In which situation do increased insulin requirements not exist in patients with diabetes?

Manual Labor Does NOT Increase Insulin Requirements

Manual labor (option e) is the correct answer—it does NOT increase insulin requirements; rather, physical activity and exercise decrease insulin needs by improving insulin sensitivity and glucose uptake independent of insulin. 1

Situations That DO Increase Insulin Requirements

Obesity (Option a)

• Obesity causes insulin resistance at the target tissue level, requiring higher insulin doses to achieve the same glycemic effect. 1
• Up to 85% of patients with type 2 diabetes are overweight or obese at diagnosis, and obesity itself causes significant insulin resistance through decreased insulin receptor function and postreceptor defects. 1, 2
• The degree of insulin resistance correlates directly with the severity of obesity and hyperinsulinemia—more severe obesity requires progressively higher insulin doses. 2

Pregnancy (Option b)

• Pregnancy increases insulin requirements due to placental hormones that induce insulin resistance, particularly in the second and third trimesters. 3
• Women with prior gestational diabetes have increased risk of developing type 2 diabetes, reflecting the metabolic stress pregnancy places on insulin secretion and action. 1

Cortisone/Glucocorticoid Therapy (Option c)

• Glucocorticoids are well-established causes of hyperglycemia and increased insulin requirements. 1
• Corticosteroids can precipitate diabetic ketoacidosis in patients with type 2 diabetes when combined with other stressors, and may necessitate temporary insulin therapy even in patients previously controlled on oral agents. 1
• The insulin resistance induced by steroids may be so severe that automated insulin delivery systems cannot respond rapidly enough, requiring reversion to manual insulin adjustment. 1
• High-dose glucocorticoid therapy is specifically listed as an indication for intravenous insulin infusion in hospitalized patients due to the magnitude of insulin resistance created. 1

Situations of Intense Physical Stress (Option d)

• Acute illness, infection, and surgery all increase insulin requirements through stress hormone release (cortisol, catecholamines, glucagon) that induces insulin resistance and increases hepatic glucose production. 1, 3
• Stress-induced hyperglycemia can precipitate diabetic ketoacidosis even in patients with type 2 diabetes who normally do not require insulin. 1
• Hospitalized patients experiencing acute illness require higher insulin doses, often necessitating intravenous insulin infusion for adequate glycemic control. 1

Why Manual Labor DECREASES Insulin Requirements (Option e)

Mechanism of Exercise-Induced Insulin Sensitivity

• Physical activity improves insulin sensitivity independent of weight loss by enhancing glucose uptake into muscle tissue through non-insulin-dependent mechanisms. 4
• Exercise activates glucose transporters in muscle cells, allowing glucose uptake even with lower circulating insulin levels. 1
• At least 150 minutes weekly of moderate-intensity exercise is recommended to improve insulin sensitivity and reduce insulin requirements. 4, 5

Clinical Implications

• Patients engaging in manual labor or regular physical activity require LOWER insulin doses to avoid hypoglycemia. 1
• The risk of developing type 2 diabetes decreases with increased physical activity, demonstrating the protective effect of exercise against insulin resistance. 1
• Insulin doses must be adjusted downward in patients who increase their physical activity level to prevent exercise-induced hypoglycemia. 1

Common Clinical Pitfall

The critical error is failing to reduce insulin doses when patients increase physical activity—this leads to hypoglycemia, which is the leading limiting factor in glycemic management. 1 Healthcare providers must proactively decrease insulin doses for patients engaging in manual labor or starting exercise programs, rather than waiting for hypoglycemic episodes to occur.