“Today we are going to start you on insulin. Given your high A1C level (a lab that shows your average blood sugar over 3 months), it is recommended so that we can better lower your blood sugar. Lowering your blood sugar is important because when your blood sugar is this high it can affect many aspects of your health including severely increasing your risk of heart disease and stroke,” I said. It was the second time I’d seen this patient in my clinic. They were quick to laugh and had a full life.

The patient hung their head. This was the first time I had started someone on insulin as a primary care doctor (we use insulin exclusively to manage diabetes in the hospital, but in the outpatient setting it’s reserved for specific indications). Starting insulin isn’t supposed to be punitive but some patients feel as though it is because of the stigma associated with diabetes.

There are numerous medical diseases and conditions that are stigmatized. Among the most common I see are diabetes, obesity, psychiatric diseases, and sexually transmitted diseases. People with diabetes are often blamed for having the disease. If or when they require insulin, the patient may feel like their need for insulin is a failure because their blood sugar was not controlled with other treatment measures. People with diabetes can be labeled as “weak” and “lacking self-control.” This labeling is out-of-place and unproductive. While lifestyle (such as diet and exercise) does contribute to the development and progression of diabetes, lifestyle is only part of the story.

In addition to individual choices, other parts of life like genetics, environment, and the social determinants of health have an important impact on health outcomes including the development of chronic diseases like diabetes. Further, it is critical to be able to have open and respectful conversations about patients’ individual situations and how their lives might be optimized to manage their diabetes and to reduce their likelihood of developing complications from diabetes. Stigma gets in the way of having these open, respectful conversations. When people have diabetes, the disease can severely increase their risk of death by heart disease and complications such as vision loss, nerve damage, kidney damage, and infection. This makes management of diabetes with a multimodal approach – including lifestyle optimization and medications – essential. Judgement has no place in developing a therapeutic plan.

When I recommended insulin to my patient, it was not as punishment. It was without judgement. It was out of concern for their health. The strategies we had tried to lower their blood sugar to that point weren’t working. The patient was doing so well otherwise. They didn’t have kidney problems. Their feet still had feeling. They hadn’t had a heart attack. I wanted them to live without these complications for as long as possible.

As the patient left the appointment, I was hopeful that our new strategy would help them lower their blood sugar. I also hoped that this patient felt respected even if they were unhappy about starting insulin. I’d see how they did with the insulin at our next visit. Time would tell if insulin at the dose we started would work for them or if we would need to make further adjustments. Chronic conditions require long-term (often life-long) treatment plans. Flexibility to adjust the plan as life develops is critical for success. This patient with diabetes was no exception. I looked forward to working together to lower their blood sugar in the months and years ahead.