrier by using premixed insulins if co-pays are a concern
or less expensive insulins for patients with no or limited drug coverage. Other strategies to
reduce this barrier include teaching patients to reuse insulin syringes, adjusting the
monitoring schedule to reduce the cost of strips and other supplies, providing information
about the least expensive sources for insulin and other supplies in your area, prescribing
less expensive insulins, and referring patients to pharmaceutical company assistance
programs. Because prices can vary a great deal at different pharmacies, provide a list of
prices for pharmacies in your area or suggest to patients that they shop around for the best
prices. This is also a good opportunity to review all medications to determine if any could be
eliminated, decreased, or provided in combination form to lower out-of-pocket expenditures.

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Provider-Identified Barriers to Insulin Therapy

Although patient-identified barriers are the most common reasons cited for delay in initiating
insulin therapy, many providers also are hesitant to initiate insulin. Because provider
attitudes are crucial for patient acceptance of insulin, it is important to determine whether
“clinician inertia” is affecting your practice. Along with overcoming patient barriers, there
are also strategies providers can use to overcome their own barriers to insulin therapy.

Refer patients for diabetes self-management education and medical nutrition therapy

Diabetes educators can be powerful allies in helping patients make the decision to initiate
insulin therapy and assisting with insulin dose titration. Recent changes in Medicare,
Medicaid, and other insurance packages have greatly increased the likelihood of
reimbursement for these essential services.

Provide ongoing self-management support

Patients need not only initial education about insulin but also continued followup and
support to sustain gains in diabetes self-care behaviors. Office staff can be extremely helpful
in supporting and reinforcing patients' self-management efforts related to insulin therapy,
particularly in the early phases, when doses are being titrated frequently.

Adopt successful strategies

Consider implementing strategies used by other successful practices, such as creating

collaborative relationships with patients and designing systems to facilitate chronic disease
care. Create proactive methods to evaluate outcomes and monitor results so that the time
spent with patients can be used most efficiently and effectively. Establishing a plan with
patients for follow up of blood glucose results by telephone or in person will also facilitate
the appropriate titration of insulin and its effectiveness.
Address emotional issues

Although it is important to address concerns about diabetes in general, when discussing the
initiation of insulin therapy, it is essential to ask patients about their thoughts or feelings
about insulin. This is the most efficient way to ensure that the messages about insulin are
supportive, tailored for each individual patient, and effective.