Originally Published Sept 2007
WHAT ARE THE GUIDELINES FOR TREATING TYPE 2 DIABETES?
General Guidelines for Treatments
Treatment for type ll diabetes generally follows certain stages that depend on the amount of residual insulin and ability to control blood glucose levels:
- Healthy lifestyle habits are the cornerstone of diabetes treatment. A healthy diet, weight control, and exercise are essential for any treatment program. Many type ll diabetics can control their condition with diet and exercise alone for years.
- If they cannot, then medication is introduced. Most often a single oral agent that stimulates or preserves any residual insulin is the first choice. (Some physicians are recommending a very aggressive initial approach for newly-diagnosed patients who have type ll diabetes. Knowing that many patients have had diabetes for years prior to diagnosis, these physicians believe that physicians should not wait to initiate treatment with one or more medications.)
- Some patients may be able to control their glucose levels with a single drug. One study reported, however, that after three years, half of the patients needed more than one agent, and at nine years, only 25% could remain on a single drug. In fact, according to a 1999 survey, 90% of diabetes specialists reported that they prescribed three or more medications for their patients.
- Eventually, natural insulin may completely fail; in such cases patients then require insulin replacement. Some people may even need to start off with insulin. Such patients may include those with severe hyperglycemia, those with signs of autoimmune diabetes, and women during pregnancy.
Treatment Goals and Intensive Control of Blood Glucose Levels
Major studies have now reported that, as in type 1 patients, rigorous control of blood glucose levels can help reduce the risk for complications in type ll diabetics, including retinopathy, kidney and nerve damage. Even short-term control of blood glucose may improve their quality of life. (It may also help prevent impotence in men. )
It is not clear, however, if controlling blood glucose has any major benefits on the heart, and heart disease is the most serious complication in type ll diabetes. Studies are mixed on the effects of intensive glucose control, with some even reporting some harm. Of particular concern is weight gain from insulin therapies, a major problem and health risk in most patients with type ll diabetes. Newer insulin-sensitizing medications may pose less of a risk for weight gain, however, and new weight loss drugs are also proving to be helpful in offsetting weight gain from other drugs.
Until more is known, at this time patients should still aim for the following test results:
- Fasting plasma glucose concentrations below 110 mg/dL.
- Glycolated hemoglobin (HbA1c) levels of less than 7%. Type ll diabetics with normal or low HbA1c levels have the lowest risk for complications. According to one 2000 study, a 1% reduction in people with elevated glycolated hemoglobin levels lowers the risk for complications by 21%.
Patients should discuss all options with their physicians.
WHAT ARE THE LIFESTYLE MEASURES FOR TREATING AND PREVENTING TYPE ll DIABETES?
Healthy lifestyle habits are the cornerstone of diabetes treatment. Lifestyle changes are difficult to initiate and sustain, however. Patients should be certain to surround themselves with a solid network of doctors, dietitians, family, and friends who understand both their condition and their needs. At least one study has found that family involvement plays a large role in adhering to lifestyle and medical regimens.
A Diabetic Diet and Weight Loss
The Diabetic Diet. The current state of the diabetic diet is in flux, and at this time, there is no single diet that meets all the needs of everyone with diabetes. Patients should meet with a professional dietitian to plan an individualized diet that takes into consideration all health needs. There are some constants, however:
- Limit fats (particularly saturated fats and trans-fatty acids).
- Limit dietary cholesterol.
- Consume plenty of fiber-rich foods in the form of whole grains and fresh fruits and vegetables.
- Limit protein.
- Reduce salt.
Weight Loss. Being overweight is the number one risk factor for diabetes type ll. A number of studies have suggested that healthy habits might prevent diabetes, but they have had significant flaws. Now, an important well-conducted 2001 study in Finland has added very strong evidence on the value of weight loss and exercise. In the study, individuals at risk for developing type ll diabetes were put on a weight loss and exercise program. Although the average weight loss was relatively small (about 10 pounds), the risk for diabetes in this group was 58% lower than the comparison group who were given no intervention. Health benefits are highest with the first pounds lost, and losing only 10% of body weight can control progression of diabetes.
Unfortunately, not only is weight loss difficult to sustain, but many of the oral medications used in type ll diabetes cause weight gain as a side effect. For obese patients who cannot control weight using dietary measures alone, weight-loss drugs, such as orlistat (Xenical) or sibutramine (Meridia), may be beneficial. In some studies, for example, orlistat not only helped subjects to reduce weight but also improved glucose, cholesterol, and lipid levels. Surgical procedures are proving to be extremely beneficial in selected cases.
Exercise
Regular exercise, even of moderate intensity (such as brisk walking), improves insulin sensitivity and can even prevent type ll diabetes. In fact, studies of older people who engage in regular to moderate aerobic exercise (eg, brisk walking, biking) lower their risk for diabetes even if they don't lose weight. Exercise also helps lower blood pressure, improve cholesterol levels, and decrease body fat. All in all, even moderate exercise reduces the risk of heart disease in people with type ll diabetes, even if they have no cardiac risk factors other than diabetes. Low-impact aerobic exercise is best. Resistance or high impact exercises can strain weakened blood vessels in the eyes of patients with retinopathy. High-impact exercise may also injure blood vessels in the feet.
In general, experts recommend the following:
- Before starting exercise, individuals over age 40 or anyone under age 40 with heart disease should take a stress test. (Because diabetics may have silent heart disease, they should always check with their physicians before undertaking vigorous exercise.)
- Patients who are taking medications that lower blood glucose, particularly insulin, should take special precautions before embarking on a workout program.
- For best and fastest results, frequent high-intensity (not high-impact) exercises are best for people who are cleared by their physicians.
- For people who have been sedentary or have other medical problems, lower-intensity exercises are recommended using regimens designed with physicians.
Monitoring Blood Glucose
In patients being treated with insulin or insulin-producing or sensitizing drugs, it is important to monitor blood glucose levels carefully to avoid hypoglycemia. Patients should aim for the following measurements:
- Pre-meal glucose levels of between 80 and 140 mg/dL .
- Bedtime levels of between 100 and 160.
Different goals may be required for specific individuals, including pregnant women, very old and very young people, and those with accompanying serious medical conditions.
Blood glucose levels are generally more stable in type ll diabetes than in type 1, so experts usually recommend measuring blood levels only once or twice a day. Usually, a drop of blood obtained by pricking the finger is applied to a chemically treated strip. The glucose level is read on a standard meter or a small, portable digital display device. A noninvasive device called the GlucoWatch, measures glucose by sending tiny electric currents through the skin and is showing promise for detecting hypoglycemia.
Improving Sleep
Some research suggests that not getting enough sleep may impair insulin use and increase the risk for obesity. More research is needed, but it is always wise to improve sleep habits.
