Mr Hendra (name disguised), 58, came to my clinic looking frustrated. He had been living with type 2 diabetes for 7 years, had changed doctors three times, had tried various medication combinations — yet his HbA1c still hovered around 9–10%, far above the <7% target. At every check-up, his doctor would increase the dose or change the medication. But the result was the same.
After a thorough evaluation across two visits, I found three things that had been missed all along. Cases like Mr Hendra's happen more often than you might imagine.
Why Is "Hard-to-Control" Diabetes Not Just About Patient Compliance?
The narrative that often circulates: "Blood sugar doesn't come down because the patient isn't disciplined about taking medication or watching their diet." This is sometimes true, but very often incomplete. There are medical conditions that make diabetes harder to control:
- Undiagnosed hypothyroidism — an underactive thyroid reduces insulin sensitivity and slows glucose metabolism
- Sleep apnoea — a sleep disorder that causes nocturnal hypoxia and elevated cortisol, both of which worsen insulin resistance
- Cushing's syndrome — excess cortisol (whether from a tumour or long-term steroid use) directly increases hepatic glucose production
- Early-stage chronic kidney disease — affects the metabolism and elimination of antidiabetic drugs
- Medication choices that don't match the phenotype — some patients are predominantly insulin-resistant, others predominantly insulin-deficient. The right drug combination must be tailored accordingly
- Dawn phenomenon and the Somogyi effect — morning glucose spikes from different mechanisms that require different therapy adjustments
What Sets a KEMD Consultant Apart from a General Internist?
The KEMD (Consultant in Endocrinology, Metabolism and Diabetes) title is earned through an additional 2–3 year fellowship after becoming an internal medicine specialist (Sp.PD), focusing entirely on complex endocrine and metabolic cases. The FINASIM title (Fellow of the Indonesian Society of Internal Medicine) reflects recognition by the academic community of internal medicine specialists.
In practice, the differences include:
- The ability to evaluate deeper secondary causes of diabetes and insulin resistance
- Experience with complex insulin therapy — not just basal insulin, but basal-bolus regimens, insulin pumps, and dynamic adjustments
- Management of endocrine complications of diabetes — autonomic neuropathy, nephropathy, retinopathy from a metabolic perspective
- Handling gestational diabetes cases and pregnancy preparation in diabetic women
- Managing post-organ-transplant diabetes or patients on immunosuppressive therapy
Fear of Insulin: Myths That Must Be Corrected
One of the biggest obstacles to optimal diabetes therapy is insulin phobia — the fear among patients (and sometimes doctors) of starting insulin therapy. Some myths I often hear:
❌ "If I'm on insulin, my diabetes must be really severe."
✅ Insulin is not a punishment or a sign of failure. It is the most physiological therapy option — replacing the hormone the pancreas is supposed to produce. In many patients, starting insulin earlier actually prevents complications more effectively.
❌ "Insulin is addictive and you can never stop."
✅ There is no addiction mechanism with insulin. In relatively recent type 2 diabetes where beta-cell reserve remains, some patients can even come off insulin once glucose levels are normalised and lifestyle improvements are maintained consistently.
❌ "Insulin injections are very painful."
✅ Modern insulin needles are extremely thin (4–6 mm, 31–32 gauge). Most patients describe the sensation as milder than a routine blood draw.
When Do You Need a Consultant Evaluation?
I recommend consulting a Sp.PD-KEMD if:
- Your HbA1c has never reached its target (<7% or as recommended by your doctor) despite >3 months of therapy
- You have recurrent hypoglycaemia (blood sugar too low) with no clear cause
- Your diabetes is accompanied by other complex conditions: heart failure, kidney disease, cancer, autoimmune disease
- You are considering pregnancy while living with diabetes
- Symptoms persist even though your glucose levels are controlled
- You want to understand your condition in greater depth before making long-term therapy decisions
What to Bring to Your Consultation
To get the most out of the consultation, bring:
- Laboratory results from the past 1–2 years (HbA1c, lipid profile, kidney and liver function)
- A list of all medications you are taking (including supplements and herbal remedies)
- Self-monitoring blood glucose records if available (measurement times and values)
- A summary of your family medical history
"A second opinion doesn't mean you distrust your previous doctor. It is your right as a patient and a smart step in managing a complex medical condition. Any condition that has been uncontrolled for years deserves a fresh perspective."
— dr. Sebastianus Jobul, Sp.PD-KEMD, FINASIM
Your metabolic health is too precious to be left in prolonged uncertainty. A proper evaluation, even if it takes time and money, is the best investment you can make in your long-term quality of life.