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October 2020, Volume 70, Issue 10

Recent Advances In Endocrinology

Social insulin resistance: The forgotten frontier

Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal, India. )
Varun Arora  ( Department of Community Medicine, Pt BDS PGIMS, Rohtak, india )
Madhur Verma  ( Department of Community/Family Medicine, All India Institute of Medical Sciences, Bathinda )
Sameer Aggarwal  ( Department of Endocrinology, Apex Hospital, Rohtak, India )


This opinion piece discusses the concept of social insulin resistance, and helps create a comprehensive biopsychosocial model of insulin resistance. Social insulin resistance is defined as a negative attitude, present in some social groups, directed towards avoidance or rejection of insulin therapy. The various aspects of social insulin resistance are described in detail.  This important construct has both clinical and public health relevance, and will help plan strategies to improve the acceptance and usage of insulin in diabetes care.

Keywords: Adherence, biopsychosocial model, clinical inertia, compliance, patient centred care, person centred care, Type 1 diabetes, type 2 diabetes.


Insulin Resistance


Insulin resistance is a well-established pathophysiologic contributor to diabetes. This phenomenon of insulin resistance has been researched in great detail, and and finds mention in three of the eight factors included in de Fronzo’s ominous octet.1 For the purposes of this communication, we use the label “biomedical insulin resistance (BIR)” to describe the dysfunction that occurs at insulin receptors in the liver, adipose tissue and skeletal muscle.


Psychological Insulin Resistance


The biomedical construct of insulin resistance has been supplemented by the concept of psychological insulin resistance (PIR).2 PIR is the term used to describe patient’s unwillingness to accept insulin prescription and/or administration. PIR is usually due to preconceived false notions about the advantages and limitations of insulin, and overlaps the syndrome of insulin distress.3


Biopsychosocial Model


Chronic disease care, including diabetes management, is based upon the biopsychosocial model of health, coined by Engel in 1977, this interdisciplinary triad examines how biomedical, psychological and social factors interact to influence health and disease.4 The biopsychosocial model has found usage in multiple fields, and is a useful taxonomic tool in health management. Applying this model to insulin resistance, the astute diabetes care professional can identify three aspects: BIR, PIR and social /societal insulin resistance (SIR).


Social Insulin Resistance


SIR can be defined as a negative attitude, present in some social groups, directed towards avoidance or rejection of insulin therapy. SIR can manifest in families, peer groups, communities and societies. Apart from lay persons, SIR is also found in some health care professionals. SIR can be passive or active. While passive SIR is the public health equivalent of clinical inertia,5 active SIR is a policy of insulin dissuasion practiced by members of society. Various myths and misconceptions are promoted by ill-informed persons to hinder the use of insulin. These barriers to health have been termed as ‘diabetes e-hearsay’.6 At the same time, the concept of quinary prevention has been promoted as a proactive means of fighting misinformation and spreading correct knowledge.7


Diabetes as a Social Syndrome


BIR and PIR are important aspects of diabetes care. Both are relevant to the management of diabetes in as individual person. Diabetes, however, is much more than a simple biomedical syndrome: it has been described as a disease of family8 and of society.9 Diabetes epidemic cannot be contained unless societal influences are modified, and society’s support harnessed.

To do so, we must understand social barriers to insulin which have been elaborated by researchers from all over the world.10 Most common barriers around the world include the mistaken beliefs about insulin; fear of needle, perceptions about difficulty in titrating insulin doses, patients’ preference to give lifestyle modification and oral medicines more time to succeed, excessive faith in traditional healers, non-scientific counselling, lack of continuity of care and financial barriers. Even caregivers with the care-givers with limited skills and knowledge have pre-fixed perceptions about the insulin and have a certain amount of prescription inertia towards insulin, language barriers and fear of hypoglycaemia and obesity risks, adherence and motivation, health assessment and glucose level patterns

This insight will help plan social marketing campaigns,11 which must be pursued in conjunction with biomedical and psychological strategies for diabetes control. There is a need to develop and validate questionnaires for screening and diagnosis of SIR, as well as create mass communication strategies to improve insulin awareness and acceptance.


Management of Social Insulin Resistance


SIR management bears uncanny resemblance to BIR treatment. Glucose-lowering drugs have been12 classified into three categories: insulin secretagogues, insulin sensitizers, and nutrient load reducers. We use this framework to suggest a three pronged rubric for the management of SIR

1. Sharing: Provide up to date information on insulin, in multiple formats, through all available communication channels

2. Sensitization: Develop behaviour change communication among patients and care givers regarding the need for good glycaemic control, and the implication of glucose levels on systemic health.

3. Suppression: Enact and enforce rules and laws to prevent dissemination of false claims related to health and wellness, in the context of diabetes care.

Specialists in community medicine and health education must be included as members of the diabetes care team. Their expertise can help plan, design and execute programmes which aim to address SIR. The tridential approach, if followed is a sustained manner, should be able also help manage PIR and BIR more efficiently.




1.      DeFronzo RA. From the triumvirate to the “ominous octet”: a new paradigm for the treatment of type 2 diabetes mellitus. Clinical Diabetology. 2009;10:101-28.

2.      Polonsky WH, Fisher L, Guzman S, Villa-Caballero L, Edelman SV. Psychological insulin resistance in patients with type 2 diabetes: the scope of the problem. Diabetes Care. 2005;28:2543-5.

3.      Kalra S, Balhara YPS. Insulin Distress. US Endocrinology. 2018;14:27–29 DOI:

4.      George E, Engel L. The clinical application of the biopsychosocial model. Am J Psychiat. 1980 ;137:535-44.

5.      Phillips LS, Branch WT, Cook CB, Doyle JP, El-Kebbi IM, Gallina DL, Miller CD, Ziemer DC, Barnes CS. Clinical inertia.  Ann Intern Med. 2001;135:825-34.

6.      Kalra S, Balachandran K. De-Hearsay (Diabetes e-Hearsay). J Pak Med Assoc. 2017;67:1293-5.

7.      Kalra S, Kumar A. Quinary prevention: Defined and conceptualized. J Pak Med Assoc. 2019 1;69:1765-6.

8.      Kalra S, Saboo B, Cho NH, Sadikot S, Hasnani D, Chandarana H, et al. Strengthening the Family–the ‘Five-I’Approach. Eur Endocrino 2019;15:15-6.

9.      Whiting D, Unwin N, Roglic G. Diabetes: equity and social determinants. Equity, social determinants and public health programmes. 2010; 77:94.

10.    Rasheed AB, Chenoweth I. Barriers that practitioners face when initiating insulin therapy in general practice settings and how they can be overcome. World J. Diabetes. 2017; 8:28.

11.    Thackeray R, Neiger BL. Use of social marketing to develop culturally innovative diabetes interventions. Diabetes Spectrum. 2003;16:15-20.

12.    Kalra S. Classification of non-insulin glucose lowering drugs. J Pak Med Assoc. 2016;66:1497-8.


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