My fiance has had type 2 diabetes for about eight years now. He has been directed by his physician to watch his diet, lose weight, take his oral medication for diabetes and exercise. He goes in for another A1c test on Tuesday and was told that if his number does not come back a “6” or better, he will be placed on insulin. He is worried that once placed on insulin, he will have to take insulin shots for the rest of his life. Is that true? If he loses the weight, could the insulin shots stop? Also, his family doctor is not directing him to see an endocrinologist, but his family doctor isn’t really providing him with a diet to follow either. Should he be seeing an endocrinologist instead?

Your fiance’s physician is being aggressive with his therapy. I tend to agree with that because there is no safe level of hyperglycemia. With diabetes for eight years, there is concern that over time, patients lose their ability to make insulin on demand. This would suggest a relative insulin deficiency. Adding insulin to oral agents is not unreasonable as a next step, especially if he is on more than one oral agent. Over 50% of patients with type 2 diabetes end up on insulin at some point in their life. Just taking insulin is viewed as a disease or a “fate worse than death” by many patients and physicians. I do not believe this to be the case. The issue is what treatment is necessary to provide the best overall health. Since type 2 diabetes tends to be a chronic disease, and insulin deficiency is part of the natural history, it is usual for patients to remain on insulin therapy chronically. However, if he were to lose a significant amount of weight, which is hard to do and sustain, he may be able to get off insulin for a while. The use of an endocrinologist as a diabetes specialist is a lighting rod for some primary care physicians who feel they are on top of the issues and are practicing good medicine. Your fiance should talk to his physician about seeing an endocrinologist if he feels strongly about this. That way, both sides can respond to one another. As for his diet, I would strongly advocate seeing a licensed dietician who is part of a diabetes education team. Contact your physician or local hospital for a referral for such a service.

JTL