Treating Type 2 Diabetes
Updated on 11/13/2008
There is no cure for diabetes. But when a treatment plan results in blood glucose levels that are normal or nearly so, a person's risk of developing complications is much lower.
There are certain things that all people with diabetes need to do to be healthy: have a meal plan, and engage in regular physical activity (which can help the body use insulin so it can better convert glucose into energy for cells). Some people also need to take insulin or pills that help the body produce insulin and/or use insulin more effectively.
Many people with type 2 diabetes can manage the disease with meal planning and physical activity alone. If type 2 diabetes is diagnosed early, when the body is still producing and using insulin fairly effectively, changing eating habits and being more active may be sufficient to control blood glucose. On the other hand, many individuals have high blood glucose levels for years before they are diagnosed, and the disease may have progressed to the point where medication is also necessary. In both cases, the goal is to take whatever actions are needed to keep blood glucose levels as close to normal as possible in order to avoid complications.
It's vital for people with diabetes to monitor their blood glucose closely; regular checking will help determine how well the meal plan, activity plan, and medications are working together to keep blood glucose levels in a normal range. See our section on home blood glucose monitoring.
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Your body changes much of the food you eat into glucose. The amount of blood glucose that comes from your diet is important, because the amount of medicine or insulin you take will be calibrated to match the amount of food that you eat every day. If you eat more food than usual without an adjustment in your medication, you may have high blood glucose (hyperglycemia). If you eat less food than usual, you may have low blood glucose (hypoglycemia).
When you eat is also important. Your meals and medication work together so that your body can use the glucose from the food for energy or store it for a later time. A dietitian can help you formulate a meal plan.
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One way people with diabetes can manage their food intake to keep their blood glucose as close to normal as possible is by calculating how many grams of carbohydrate they eat. Carbohydrate tends to have the greatest effect on blood glucose.
The balance between the amount of carbohydrate you eat and the available insulin determines how much your blood glucose level goes up after meals or snacks. To help control your blood glucose, you need to know what foods contain carbohydrate, the size of a "serving" of different foods, and how many carbohydrate servings to eat each day. There's no magic number of daily servings that's right for everyone; instead, it is important to work with a dietitian to determine what will work for you. By checking your blood glucose, you can see whether changes are needed. If your levels are too high, for example, you may need to eat fewer carbohydrate servings, be more physically active, or work with your diabetes team to adjust your medications.
Foods that contain carbohydrate include grains, pasta, and rice; breads, crackers, and cereals; starchy vegetables such as potatoes, corn, peas, and winter squash; legumes such as beans, peas, and lentils; fruits and fruit juices; milk and yogurt; and sweets and desserts. Nonstarchy vegetables such as broccoli, salad greens, and green beans are very low in carbohydrate.
Carbohydrate counting can be used by anyone with diabetes, not just people taking insulin. This method can ensure that the right amount of carbohydrate is eaten at each meal and snack. Likewise, insulin and medications may be adjusted based on what the person wants to eat. For example, if you want to eat a much larger meal, this approach can help you determine how much extra insulin to take.
The amount of food you eat is closely related to blood glucose control. If you eat more food than is recommended on your meal plan, your blood glucose goes up. Although foods containing carbohydrate have the most impact on blood glucose, most foods have some effect.
The only way you can tell if you are eating the right amount is to measure your foods carefully:
- Practice, practice, practice. Don't rely on measuring once and then just "guesstimating." Pull out the scales at least once a week to check yourself.
- Use a glass that you know holds only 4 or 8 ounces. You can also place a piece of tape on the outside of a glass to mark off a serving.
- A bread serving is based on a 1-ounce slice of bread. Many single bread servings may weigh more than 1 ounce and therefore have more impact on blood glucose. Check labels of such items as light breads, bagels, or rolls.
- Know the weight of fruit servings for portion control.
- Check your cereal portion using measuring cups.
The use of alcohol should be discussed with your physician and healthcare team. As a general guideline, people using insulin can have two alcoholic beverages in addition to their regular meals, but no food should be omitted in exchange for an alcoholic drink. For persons who are not on insulin and are watching their weight, alcohol is best substituted for fat choices and, in some cases, bread or other starch choices.
Some alcoholic beverages are high in sugar and carbohydrate: sweet wines, sweet vermouth, and wine coolers, for example. Use these sparingly.
When making the decision about whether to use alcohol, you should understand what the potential effects of alcohol are on your health. Alcoholic beverages can cause your blood glucose to drop, and may worsen other medical problems. Make sure you discuss the use of alcohol with your doctor. Here are some general guidelines:
- With your doctor's approval, alcohol should be limited to two drinks a day for men, one a day for women. A "drink" is defined as a 12-ounce beer (preferably light beer); a 5-ounce glass of wine; a 2-ounce glass of dry sherry; or 1.5 ounces of a distilled beverage, such as whisky, rye, vodka, or gin. Even if your doctor approves the use of alcohol, however, you still may want to avoid the extra calories if you are trying to lose weight.
- Alcoholic beverages can make your blood glucose drop. Avoid the risk of low blood glucose by having your drink at mealtime or by having a snack along with the drink.
- Avoid drinks that contain large amounts of sugar.
- Drink with caution, and carry identification that says you have diabetes. Signs of low blood glucose are similar to those of intoxication. Make sure your companions know you have diabetes and know how to treat you if necessary.
- People taking oral hypoglycemic agents may have a reaction to alcohol. Discuss this with your doctor.
Until fairly recently, there was only one type of diabetes medication available for treating type 2 diabetes. These medications, called sulfonylureas, stimulate the pancreas to produce more insulin. Examples of sulfonylureas include DiaBeta (glyburide), Micronase (glyburide), Glynase PresTab (micronized glyburide), Glucotro1 (glipizide), Glucotrol XL (glipizide extended release), and Amaryl (glimepiride).
In the past five years or so, several other types of diabetes pills have come on the market. They work in a variety of other ways on the multiple factors that are believed to contribute to high blood glucose. These medications include:
- Insulin sensitizers, which help keep blood glucose levels within a target range by making the body more sensitive to insulin's effects. These medications may also help decrease the amount of glucose released by the liver. Examples of insulin sensitizers include Actos (pioglitazone) and Avandia (rosiglitazone).
- Starch blockers. These medications help control blood glucose by slowing the digestion of carbohydrates (sugars and starches) in the small intestine. They decrease peaks in blood glucose levels that occur after eating by delaying absorption of carbohydrates (sugars and starches) into the bloodstream. Examples of these medications are Precose (acarbose) and Glyset (miglitol).
- Pills that stimulate the pancreas to produce more insulin right after a meal. Examples include Prandin (repaglinide) and Starlix (nateglinide).
- Medications that reduce the amount of glucose the liver releases between meals. Examples: Glucophage (metformin); Riomet (metformin liquid); and Glucophage XR, Fortamet, and Glumetza (metformin extended release).
- DPP4 Inhibitor. This medication improves the level of your body's insulin after a meal and lowers the amount of glucose made by your body. Example: Januvia (sitagliptin).
Frequently, physicians will prescribe one type of oral medication and discover it isn't helping to control blood glucose effectively. In the past, the patient would most likely have been put on insulin. Now, physicians can try another type of medication—or one of several combination drugs. Glucovance combines glyburide and metformin to both stimulate insulin production and decrease the amount of glucose produced in the liver. Metaglip, a combination of glipizide and metformin, works similarly. Avandamet is a combination of rosiglitazone and metformin. It helps your muscles use insulin more effectively and decreases the amount of glucose released by the liver. Actoplus Met, a combination of pioglitazone and metformin, works in a similar manner. Avandaryl combines rosiglitazone and glimepiride. It stimulates the pancreas to produce more insulin and helps your muscles to use insulin more effectively. Duetact combines pioglitazone and glimepiride and has a similar mechanism of action. Janumet is a combination of sitagliptin and metformin. This medication improves the body's insulin level after a meal, lowers the amount of glucose made by the body, and reduces the amount of insulin released by the liver between meals.
There are several types of insulin, classified by how soon and how long they act. It is helpful to know when the insulin you take starts to work, its peak (when the insulin is working its hardest), and the duration (how long the insulin works). Premixed combinations of slower- and fast-acting insulins are also available.
- Rapid-acting insulins include insulin aspart (Novolog); lispro (Humalog), and insulin glulisine (Apidra). They begin to act in 10 to 30 minutes and reach their peak in 30 minutes to three hours, and their effects last between three and five hours.
- Short-acting insulin is regular insulin. It begins to work in 30 to 60 minutes, peaks in one to five hours, and lasts as long as eight hours.
- Intermediate-acting insulin, NPH, begins working in one to four hours. It peaks at between four to 15 hours, and lasts 14 to 26 hours.
- Long-acting insulin, glargine (Lantus), begins working in one to two hours, does not peak but has consistent effects, and lasts as long as 24 hours.
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An insulin pump is a small, computerized device that delivers insulin continuously throughout the day. It attempts to mimic the pancreas's normal release of insulin, but you must tell the pump how much insulin to inject. It delivers insulin in two ways: a basal rate, which is a continuous small trickle of insulin that keeps blood glucose stable between meals and overnight; and a bolus rate, which is a much higher rate of insulin taken before eating to "cover" the food you plan to eat.
Effective, safe use of the pump requires a commitment to checking blood glucose at least four times a day, counting carbohydrates, and adjusting your insulin doses based on blood glucose levels, carbohydrate intake, and physical activity.
The main advantages of pump therapy are:
- increased flexibility in lifestyle
- predictable and precise insulin delivery
- the ability to accurately deliver one tenth of a unit of insulin
- tighter blood glucose control, while reducing the risk of low blood glucose
- reducing episodes of severe hypoglycemia
- reducing wide fluctuations in blood glucose, and helping manage the "dawn phenomenon" (the early-morning rise in blood glucose).
The main disadvantages of pump therapy are:
- the risk of skin infections at the catheter site
- the cost
- the need to check blood glucose at least four times per day.
Hints for handling and storing insulin
To make sure your insulin is safe and effective:
- Store unopened bottles in the refrigerator, and do not use after the expiration date. Don't freeze insulin.
- Store bottles you are using at room temperature (59 to 86 degrees Fahrenheit) for 28 to 30 days. The strength of the insulin may be altered after that.
- Avoid exposing the bottles to temperature extremes (less than 36 degrees Fahrenheit or more than 86 degrees Fahrenheit).
- Don't use regular insulin, aspart, lispro, or glargineThere is no cure for diabetes, but thwn e if it becomes cloudy in appearance.
- Don't use intermediate-acting insulin if it becomes clumped or crystallized or if the bottle becomes frosted.
- Make sure that you recheck your dosage whenever you change insulin.
- Get guidance from your healthcare team before mixing insulins or prefilling syringes.
Taking insulin is often associated with weight gain, which can prompt people to cut back on their insulin intake. Reasons for the weight gain include:
- People who have poorly controlled diabetes sometimes experience weight loss because their bodies are unable to properly convert food into energy. Taking insulin helps reverse that process and can result in a weight gain.
- When blood glucose runs high, you can become dehydrated as your body works to clear itself of all that excess glucose. Getting your blood glucose under better control may cause you to retain fluid.
- Once you start taking insulin injections, glucose in your blood can get into the body's cells and be used rather than remaining in your bloodstream and being excreted in your urine.
- High blood glucose may cause people to feel hungry and eat more, because not all the food taken in can be properly processed to nourish the cells. Frequently, eating patterns continue after insulin has been started and allows more-efficient use of nutrients.
Some people cut back on their insulin once they discover they can lose a few pounds quickly by doing so. But when they go back to using the right amount of insulin, they discover that they gain the weight back—and perhaps more—in equally rapid fashion. Manipulating insulin to lose weight is an unhealthy habit to get into. Letting your blood glucose run high can lead to long-term complications. Better to make careful adjustments in how much you eat.
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