How Type 2 Diabetes Is Treated

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There's no one-size-fits-all treatment for type 2 diabetes. According to the American Diabetes Association (ADA), the key to managing this increasingly common condition is piecing together a protocol that fits each individual's situation. That said, the elements of treating type 2 diabetes are well-established: lifestyle changes (diet, exercise, weight loss); medications and/or supplementary insulin for people for whom these efforts aren't enough to normalize blood sugar levels; and for some people, bariatric surgery. This may sound like a lot to consider, but the good news is this: When a treatment plan is carefully implemented and followed, type 2 diabetes can be reversed. This isn't the same as cured, but it does mean a lowered risk of complications, and for some it also may mean the ability to wean off medication, all the while enjoying a healthier, happier way of life.

Lifestyle

Changing (or implementing) certain lifestyle practices is nearly always step one of treating type 2 diabetes. A primary goal is to bring about weight loss. According to Johns Hopkins Medicine, a loss of just 5 percent to 10 percent of total body weight can have a dramatic effect on blood sugar levels in people with type 2 diabetes.

Diet

Diet is one of the most important factors in managing diabetes. It's especially important to reduce carbohydrate intake, which can lead not only to weight loss but also improved blood sugar control and lower levels of triglycerides (a fat associated with an increased risk of heart disease).

Although there's no such thing as an official "diabetes diet," there are a variety of approaches to eating and nutrition that have been found to be helpful, including:

  • The Plate Method. This is an easy way to control portions. It emphasizes non-starchy vegetables, whole grains, and lean protein—as well as fiber, which can help to slow increases in blood sugar levels—by dedicating specific percentages of the plate to certain foods: one half to non-starchy vegetables (salad, broccoli, string beans, cauliflower, tomatoes, etc.); one quarter to lean protein (three to four ounces of roasted chicken, grilled or baked fish, or lean red meat), and one quarter to complex carbohydrates (for example, quinoa, brown rice, barley, sweet potato, chickpeas or black beans). Room can be made for a bit of healthy fat as well (a third of an avocado, for instance, or a teaspoon of olive oil).
  • Carb consistency. Because carbohydrates impact blood sugar more than the other macronutrients (protein and fat), taking in the same amount of carbs at each meal will help keep glucose levels steady. This might mean, for instance, sticking to 45 grams of carbs for breakfast and lunch, 15 grams of carbs for a between-meal snack, and 60 grams of carbs for dinner—every day.
  • Limiting foods that dramatically increase blood sugar levels. These include refined, processed carbohydrates, like white bread and pasta; sugar-laden sweets such as cookies, cake, and candy; fruit juice; and dried fruit and grapes. It's typically fine to eat two or three servings of fresh whole fruit per day.

Besides these basic guidelines, there's preliminary evidence that dramatically reducing carbohydrates—to 20 grams or less per day—can have a profound and positive impact on type 2 diabetes.

In one study at Duke University, people with obesity and type 2 diabetes who followed a very carb-restricted diet for six months had lower hemoglobin A1c results and lost more weight than those who followed a reduced-calorie diet. What's more, 95 percent of subjects on the very low carb diet were able to reduce or totally eliminate their diabetes medications, compared to 62 percent of the reduced-calorie diet. Both groups also exercised regularly and had the support of group meetings. This is just one study though: It's vital to consult with a dietitian who specializes in diabetes before making major dietary changes.

Exercise

Regular exercise is critical for managing type 2 diabetes. Physical activity burns calories and therefore contributes to weight loss. But exercise also can have a direct impact on blood glucose control, because insulin resistance is closely linked to increased fat and decreased muscle mass: Muscle cells use insulin far more efficiently than fat, so​ by building muscle and burning fat, you can help lower and better control your blood glucose levels.

The ADA recommends the following exercise guidelines for adults with type 2 diabetes:

  • 150 minutes or more of moderate-to-vigorous aerobic activity per week, spread over at least three days, with no more than two days in a row without activity
  • Two to three sessions of resistance exercise on nonconsecutive days per week
  • Two to three sessions per week of flexibility and balance training (yoga or tai chi, for example) for older adults

The ADA also recommends that people with type 2 diabetes not sit for prolonged periods of time, and should aim to get up and move about every 30 minutes or so.

Quitting Smoking

According to the U.S. Centers for Disease Control and Prevention (CDC), people who smoke are 30 percent to 40 percent more likely to develop type 2 diabetes than nonsmokers; even using smokeless tobacco can increase diabetes risk. What's more, smokers who have diabetes are more likely to develop serious complications.

On the positive side, people with diabetes who stop smoking begin to see improvements in their diabetes symptoms and overall health benefits almost immediately. There are many approaches to smoking cessation; discussing the options with a doctor or certified diabetes educator can home in on one that is most likely to work.

Prescriptions

When dietary changes, exercise, and weight loss aren't enough to control blood sugar levels, there are any number of medications that have been developed in the past decade to help.

Some are oral medications, others are delivered by injection. Most are meant to be used along with diet and exercise, not as a replacement for healthy lifestyle measures. All drugs that follow have been approved by the FDA for treating type 2 diabetes.

Oral Diabetes Medications

Sulfonylureas

Sulfonylureas are the oldest class of oral diabetic medications. They work by stimulating the pancreas to release more insulin into the bloodstream.

  • tolbutamide
  • tolazamide
  • Diabinese (chlorpropamide)
  • Glucotrol (glipizide)
  • DiaBeta, Glynase (glyburide)
  • Amaryl (glimepiride); also in combination with rosiglitazone (Avandaryl) and pioglitazone (Duetact)

Biguanides

Biguanides lower the amount of glucose being produced by the liver while making the body more sensitive to insulin.

  • Glucophage (metformin)
  • Glucophage XR (extended-release metformin)

Thiazolidinediones
Thiazolidinediones
sensitize muscle and fat cells to accept insulin more readily. These drugs pose certain health risks that will need to be considered before being prescribed.

  • Avandia (rosiglitazone); also combined with metformin (Avandamet) and with glimepiride (Avandaryl)
  • Actos (pioglitazone); also in combination with alogliptin (Oseni); with metformin (Actoplus Met); and with glimepiride (Duetact)

In May 2007, the FDA has issued a safety alert regarding the risk of heart attacks and other cardiovascular events when taking Avandia. Both Avandia and Actos have been banned in France and Germany.

Alpha-Glucosidase Inhibitors

Alpha-glucosidase inhibitors delay the conversion of carbohydrates to glucose during digestion. This helps to regulate blood glucose levels and prevent sugars from peaking too high.

  • Precose, Prandase (acarbose)
  • Glyset (miglitol)

Meglitinides

Meglitinides help stimulate insulin production when glucose is present in the blood; it's not as effective if blood sugar levels are low.

  • Prandin (repaglinide); also in combination with metformin (Prandimet)
  • Starlix (nateglinide)

DPP-4 Inhibitors

Dipeptidyl peptidase-4 (DPP-4) is an enzyme that destroys incretins—hormones that help the body produce more insulin when needed. DPP-4 inhibitors work by blocking this enzyme.

  • Januvia (sitagliptin); also in combination with metformin (Janumet) and with ertugliflozin (Steglujan)
  • Onglyza (saxagliptin); also in combination with metformin (Kombiglyze XR), with dapagliflozin (Qtern), and with metformin and dapagliflozin (Qternmet)
  • Tradjenta (linagliptin); also in combination with metformin (Jentadueto) and with empagliflozin (Glyxambi)
  • Nesina (alogliptin); also in combination with metformin (Kazano) and with pioglitazone (Oseni)

FDA Warning About DPP-4 Inhibitors

It's important to note that in August 2015, the FDA added a Warning and Precaution about a potential side-effect of DPP-4 inhibitors—severe and potentially disabling joint pain. If you are taking a medication that contains a DPP-4 inhibitor and develop joint pain, let your doctor know right away. You may need to switch to a different medication.

Selective Sodium-Glucose Transporter-2 Inhibitors

Selective sodium-glucose transporter-2 (SSGT-2) inhibitors lower blood sugar by causing the kidneys to remove glucose from the body through urine.

  • Farxiga (dapagliflozin); also in combination with saxagliptin (Qtern), with saxagliptin and metformin (Qternmet XR), and with metformin(Xigduo XR)
  • Jardiance (empagliflozin); also in combination with empagliflozin and linagliptin (Glyxami) and with empagliflozin and metformin (Synjardy)
  • Steglatro (ertugliflozin); also in combination with ertugliflozin and metformin (Segluromet) and ertugliflozin and sitagliptin (Steglujan)
  • Invokana (canagliflozin); also in combination with metformin (Invokamet)

A Special Risk With Canagliflozin

Canagliflozin has a special warning that taking it can increase the risk of amputation of a toe, foot, or leg due to infection or other complications. Call your doctor right away if you have any pain, tenderness, sores, ulcers, or swollen, warm, reddened area in your leg or foot, fever or chills, or other signs and symptoms of infection.

Injectable Diabetes Medications

Incretin Mimetics

Also known as GLP-1 receptor agonists, incretin mimetics mimic the action of incretins to stimulate the production of insulin. They also slow the rate of digestion so that glucose enters blood more slowly.

  • Byetta, Bydureon (exenatide)
  • Victoza, Saxenda (liraglutide); also in combination with insulin degludec (Xultophy)
  • Trulicity (dulaglutide)
  • Tanzeum (albiglutide)
  • Lyxumia (lixisenatide)

Amylin Analog

Amylin is a hormone released by the pancreas at the same time as insulin. It inhibits the secretion of glucagon (another pancreatic hormone that prevents blood glucose levels from dropping too low); slows the rate at which food is emptied from the stomach, and helps promote a feeling of fullness after eating.

As with insulin, people with type 2 diabetes do not produce normal amounts of amylin and so it's believed that replacing amylin helps control blood sugar levels. Human amylin destroys the beta cells that produce insulin and so a synthetic version, or analog, of amylin, was approved by the FDA in March 2005.

This drug, Symlin (pramlintide), has been found in studies of more than 3,000 people with both type 1 diabetes and type 2 diabetes to help control blood sugar levels without common side effects of other medications such as low blood sugar events and weight gain.

Insulin

Although supplemental insulin is vital to managing type 1 diabetes, it is only necessary for certain people with type 2 diabetes—typically those who:

  • already had very high blood sugar levels when they were diagnosed
  • are very insulin resistant
  • haven't been able to control blood sugar with oral medicine, diet, and exercise

A person's insulin regimen will be tailored to his or her specific needs. Some people may need to take a long-acting insulin in the morning that will work continuously throughout the day to normalize blood sugar levels, while others will benefit most from a short-acting or rapid-acting insulin taken at mealtime. And still other people may need to take both types of insulin.

Insulin cannot be taken orally: It must be injected. However, there are several delivery options. The most common is an insulin pen—a device that's fitted with a small needle. Other options include a basic needle and syringe or an insulin pump or patch attached to the body. There also is a type of insulin that can be inhaled.

Blood Glucose Monitoring

For people with type 2 diabetes who take insulin, blood glucose monitoring may be essential for a number of reasons. It can provide a picture of how well treatment is working, how blood sugar levels are affected by food and physical activity, and more.

Most people who take multiple injections of insulin will be advised to take a blood sugar reading before meals and at bedtime. For those who take only a long-acting insulin, it may be necessary to test only twice a day, before breakfast and before dinner.

Monitoring is done with a device called a blood glucose meter, or glucometer, that can measure the level of sugar in blood based on a single drop taken from a fingertip. Most devices are designed to do single tests, but there are some that provide continuous glucose monitoring.

Bariatric Surgery

Bariatric surgery is, simply stated, a procedure designed to help a person who is very overweight or obese lose weight. According to the American Society for Metabolic and Bariatric Surgery (ASMBS), in studies of bariatric surgery performed on more than 135,000 patients with type 2 diabetes, the results were significant: Nearly 90 percent had lower blood sugar, were able to reduce the dosage of medication, and experienced improvements in health problems caused by diabetes. What's more, 78 percent of patients went into remission after losing weight as a result of surgery.

People with type 2 diabetes who are candidates for bariatric surgery are those with a body mass index (BMI) greater than 35. Although there are several types of bariatric surgery, a procedure called the Roux-en-Gastric Bypass, in which the gastrointestinal tract is altered in such a way that food bypasses most of the stomach and upper portion of the small intestine, tends to have the greatest effect on blood sugar levels, leading to "remission of type 2 diabetes in 80 percent of patients and improvement of the disease in an additional 15 percent of patients," according to the ASMBS.

As with any surgical procedure, bariatric surgery has risks. It also requires significant lifestyle changes—particularly in regards to diet: People who undergo weight loss surgery are required to follow a specific nutrition plan that's high in protein and limits refined carbs and foods with added sugar, for example. They also must commit to taking nutritional supplements.

That said, given the potential complications associated with type 2 diabetes, particularly for people who also are obese, the benefits of surgical intervention may well outweigh the risks. As for the requisite dietary changes, they too will be worth it, especially since making them will further contribute to a healthier way of life overall.

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