Taking insulin sooner means more effectively avoiding complications, and quite likely even regeneration of beta cells, helping to halt the progression of the disease, according to results of the recent British UKPDS study. On the other hand, insulin therapy is difficult, expensive, time-consuming for providers (all that education!), and results don't really outshine those of oral drugs on the whole, many US doctors say.

In Europe, where providers are convinced of the health benefits, there appears to be an aggressive campaign to put more Type 2s on insulin sooner - in part with the thinking that shots will force patients to take the disease more seriously, vs. just popping a pill and assuming 'it's all taken care of."

But that approach would never work here, says Dr. Mayer Davidson of UCLA, who spoke the counterpoint at this weekend's conference. 'Taking insulin is a big lifestyle change. It's hard! You can't just give a person vials and syringes and send them on their way," he says.

Davidson works with poor and poorly educated patients in LA, mostly with a 6th grade education or less. It's a transient Latino population in which patients may disappear to Mexico for several months at a time. 'Insulin as an initial treatment for Type 2 diabetes here? We say ‘No way, Jose,'" he says.

Dr. Peter Butler, also of UCLA, who spoke in favor, agrees that the potential success of insulin therapy comes down to two key factors: patient profile (target population) and the hassle factor/fear associated with using needles regularly. But the health benefits far outweigh the work necessary to overcome these obstacles, he says.

'The point is that treating blood glucose in Type 2 is important - and not just looking at blood pressure and lipids as some doctors imply," he says. Insulin is by far the most effective tool for controlling blood glucose (BG), more immediate and more controllable than any pills available to date.

'We (doctors) can't hide behind the orals," Butler says. 'We know that lifestyle is the biggest obstacle. But if you just get your patients to do a bedtime injection, it's not that hard, not that big of an intrusion. And it only takes 10 minutes to teach."

According to Butler, the bottom line is: Which therapies halt diabetes progression? 'If we allow beta cells to rest, they're more likely to regenerate. Taking insulin gives them a rest," he says.

Here's the trouble: Many doctors use insulin as a threat or a weapon. 'They say things like, ‘If you don't stick to your diet and exercise, I'm going to have to put you on insulin!" Butler notes. If we can do away with this evil-insulin mentality, getting more Type 2's on insulin for the best possible BG control is going to be a hell of a lot easier, this doctor says.