Twitter Chat Summary – Smooth the Transition to Insulin in Type 2 Diabetes

The Johnson & Johnson Diabetes Institute, in partnership with The Diabetes Influencers Network, has launched a series of Twitter chats from August through December 2016 geared to diabetes healthcare professionals. Topics will cover the gamut from using social media for career growth to helping clients accept the diagnosis of diabetes to offering guidance on healthy restaurant eating.

These lively Twitter chats will be facilitated by Hope Warshaw, MMSc, RD, CDE, BC-ADM. Warshaw is a Johnson & Johnson Diabetes Institute Faculty member and is serving during 2016 as president of the American Association of Diabetes Educators.

Our recent Twitter chat took take place on Thursday, October 20 from 9:00 – 10:00 pm ET, 8:00 – 9:00 pm CT, 6:00 – 7:00 pm PT. The topic was: Smooth the Transition to Insulin in Type 2 Diabetes. Following is a summary of that Twitter chat.

Q1: How do you listen for resistance to starting insulin from a person w T2 #diabetes? What open-ended questions do you ask? #DiabetesINFL

maureensrn Resistance may manifest as-> denial of current status; bargain for another trial of oral meds #DiabetesINFL
doctablet Major educational goal of diabetes management in primary care setting would be to ensure basal #insulin is dosed safely #DiabetesINFL
nutritionjill #ad See resistance in body language like crossed arms. #diabetes #DiabetesINFL
gabriellerdcde Patients immediately think they’ve failed, how to overcome that emotion? #DiabetesINFL
eatingsoulfully Tell me your concerns regarding insulin?
#DiabetesINFL
nutritionjill ad Resistance likely when the patient is not engaged in conversation. #DiabetesINFL
hopewarshaw Open-ended question I use: Why do you think your provider recommends you start on insulin? You? #DiabetesINFL
gabriellerdcde How does this step make you feel? #DiabetesINFL
maureensrn Resistance may manifest as-> patient only shares bad outcome stories of insulin therapy#DiabetesINFL
askdrbev As a clinical psychologist and CDE, I ask my patients w/T2D how they feel about starting insulin. #DiabetesINFL
eatingsoulfully What is it about insulin that troubles you the most?
#DiabetesINFL
doctablet Have you ever known anyone on insulin #DiabetesINFL
hopewarshaw Words I hear: “I just want to give staying on my diet and getting more exercise one more chance.” #DiabetesINFL
nutritionjill ad: I ask questions like: What have you heard about taking insulin injections? That sure opens up conversation. #DiabetesINFL
hopewarshaw Yes, how do you reframe? #DiabetesINFL https://t.co/0iWUpMRTta
askdrbev Reluctance of PWDs T2D to start insulin is known as psychological insulin resistance. It’s helpful to address PWD’s fears. #DiabetesINFL
askdrbev As a PWD living w/T1D for 41 years, I try to validate their resistance to starting injections. It’s normal to be anxious. #DiabetesINFL
corlansky Do you know anyone using #insulin? #DiabetesINFL
hopewarshaw Definitely!! Fears of insulin are REAL, present a hurdle. #DiabetesINFL https://t.co/jlyhCUQ5ZA
maureensrn Assess patients previous exposure to those using insulin. Outcomes? Problems? Preconceived ideas? #DiabetesINFL
hopewarshaw Open-ended question I use: What do you know abt taking insulin? Do you know ppl who take insulin? Their experiences? #DiabetesINFL
nutritionjill But then often hear “cause I was bad.” So sad to hear this. #DiabetesINFL https://t.co/hII4sBo56L
corlansky Starting #insulin does not mean you have not failed #DiabetesINFL
corlansky Do you have family members on #insulin? #DiabetesINFL
doctablet Insulin can often help your pancreas recover from the injury of high blood sugar #DIABETESINFL
hopewarshaw How do you think having #diabetes helps you with this transition to insulin ppl face? #DiabetesINFL https://t.co/zc219qaZcj
maureensrn Progression on diabetes does not equal failure of patient efforts! #DiabetesINFL
aprilsaundersrd Ask them! “How do you feel about taking insulin?” Or “What are you thoughts on taking insulin”? #DiabetesINFL
hopewarshaw Tx! Do you feel this resonates with ppl? Does it help over that psychological insulin resistance? #DiabetesINFL https://t.co/1MgUv15GNE
gabriellerdcde Diabetes changes over time, so treatment does too. Does not = failure. #DiabetesINFL
hopewarshaw Words I hear: “It’s just going to be too hard, inconvenient for me to manage taking insulin. So much to do.” You? #DiabetesINFL
hopewarshaw Got to address this failure mentality! #DiabetesINFL https://t.co/hIwmXAuJ9j
gabriellerdcde @hopewarshaw Yes, the idea just overwhelms them #DiabetesINFL
corlansky I ask: Do you know anyone using #insulin? #DiabetesINFL
barbruhsrd With so much innovation in insulin and how it’s delivered (pumps) diabetes can be well controlled #DiabetesINFL
predictbgl Don’t need pump for good control – insulin + dose calculation gives same results at low cost #DiabetesINFL https://t.co/wOhv53f0rV https://t.co/Ig59lsY8M7

Q2: What misconceptions about taking insulin do you hear from ppl w T2 #diabetes most frequently? How do you address? #DiabetesINFL

doctablet # insulin is not dangerous if used correctly. it simply pushes sugar into the cell #DiabetesINFL https://t.co/YbR5u1fvH9
nutritionjill ad: some mistakenly believe that insulin leads to severe complications of #diabetes #DiabetesINFL
eatingsoulfully If I need insulin it means I failed to manage my diabetes.
#DiabetesINFL
gabriellerdcde The needle will be huge and hurt! #DiabetesINFL
maureensrn Misconception-> insulin = patient failure d/t noncompliance of current therapy#DiabetesINFL
nutritionjill ad And some think that they require insulin because they were “bad” or “failed” #DiabetesINFL
eatingsoulfully Some associate insulin with more health problems down the road.
 
#DiabetesINFL
hopewarshaw Misconceptions often stem from ppl client knows/has known who take insulin. Suggest explore client’s beliefs #DiabetesINFL
maureensrn Misconception-> insulin = too costly; too risky; too complicated#DiabetesINFL
maureensrn Focus that insulin therapy is to get blood sugar regulated more quickly; reduce complications. #DiabetesINFL
hopewarshaw Misconception: Taking insulin means I now have serious, bad diabetes. Do you hear this? #DiabetesINFL
nutritionjill #client: When, in fact, there will be less if insulin is used as needed. Better glucose control is critical. #DiabetesINFL https://t.co/hFb56hL1vL
askdrbev Most frequent misconception I hear from PWDs is self-blame and feeling guilty. I reassure them it’s not their fault. #DiabetesINFL
askdrbev Many PWDs assume that taking shots will hurt. I explain that shots are given just under the skin – which does not hurt. #DiabetesINFL
hopewarshaw Misconception: Taking insulin is painful b/c of sharp needles, sting insulin. Suggest let person feel insulin injection. #DiabetesINFL
gabriellerdcde PWD think insulin = permanent. Were in denial before, thought they had touch of sugar. #DiabetesINFL
hopewarshaw Do you let person just take/test/feel an injection? #DiabetesINFL https://t.co/PqzvWa3Usa
hopewarshaw Misconception: Concern abt having regular hypoglycemia due to insulin. Suggest offer fact. Very low events in T2 #diabetes #DiabetesINFL
doctablet Misconception that insulin delivery is complicated. I use the pen analogy to help simplify things some #DiabetesINFL https://t.co/HCVs4mMoec
gabriellerdcde Yes! Show them the needle, let them take empty syringe and poke self #DiabetesINFL
gabriellerdcde Many think it is needle like vaccine needle when its actually quite small #DiabetesINFL
corlansky Don’t blame self for poor diabetes control #DiabetesINFL
corlansky Misconception: I can’t ever eat what I want and now I’m being put on insulin. #DiabetesINFL
corlansky Huge Misconception: Insulin causes weight gain #DiabetesINFL
hopewarshaw Doesn’t have to does it. What helps prevent wt gain? #DiabetesINFL https://t.co/TZIXwwGDDh

Q3: What fears about taking insulin do you hear most frequently from ppl w T2 #diabetes? How do you discuss, allay fears? #DiabetesINFL

nutritionjill #client: fear of injection pain, hypoglycemia, fear that insulin leads to loss of limbs. #DiabetesINFL
hopewarshaw Common fears abt taking insulin: Frequent hypoglycemia. Discuss likelihood, how to prevent, be prepared to treat. #DiabetesINFL
maureensrn Insulin “injections” = negative feelings such as “drug addict” #DiabetesINFL
eatingsoulfully Fear of Hypoglycemia, needles, injecting, weight gain #DiabetesINFL
nutritionjill #client: And fear of weight gain, fear that they will always require insulin. #DiabetesINFL
gabriellerdcde “I’m going to lose my toe like my aunt did” “I’ll never afford insulin” “I can’t eat anything now” #DiabetesINFL
maureensrn Insulin therapy too complicated and risky ( higher risk of hypoglycemia) #DiabetesINFL
hopewarshaw Concern frequent hypoglycemia. How do you discuss this w ppl w T2 #Diabetes? #DiabetesINFL
askdrbev 1 fear PWDs have is the fear of how big the needles are. Having never seen a pen tip, I show them how tiny it really is. #DiabetesINFL
eatingsoulfully Allay fears by discussing needle size, ie smaller and thinner than ever before
#DiabetesINFL
maureensrn Additional therapy = additional costs. Insulin therapy may be financial threat. #DiabetesINFL
askdrbev Fear of hypoglycemic episodes. We discuss strategies such as frequent blood sugar testing & treating w/fast acting carbs. #DiabetesINFL
eatingsoulfully Allay fears by showing patients that injections are painless.

#DiabetesINFL

hopewarshaw Common fears abt taking insulin: I’ll gain weight. Suggest assure doesn’t need to happen. Give strategies to prevent. You? #DiabetesINFL
eatingsoulfully @HopeWarshaw I also give strategies to prevent weight gain. #DiabetesINFL
gabriellerdcde @HopeWarshaw Carb counting. Mediterranean diet. Plate method #DiabetesINFL
corlansky Fear of #hypoglyglycemia, #diabetes education is important! #DiabetesINFL
maureensrn Address potential weight gain with routine weights, food journals, activity logbook. #DiabetesINFL
eatingsoulfully I discuss the concept of carb counting to control amount of insulin required. #DiabetesINFL
corlansky “Taking #insulin is not sexy. Will I have a sex life?” Good BG control is important! #DiabetesINFL
corlansky Reassure ppl w/T2 #diabetes newer insulins mimic natural release of insulin #DiabetesINFL
corlansky Show short needles and explain single use, less sting #DiabetesINFL

Q4: Do you explain T2 #diabetes to clients as a progressive disease that over time many ppl need to take insulin? Not failure! #DiabetesINFL

hopewarshaw Discussion/concept T2 #Diabetes as “progressive” disease is new concept to many. I describe with real, actionable words. #DiabetesINFL
nutritionjill #client: Many do not understand progressive beta cell failure. I like to say you did not fail, your pancreas did. #DiabetesINFL
eatingsoulfully Absolutely! I explain that diabetes is a progressive disease.
#DiabetesINFL
maureensrn Patients must understand diabetes is progressive. #DiabetesINFL
nutritionjill #client At 1st visit w/type 2 patient, I explain pathophysiology of disease & how their drugs fit into it. #DiabetesINFL
askdrbev I explain as we age, we may need glasses to see better, hearing aids to hear better, & insulin to help the aging pancreas. #DiabetesINFL
maureensrn Insulin therapy is not a sign of failure/noncompliance#DiabetesINFL
maureensrn Insulin therapy is not a sign of failure/noncompliance #DiabetesINFL
askdrbev To reduce psychological insulin resistance, it helps PWDs to “blame” their pancreas, not their failure, to start insulin. #DiabetesINFL
gabriellerdcde Studies show patients prefer “diabetes changes over time” rather than word “progressive” #DiabetesINFL
maureensrn Patient education is paramount on disease process and progression. #DiabetesINFL
hopewarshaw What words do you use to describe T2 #diabetes w current knowledge as progressive disease, need for progressive therapies? #DiabetesINFL
eatingsoulfully I also discuss the natural history of diabetes and pathophysiology. #DiabetesINFL
gabriellerdcde Need to unpack all the tools in the tool box and insulin happens to be one of them #DiabetesINFL
doctablet the pancreas can only work overtime for so long, it eventually needs help with insulin #DiabetesINFL https://t.co/rItsLpbmUK
hopewarshaw I say, progression not your fault, failure to manage. It’s how we now know disease progresses. We didn’t know years ago. #DiabetesINFL
hopewarshaw I say, due to progression you’ve got to match treatment/meds to current status. Healthy eating, exercise always help. #DiabetesINFL
hopewarshaw I say, good thing abt insulin is that you can increase dose(s) as needed to control BGs. Work closely w your prescriber. #DiabetesINFL
eatingsoulfully Diabetes is a progressive disease that requires progressive therapy for management. #DiabetesINFL
corlansky Importance of staying on top of your blood glucose to prevent or slow down long term complications #DiabetesINFL
corlansky Sometimes use #insulin in ppl w/T2 to get sugars down. May not be on #insulin rest of life #DiabetesINFL

Q5: Do you hear resistance from physicians/prescribers to starting ppl w T2 #diabetes on insulin? Why? What do you hear, see? #DiabetesINFL

nutritionjill #client: I think some HCP believe their patients will not be compliant w/insulin treatment. #DiabetesINFL
maureensrn HCP may be hesitant to insulin therapy d/t patient literacy, financial status #DiabetesINFL
gabriellerdcde HCPs often let people try diet/exercise for too long #DiabetesINFL
hopewarshaw Transitioning ppl w T2D to insulin has challenges: dealing w resistance, dosing, titrating dose(s). Takes time, follow up. #DiabetesINFL
maureensrn HCP may be resistant d/t lack of patient education resources. #DiabetesINFL
askdrbev I encouraged one patient to ask her PCP to start her on insulin. After 9 months, he “fired” her b/c she was too much work! #DiabetesINFL
eatingsoulfully Many make the assumption that the patient will be “non-compliant”
#DiabetesINFL
doctablet HCP’s have a bigger fear of needles than patients with diabetes
#DiabetesINFL
gabriellerdcde HCPs often let people try diet/exercise for too long #DiabetesINFL
askdrbev Blessing in disguise! My patient started seeing an endocrinologist and now her A1C has improved with insulin. 🙂 #DiabetesINFL
eatingsoulfully Surprisingly, there are MDs who don’t want to manage ppl on insulin.
#DiabetesINFL
hopewarshaw Prescribers may use scare tactics abt starting insulin to encourage regimen adherence, rather than probe resistance #DiabetesINFL
maureensrn when dealing with solo HCPs, less likely to prescribe insulin as they don’t have educational resources & time to teach. #DiabetesINFL
gabriellerdcde Seems insulin better managed by endo than most family docs. Most not all. #DiabetesINFL
hopewarshaw Prescribers sometimes collude w person w T2 #Diabetes in dual resistance to progress to insulin. What do you see? #DiabetesINFL
hopewarshaw Perhap Q is how can we help/support primary care providers to transition PWD to insulin? #DiabetesINFL https://t.co/kTEqXZw1rq
hopewarshaw As HCP do you talk to/intervene w prescribers on behalf clients who you know need insulin? If so, how? #DiabetesINFL
hopewarshaw No doubt starting and rapidly titrating insulin to goal is time consuming for PCPs, #diabetes educators can help!! #DiabetesINFL https://t.co/YwDTgwZvpA
aprilsaundersrd A lot! Don’t know why! Send us people when a1c 11% on 2 orals 🙂 #DiabetesINFL

Q6: Do you hear people say that if they take insulin they now have type 1 #diabetes? What words do you use to correct this? #DiabetesINFL

nutritionjill #client: I explain that type 1 is an autoimmune dz w/loss of insulin production. Type 2 has many more components. #DiabetesINFL
nutritionjill #client: Type 1 will always need insulin to live. Type 2 sometimes need insulin to get over a hump like surgery or injury. #DiabetesINFL
gabriellerdcde ALL THE TIME! Always explain T1D is diff disease pathway #DiabetesINFL
maureensrn Explain differences between T1DM & T2DM re: insulin production #DiabetesINFL
hopewarshaw Worth informing accurate info? No, you still have T2 #diabetes. Millions of ppl with T2 take/need insulin to control BGs #DiabetesINFL
askdrbev Yes, tricky distinction to explain. I say “once a PWD T2D, then always a PWD T2D” – but managed with insulin. #DiabetesINFL
doctablet type 1 is a condition where patients make no insulin at all due to an abnormal immune reaction
#DiabetesINFL
maureensrn Explain T2DM therapy may combine oral and injectable meds #DiabetesINFL
eatingsoulfully I tell them starting insulin does not change their diagnosis
#DiabetesINFL
eatingsoulfully I review the pathophysiology of type 2 #diabetes
#DiabetesINFL
hopewarshaw Actually few types of #diabetes. Same name, big differences. What’s impt? You manage your diabetes best you can over yrs #DiabetesINFL
maureensrn Include family education for additional support when possible. Insulin w/ T2DM can be very overwhelming for family #DiabetesINFL
eatingsoulfully I describe the difference between type 1 and type 2 #diabetes
#DiabetesINFL
hopewarshaw I feel like a broken record (or CD) these days with Early, aggressive management is best #DiabetesINFL https://t.co/z3TsIPFlaD

Q7: Are there ways you see physicians/prescribers start ppl on insulin that works smoother, more successful? What works well? #DiabetesINFL

hopewarshaw Thanks for sharing resources. Look good! #DiabetesINFL https://t.co/nbvCFH3e3f
hopewarshaw Sometimes you just need insulin, eh? And may be able to get off for a time. #DiabetesINFL https://t.co/oQuTjB2O2z
maureensrn Assess patient willingness to use insulin; get patient into DSME classes #DiabetesINFL
hopewarshaw Allow client’s concerns, apprehensions to be heard, addressed. May expose needle phobia, budget concerns, storage issues #DiabetesINFL
nutritionjill #client: Mostly it should be discussed in a non-threatening way. #DiabetesINFL
askdrbev I HATE when HCPs use insulin therapy as a threat to force diabetes adherence! This makes PWDs feel unnecessarily guilty. #DiabetesINFL
gabriellerdcde Start insulin and send to CDE immediately and/or group classes #DiabetesINFL
nutritionjill #client:: Answer all questions, assure that person is not a failure. Send to educator. #DiabetesINFL
maureensrn Frequent contact with new insulin users- motivational interviewing; logbooks, meter checks. #DiabetesINFL
hopewarshaw Ask client abt daily life, schedule. Discuss how they’ll fit taking insulin in their life, schedule. Others? #DiabetesINFL
askdrbev It would be helpful if HCPs would introduce the idea – early in treatment – that insulin may be needed in PWD’s treatment. #DiabetesINFL
eatingsoulfully Understanding patient barriers and negative perceptions about insulin
#DiabetesINFL
hopewarshaw Be aware of work life related concerns/issues – shift work/changes, storage, carrying hypo treatments. Ask, be sensitive. #DiabetesINFL
hopewarshaw Quickly get ppl over hurdle of pain, challenge of injection, taking insulin. Have them do a shot. You? #DiabetesINFL
hopewarshaw Start slowly if possible, then escalate dose, and number of shots. Perhaps one injection long-acting insulin at night. #DiabetesINFL
gabriellerdcde PWD feel at ease after doing 1st shot with support in office #DiabetesINFL
eatingsoulfully Review the natural history of type 2 #diabetes.

#DiabetesINFL

gabriellerdcde Basal at first, get PWD comfy then add meal time dose #DiabetesINFL
eatingsoulfully Start low (insulin dose) go slow (titrating the dose) #DiabetesINFL

Q8: Taking insulin has changed dramatically for better, easier over last decade +. How do you explain taking insulin today? #DiabetesINFL

hopewarshaw Newer insulins = less hypoglycemia. Easier to get/take the insulin you need when you need it. #DiabetesINFL
nutritionjill #client: taking insulin is simpler b/c of delivery systems, esp pen. So convenient, not painful. #DiabetesINFL
hopewarshaw Insulin pens w/ needle more convenient to carry now. Can be room temp up to 30 days. Pens in use don’t need refrigeration #DiabetesINFL
nutritionjill #client: Also many more types of insulin & when taken properly & matched to food intake, lower chance of hypoglycemia #DiabetesINFL
corlansky Pens easy to use, can stay at room temp, making travel easy #DiabetesINFL
doctablet Use weight based doses of basal insulin to avoid hypoglycemia. Do NOT titrate on fasting alone #DiabetesINFL
maureensrn Multiple education avenues- videos, brochures, classes, hands on training #DiabetesINFL
askdrbev 41 yrs ago, I was taking 1 shot of NPH/day. Needle tips were longer, not as fine. Insulins were made from beef and pork. #DiabetesINFL
eatingsoulfully Insulin we have today is associated with less hypoglycemia. #DiabetesINFL
maureensrn Review variety of insulin delivery systems. Focus on patient strengths. #DiabetesINFL
askdrbev Due to the impurities in the insulin 41 yrs ago, I would get an allergic reaction at my injection site! So improved now! #DiabetesINFL
eatingsoulfully Pens make it easier to dose and inject insulin. #DiabetesINFL
maureensrn Assess patients for special needs- visual, tactile- utilize appropriate delivery system. #DiabetesINFL
gabriellerdcde Pens are so simple to use, pen needles smaller than ever, better insulins come out every year #DiabetesINFL
eatingsoulfully Insulin can be prescribed based on the individual’s lifestyle.
#DiabetesINFL
corlansky Many options and choices for PWD today, find what works for you! #DiabetesINFL

Q9: What suggestions do you provide to ppl w T2 #diabetes to make taking insulin easier, less painful, more convenient? #DiabetesINFL

nutritionjill #client: Keep food and blood glucose records to see what’s happening. Monitor more often to avoid hypo #DiabetesINFL
nutritionjill #client: For convenience & ease, many ppl like the insulin pen. #DiabetesINFL
hopewarshaw Take time when buying needles to see what’s available. Ask in pharmacy. Get shortest, thinnest that work for you. #DiabetesINFL
hopewarshaw Make sure to keep a backup supplies insulin pens or vials, needles. Keep insulin in box, in refrigerator. Suggestions? #DiabetesINFL
maureensrn DSME classes and support groups. Learn from others; share ideas with other T2DM. #DiabetesINFL
askdrbev I hear PWDs “forget” to take shots. To make more consistent & convenient, I suggest taking shots at dinner (w/other meds). #DiabetesINFL
gabriellerdcde Set reminders on cell phone to not miss dose #DiabetesINFL
maureensrn Review delivery systems- injectables, vials, pens, pumps find what works best for patient. #DiabetesINFL
askdrbev I use the term “jiggly” parts (i.e., stomach, thighs) rather than say inject into the “fat” (stomach). It sounds kinder. #DiabetesINFL
maureensrn In depth education on storage, supplies, site rotation. #DiabetesINFL

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Jackie Newgent, RDN, CDN, is a registered dietitian nutritionist and classically-trained chef. With a passion for helping people (including her father) with diabetes, she’s author of The With or Without Meat Cookbook: The Flexible Approach to Flavorful Diabetes Cooking and the award-winning The All‐Natural Diabetes Cookbook, both published by the American Diabetes Association. Jackie is also author of 1,000 Low-Calorie Recipes and Big Green Cookbook. Her next book, The All-Natural Diabetes Cookbook—2nd Edition, was published in 2015.

Nutritionist Rania Batayneh, MPH is the author of the best-selling book, The One One One Diet. She holds a master’s degree in public health nutrition from the University of Michigan School of Public Health and is also a Wellcoaches Certified Health and Wellness Coach endorsed by the American College of Sports Medicine (ACSM).

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