Type 2 diabetes is the result of insulin resistance which is the body’s inability to use insulin properly. This insulin resistance is caused by genetics (a family history of type 2 diabetes), lack of exercise, and/or being over weight or obese. The body’s normal response is to over produce insulin in an attempt to "overload" the system. Unfortunately this over production of insulin cannot be sustained and with time the body makes less and less insulin due to the loss (death) of the pancreas’s insulin producing beta cells. The general consensus in the medical community is that at the time of diagnosis most patients have lost 50% of their beta cell function.
Due to this progressive loss of beta cells type 2 diabetes changes over time typically requiring the addition of medications every few years and in most people eventually resulting in the need for insulin therapy. Many people feel that the addition of insulin to their treatment regimen is the result of their failure as a patient to properly care for themselves. But this is not the case — insulin therapy is often inevitable due to this progressive loss of beta cell function.
When diagnosed early in the disease process people can often control their glucoses with therapeutic lifestyle changes such as diet, weight loss, and exercise. However, over time nearly all patients require the addition of oral medications. These are often added in a step-wise fashion meaning one at a time as glucose control slowly worsens over time. A typical time course for a patient would be to begin with lifestyle change then in a few years as HbA1c and glucoses start to rise again a medication is added to improve control then a few years later a second medication is added and then a third and so on until non-insulin medications have been exhausted and insulin is finally started 5-10 years after the diagnosis. With that being said, everyone is different but this is a very common story. The use of insulin earlier in the treatment of diabetes has become more commonplace, especially with the new American Diabetes Association treatment algorithm that suggests insulin as a possible second-line agent after Metformin and lifestyle modification.
Now here comes the good news. There are medications that may have the potential to preserve the function of the beta cells. Therefore potentially stopping or at least slowing the progression of the disease process. Some experts believe that early insulin use may also help to prevent beta cell death. These newer medications include Exenatide, Pioglitazone, Rosiglitazone, and Sitagliptin. The hope is that these newer medications in combination may slow the progressive nature of type 2 diabetes and thus allow for a longer time of glucose and HbA1c control without the continual addition of more medications and delay the need for insulin therapy. But no matter what, diet, weight loss, and exercise are imperative throughout the course of the disease and help to improve the underlying insulin resistance.
