Thursday, February 9, 2012

Diabetes type 2

Author: Anne Peters, MD, FACP, CDE Director, USC Clinical Diabetes Programs Los Angeles, CA

2009-06-06

Type 2 Diabetes : Managing Your Numbers to Achieve Greater Health - By Anne Peters, MD

Type 2 diabetes is an increasingly common disease, both in the United States and around the world.  It used to be called “adult onset” diabetes, but now we know it can occur at any age - although it is still most common in adults.  In addition to causing high levels of sugar in the blood, in can cause high blood pressure as well as unhealthy cholesterol levels.  These abnormalities put people at high risk for heart attacks, strokes, and the other complications associated with high blood sugar levels.  These possible complications understandably frighten patients, especially since many have seen family members lose a leg or go blind from the disease.  In this era however, not only can diabetes be treated, if treated adequately many of its complications can be avoided.  In fact, type 2 diabetes itself can often be prevented, if picked up soon enough.  Therefore the treatment of type 2 diabetes should be undertaken with a commitment to a lifetime of appropriate health care and the expectation of long and healthy life.


Type 2 diabetes is being diagnosed more frequently in children and adolescents.

What is Type 2 Diabetes?

    Type 2 diabetes is both a genetic disease, one that almost always runs in families, and a disease of lifestyle, usually related to gaining weight and being inactive. People with type 2 diabetes always have two problems at the level of their cells, insulin RESISTANCE and insulin DEFICIENCY.
     Insulin is a hormone that puts sugar into cells.  It also influences the breakdown of fat in our fat cells and regulates how much sugar and fat we have floating around in the blood stream.  Insulin is the body’s regulator of fuel.  Too much insulin and the blood sugar level goes too low; too little insulin and our blood sugar levels go too high.  Interestingly the body doesn’t really care, in the short term, if blood sugar levels are too high.  Generally there are no symptoms when the blood sugar level is elevated to 200 mg/dl instead of the normal 100 mg/dl.  This is why we call diabetes the silent killer—blood sugar levels can be high for many years without causing symptoms, but damage is still occurring to the eyes, kidneys, nerves, and blood vessels. 
    When the body is resistant to insulin it means that it takes larger amounts of insulin than usual to keep blood sugar levels in the normal range.  The body is smart—it knows what normal is and the beta cells in the pancreas (the organ that makes insulin) keep making extra insulin in order to correct for the insulin resistance.  The exact mechanism of the insulin resistance is not known, although getting older, gaining weight, being less active, having diabetes genes, taking certain medications (like prednisone), pregnancy, and getting sick make it worse.  On the other hand, although the effects of aging and our genetics can’t be changed, we know that losing weight, increasing exercise, and avoiding medications that worsen insulin resistance can improve insulin sensitivity. 
    Insulin resistance may develop 10 – 15 years before diabetes occurs.  For many years the body can make extra insulin and overcome the resistance, keeping blood sugar levels normal.  At some point, due to years of extra work combined with a genetic risk for wearing out, the beta-cells burn out and start to make too little insulin.  At this point blood sugar levels rise.  In some people this happens sooner, in some it happens later. Beta-cells from a nondiabetic person are filled with little droplets of insulin, waiting to be released.  Beta-cells of someone with diabetes are half filled with gunk, which looks like pink chewing gum under the microscope (see photo).  Not all of the beta-cells are destroyed—there are enough left to make some insulin, but only about half of what is needed.  Therefore when type 2 diabetes is diagnosed both insulin resistance and insulin deficiency are present.
 Beta-Cell photos from the lab of Dr. Peter Butler, Professor of Medicine, Director of Larry L. Hillblom Islet Research Center, at UCLA.


Is type 2 diabetes caused by genes or the environment?

      The answer to this commonly asked question is that it is always both.  A person must have the genes for type 2 diabetes as well as live in a facilitative environment in order to develop the disease.  The genes that cause type 2 diabetes were once believed to be genes that helped us survive.  The story behind this is called the “Thrifty Gene” theory.  It is believed that the genes that now cause diabetes once helped us outlast famine by making us expert at storing fat and keeping our blood sugar levels up when we didn’t have enough food.  These genes were most effective at helping us store fat where it is most needed—around the middle, near the internal organs.  The fat stored in the center is different from other types of fat, possibly providing better fuel to the body during starvation.  But now that we are not starving this fat builds up, and waistlines expand.  This central fat, called central obesity, is very common in people with type 2 diabetes.  This fat contributes to causing diabetes, damaging the pancreas so it makes less insulin, signaling liver to make extra and abnormal fat, and pouring inflammatory toxins and free fat (fatty acids) into the circulation.  All of these abnormalities contribute to raising blood sugar, blood pressure, and lipids, leading to type 2 diabetes and its complications.
     People who develop diabetes have these once-upon-a-time good genes, but now live in an environment not suited for their genetic makeup.  To develop diabetes a person has to have the genes that cause type 2 diabetes and live in an environment where there is too much food and too little exercise (both of which increase insulin resistance).  So when people live in a rural environment, such as the countryside in Mexico, where food is scare and physical labor common, diabetes doesn’t occur.  But then they move into the cities and change their habits; they develop diabetes as we see commonly in Latino populations in the United States.  This is also why there is an epidemic of diabetes in places like China and India—the rising middle class and relative prosperity means more food, less exercise, and the resulting increase of type 2 diabetes.

What are the risk factors for diabetes?


      Most people who have type 2 diabetes are overweight and nearly everyone has a family member who has type 2 diabetes or heart disease.  It is much more common in people who have ancestors who are American Indian, Latino, African American, Asian, or from the Pacific Islands.  Also people commonly have ancestors from Eastern Europe or Russia.  In these populations diabetes genes are more common than in individuals from other parts of the world.  Besides having a family history of diabetes and being from a high risk ethnic group, other risk factors include age greater than 45 years, being overweight (especially around the center), having high blood pressure, abnormal cholesterol levels (low HDL cholesterol levels and/or high triglyceride levels) or an abnormal blood sugar level, and if female, having had a baby weighing greater than 9 pounds, prior gestational diabetes, and/or polycystic ovarian syndrome (PCOS).  A tool for assessing your risk for developing diabetes can be found on the Web site for the American Diabetes Association. http://www.diabetes.org/risk-test.jsp
Type 2 diabetes is more common in people who are Latino, American Indian, African American, Asian, or from the Pacific Islands.

What are the symptoms of diabetes

     Most people do not have symptoms of diabetes and are diagnosed as a result of a routine blood test in the doctor’s office.  If present, the symptoms of diabetes tend to be subtle at first and become more dramatic over time.  A frequent complaint is getting up more often at night to urinate.  This is called nocturia and happens because the extra sugar in the blood is leaking out into the urine pulling along more water with it.  This also happens during the day with a compensatory increase in thirst, and is called polyuria.
     Sometimes people lose a lot of weight before they are diagnosed with diabetes. The reason people lose weight when blood sugar levels are very high is because all the sugar, the fuel for the body, is on the outside of the cells instead of on the inside, where it is needed.  So even though someone may eat thousands of calories per day, if the body can’t use the calories it is ingesting, the person starts to starve.
People with high sugar levels are often prone to infections and if they get infections they don’t recover or heal as quickly as usual.  This is because high sugar levels inhibit the body’s ability to fight infection—the white blood cells, which are the infection fighting cells, don’t work as well when sugar levels are high.  Women who are getting diabetes will often complain of frequent vaginal yeast infections because it seems that yeast are particularly fond of a high sugar environment.
     High blood sugar levels seem to make people more tired.  The increase in blood sugar levels happens so gradually that people don’t notice how tired they are, but once the blood sugar levels come down people often say that they have more energy than they have had in years.

What blood tests are needed? 

     Anyone with risk factors for diabetes, including being over the age of 45 years, or anyone who has symptoms should be screened for diabetes.  The test is really simple—all that is needed is to have a fasting blood sugar level taken.  Fasting means nothing to eat or drink (except water) for 10 to 12 hours before the blood test is drawn.  Usually the blood is taken first thing in the morning.
     Blood sugar levels fall into three categories:  equal to or above 126 mg/dl is diabetes, between 100 and 126 mg/dl is prediabetes, less than 100 mg/dl is usually normal.  People used to be diagnosed with diabetes with an oral glucose tolerance test, a 2-part testing process in which  a fasting blood sugar level was taken, the patient then drank a very sweet type of cola or orange drink, after which another level was taken two hours later.  These tests aren’t done very often these days, but can be helpful if more information is needed.  However, they are still done in nearly every woman during pregnancy.
     A glycated hemoglobin level or HbA1c is a measure of the average sugar level in a person’s blood over the past three months.  It should be tested every three to six months.  This is a great way to tell what overall blood sugar levels are—a fasting or random blood sugar is just one minute in time compared to the up and down fluctuations of blood sugars throughout the day.  The HbA1c is the average of all of the ups and downs of the blood sugar levels for the past three months and relates to the risk for having complications of diabetes.  Therefore, the HbA1c level should be as close to the normal range as possible, which is 4 – 6%.  People with prediabetes often have HbA1c levels in the normal range, and when it creeps up above normal it is a sign that blood sugar levels are rising.
     At the same time the fasting blood sugar level is tested, a fasting lipid panel should also be measured.  The following levels should be tested:  triglycerides, total cholesterol, LDL (bad) cholesterol, and HDL (good) cholesterol.  If the triglycerides are above 150 mg/dl and the HDL is below 50 (female) and 40 (male) this is a risk for prediabetes or diabetes. 

What are the next steps after an increased blood sugar level is discovered?    

     The first step is not to panic.  The second, equally important point is not to go into denial.  Although not curable, diabetes is treatable and the earlier the better.  Vitally important is to find a team of health care providers to work with.  Most people are treated for their diabetes by their regular provider - often an internist, a family practitioner, or nurse practitioner.  In addition to a primary health care provider, the team should include a dietitian who is expert in the treatment of diabetes and a diabetes educator, often a nurse, who can teach about monitoring blood sugar levels and provide diabetes education.  Diabetes classes are held at many local hospitals and may be useful.  More complicated cases should be referred to an endocrinologist who specializes in diabetes.  An eye care professional should be seen for a dilated eye exam and if abnormalities of the feet are found, a podiatrist (a foot doctor) should be consulted.
A common complication is diabetic neuropathy - numbness, tingling, or pain in the feet.
  
Even the best health care team needs guidance from the patient—each individual must learn about their disease and work to utilize available resources to their advantage.  The following Web sites provide excellent information on diabetes:  http://www.diabetes.org, http://www.dlife.com, and http://ndep.nih.gov .

To help formulate an approach for treating prediabetes and diabetes, the following points should be remembered:
  1. Any increase in fasting blood sugar level above 100 mg/dl needs to be followed and understood.  It is not  “normal” to have a blood sugar level above 100 mg/dl, even though mildly elevated numbers are too often considered “not serious.”  Diabetes and heart disease can be prevented if caught soon enough.
  2. Once diagnosed with prediabetes or diabetes the following are needed:
  • Nutrition education (by a dietitian knowledgeable in diabetes) with necessary changes in diet and exercise
  • Diabetes education (in a class or in individual sessions)
  • An assessment of mood and depression, with treatment if needed 
  • Smoking cessation (if applicable)
  • Close follow-up to reach targets for blood sugar, lipids, and blood pressure (targets will be discussed below)
  • Long term follow-up to maintain targets over time 



The Treatment of Type 2 Diabetes


How is type 2 diabetes treated?    

     Type 2 diabetes is generally treated with changes in lifestyle (diet and exercise), oral medication, and sometimes injected medication.  Each individual varies in terms of which treatments they need and often diabetes get worse over time, requiring more medication.  The goal is to keep blood sugars as close to the normal range as possible.  This means a blood sugar levels prior to eating of around 100 mg/dl (range of 90 – 130 mg/dl), a 2-hour after eating blood sugar level of less than 160 mg/dl, and a HbA1c (measured every 3-6 months) which is less than 7% and ideally in the normal range of 4-6%. 
     Mealtime blood sugar levels are tested by patients at home with a blood sugar meter, often (incorrectly) called a glucometer (Glucometer® is a specific brand of a self-monitoring blood glucose device, and there are many brands from which to choose).  These devices are which readily available over-the-counter at drugstores, but if a physician prescribes the meter and the strips insurance companies and Medicare will generally pay for them.  Each person will be advised when to test their blood sugar levels, and this will usually be before meals and sometimes after meals to be sure the results are within range.  Blood sugar testing is relatively easy, although not entirely painless—it involves pricking the finger with a lancing devices and then touching the ensuing drop of blood to a blood sugar monitoring strip from the meter.  Meters generally read the blood sugar within seconds, giving an immediate result.  Often meters have a memory that stores the values.  Make sure that the information obtained from home blood sugar testing is useful—bring results anf meter to your health care team at each visit and contact your team in between visits if your levels are unusually high or low.  Because of the ability to monitor diabetes at home each person with diabetes can learn in a direct way how lifestyle and medications impact their disease and will have a warning if blood sugars are getting out of control and require intervention.  Ask your healthcare team for guidance as to the blood sugar levels above and below which you should call for assistance.
Exercise helps reduce insulin resistance and helps lower blood sugar levels.

What is the best approach to diet and exercise?

     All people with diabetes, lean or overweight, benefit from lifestyle changes.  Exercise helps reduce insulin resistance and helps lower blood sugar levels.  Weight loss also makes the body more sensitive to insulin in patients who are overweight.  Even patients who are not overweight will respond to a healthy eating plan, because eating less refined carbohydrates helps reduce the rise in blood sugar levels that occurs from over eating.  Therefore, no matter what the treatment for diabetes it is always helped by healthy lifestyle habits.
    The greatest misconceptions about diabetes tend to be around nutrition. Part of this is because over the years we have changed the advice we give patients, but the other part is that there is simply a lot of bad advice being circulated. Developing an individualized meal plan along with a dietitian, one that takes into account personal food preferences and goals along with a healthy approach to food, is the ideal scenario. The goal is to develop a new set of habits that last a lifetime, rather than to lose weight quickly only to regain it. Many people try more than once to lose weight before they can keep it off. 
    Since there is no specific diabetic diet, and there are many, many commercial diets available, the most effective approach begins with formulating lifestyle goals.  An individual who is overweight needs to lose weight.  Often this doesn’t mean losing down to an “ideal” body weight - to prevent diabetes generally a person needs to lose 10 – 20 pounds, although the weight loss must be maintained.  Similarly, losing that amount of weight will help lower blood sugar levels and can be an effective start at treating diabetes.  Depending on the weight of the person, more weight loss may be required to bring blood sugar levels to normal, but weight loss through healthy eating habits and exercise nearly always improves diabetes.
    There are many approaches to weight loss (see Appendix 2 for one approach to lifestyle management).  Fundamentally all lead to the consumption of fewer calories.  Regardless of the approach used (and nearly all diets work initially) it is maintaining the weight loss that is the hard part.  The Atkins Diet and South Beach diet are good plans to follow for independent weight loss.  Some people like to be part of a group, such as Weight Watchers or Overeater’s Anonymous.  Others prefer interactive diet programs found on the Internet.  There are meal replacement programs where special foods are purchased or a hybrid where a liquid supplement such as Slim-Fast, Choice, or Glucerna is consumed for breakfast and lunch and then a healthy meal is eaten for dinner.  Sometimes diet pills can be helpful, such as Meridia and Xenical.  All of these methods help people lose weight, but don’t always help keep it off permanently.  That is where a dietitian fits in.  Dietitians can teach how to balance eating when not on a strict diet plan, in a more normal life situation.  Finally, bariatric surgery (sometimes referred to a “stomach stapling”) is an option for some, and does produce long-term weight loss.  This should be considered only after nonsurgical attempts at weight loss have been tried.

    Patients with type 2 diabetes who do the best in the long term often learn to eat less carbohydrate at each meal (avoiding foods that are white—white flour, white rice, white pasta, etc), and eat a balance of 40% carbohydrate, 30% healthy fat, and 30% high quality protein.  Usually people eat five times a day but each meal is smaller than normal and the two snacks in between tend to be lower calorie, balanced snacks (100 – 150 calories, with 15 – 20 g carbs and 7 g protein).  This frequent eating helps to decrease between meal hunger and helps control the amount eaten at any one time.
     When eating carbohydrates, the more “natural” the carbohydrate, the better.  So fresh fruits and vegetables are better than fruits and vegetables that are cooked, mashed, pressed, pureed, baked or altered in any way that breaks down their natural fibers and nutrients.  The less processed the food the better, as well.  Therefore whole wheat bread is better than white bread and brown rice is better than white rice.
Eat fresh, uncooked fruit as much as possible, with the exception of bananas, that can often raise blood sugar levels too high.
 
There is a long-term study called the National Weight Loss Registry, http://www.nwcr.ws which is being done by Drs. James Hill and Rena Wing. This is a study of people who were able to lose at least 30 pounds and keep the weight off for more than 6 months. These people did not necessarily have diabetes, but one can learn a lot from them.  In this study the patients lost an average of 60 pounds and have kept it off for five or more years.  Most had tried many times before to lose weight but kept gaining back what they’d managed to lose, and more.  Yet when they were finally successful at losing weight and keeping it off, something happened, a “hitting bottom,” that prompted them to change.  Sometimes this was seeing a loved one die from the complications of being overweight or sometimes it was medical news that being overweight was hurting them.  These patients made a decision to change their habits and they did.

     Interestingly, the most common diet that most of them eat is a high carbohydrate diet.  Most eat small meals and snacks five times per day.  Almost all are physically active and they weight themselves often to be sure they are not gaining the weight back.  They have also learned to eat in a way so that they don’t feel deprived—they still eat the foods that are “bad” (the cakes and candy and French fries) but they eat less of them.  This particular style may not be right for everyone.  However, these success stories show that a balanced approach works the best.

Does having diabetes mean not eating sugar? 

    Often when people get diabetes they think that high sugar levels in their blood mean that they’ve been eating too much sugar in their diets. This is only partly true.  Sugar in the blood stream comes from two sources—carbohydrate and protein. The body needs sugar to make the brain properly work, so it has many ways to keep blood sugar level normal.The first is by eating sugar, which is the carbohydrate (starch and sugar) in the diet.  If one doesn’t eat sugar the body makes sugar by converting protein into sugar in the liver.  Therefore, to simply stop eating sugar won’t make your blood sugar levels normal.  A balance needs to be reached between the carbohydrate, protein, and fat that is consumed, so that weight loss occurs (if you are overweight) and blood sugar levels after eating are controlled.
     Most think of sugar as coming from simple sugar that we eat.  But simple sugar is just another form of carbohydrate.  Carbohydrates are everything from table sugar to rice to pasta to potatoes to flour.  Starches are long chains of sugar molecules; table sugar is shorter chains.  It is all broken down in the intestines as it is absorbed, so it comes into the blood stream as sugar.  Some sugar is absorbed more quickly—like the sugar in soda or in juice, and other sugar is absorbed more slowly, like the sugar that comes in raw fruits and vegetables.  How quickly a sugar is absorbed depends on the form the sugar is in—processed foods lead to a more rapid increase in sugar levels and raw foods to a lower rate of absorption.  High fiber foods, for example, lead to sugar that is more slowly absorbed.
     A term that is used to describe how quickly the sugar in food is absorbed is called the glycemic index.  A low glycemic index means that the sugar is absorbed more slowly.  A high glycemic index indicates a more rapidly absorbed food.  When monitoring carbohydrate intake, which is the same thing as counting how much sugar is eaten, it helps to know the total amount you have eaten, as well as the glycemic index. Helpful books and Web sites exist, to help with the calculation of carbohydrate content of the meal  http://www.calorieking.com, or http://www.atkins.com/carb-counter .
The 10,000 steps in a day goal is a marker to the Surgeon General's recommendation of 30 minutes of activity on most days. 

How does exercise help in the treatment of type 2 diabetes?

     Exercise is very beneficial in the treatment of type 2 diabetes.  It works to reduce insulin resistance which in turn lowers blood sugar levels.  It also has a positive benefit on cholesterol levels, blood pressure, and cardiovascular health.  To maintain maximal levels of health, the best approach to exercise includes both aerobic exercise (such as walking, running, cycling, swimming) with resistance training (such as lifting weights).  Ideally exercise should be undertaken 5 days per week, for 45 to 60 minutes a day, although less exercise is better than no exercise.
     Prior to embarking on an exercise program a person with diabetes should see a physician to check for cardiovascular disease and any other health problems that might limit participation in exercise.  Once cleared to exercise, start slowly, just 5 to 10 minutes at a time and increase weekly.  Gradual acclimation is better than overdoing it at first.  Injuries can derail any plans for exercising and should be prevented if at all possible.  
   Certain medications may need to be adjusted when exercising.  These include sulfonylurea agents, meglitinides, and insulin.  Generally the dose needs to be reduced so that blood sugar levels do not fall too far.

How do medications work in the treatment of type 2 diabetes?

    To understand how medications for type 2 diabetes work it is necessary to remember the pathophysiology (the disturbance of the cell’s function that causes the disease) of type 2 diabetes.  Type 2 diabetes is always insulin resistance plus insulin deficiency.  It is almost always a progressive disease, with a decrease in insulin production over time.  In treating diabetes we know that insulin resistance can be lowered through weight loss and exercise.  Insulin deficiency can’t directly be treated this way, but reducing insulin resistance means that the body has to make less insulin to keep blood sugar levels normal.  So lowering insulin resistance will put less strain on the body to make insulin, and beta-cell failure may not happen as quickly.  Therefore, lowering insulin resistance lessens insulin deficiency.
    Treatments for diabetes either reduce insulin resistance and/or increase the production of insulin (or deliver insulin directly in the form of insulin injections).  In most cases the initial treatment for type 2 diabetes is diet and exercise to lower insulin resistance and metformin, an oral medication described below.  If metformin alone doesn’t work, additional medications are added.  If diet and exercise are successful, sometimes the metformin can be stopped and lifestyle changes alone used for treatment.  The recommendations for treatment can be found in the American Diabetes Association Clinical Practice Recommendations http://care.diabetesjournals.org/content/vol31/Supplement_1/.  A new set of guidelines is published in January each year as a supplement to the journal Diabetes Care.  See Appendix 1 for recommendations about routine laboratory testing in people with type 2 diabetes.

Drugs for Treating Type 2 Diabetes 

    Use of medications should be discussed with your health care provider.  Women who are pregnant, lactating, planning pregnancy, or who are fertile must discuss use of these medications with their physicians.  Most drugs are not recommended in pregnancy, and insulin is generally used in women with type 2 diabetes who are planning pregnancy.  Some drugs, such as metformin, glitazones (Actos and Avandia), and exenatide (Byetta) can reduce insulin resistance and restore fertility in women who were infertile due to insulin resistance.  Byetta can cause some birth control pills to work less effectively.  Therefore, in women of childbearing age, issues of pregnancy, birth control and treatment of type 2 diabetes should be carefully discussed with their healthcare provider.  Women with type 2 diabetes can have happy, healthy babies, but pregnancies must be planned, medications stopped and adjusted, and the pregnancy closely monitored.

1.  Metformin (metformin, Glucophage, metformin XR, Glumetza, Fortamet)
    Metformin (Glucophage) was introduced in the United States in the mid 1990’s but had been used worldwide since 1957.  This class of drugs has actually been used since medieval times since the active ingredient was found in a plant called French Lilac or Goat’s Rue.  This was an herbal medicine used to treat people with symptoms of diabetes before we even knew what diabetes was. 
    This long track record with metformin makes it well known, in terms of both risk and benefits.  Interestingly no one has ever really figured out exactly how it works.  It doesn’t increase insulin levels and probably works primarily by decreasing the amount of sugar made by the liver overnight.  Metformin may also have a small effect on lowering insulin resistance.  It does not cause weight gain (often people feel slightly less hungry on the drug) and is an effective agent to lower blood sugar. 
    The side effects to metformin are mostly related to the gut—nausea, diarrhea, bloating, sometimes cramping and abdominal discomfort are common.  Most people can tolerate these side effects, but not always.  If the diarrhea is too severe then the drug cannot be used.  The best way to start this drug is in a low dose, only one pill a day with food, and then increase gradually every 2 weeks.  In this way the body gets used to it, and fewer side effects occur.  If tolerance doesn’t develop, and severe gastrointestinal symptoms persist, the drug should be stopped (after consultation with your health care team).  There are long acting forms of metformin, such as metformin XR, Glumetza and Fortamet, which tend to cause fewer gastrointestinal side effects. 
    The more serious metformin side effect is called lactic acidosis.  This is a condition where acid builds up in the blood and can lead to death.  Fortunately this occurs extremely rarely, and almost not at all, if the proper patients are started on metformin.  The FDA has very strict regulations that are to be followed before starting metformin, and the drug has a black box warning (meaning the drug can cause serious, possibly life threatening, side effects) for lactic acidosis.  The rules for using metformin are as follows: Kidney function must be normal.  Usually this is measured with a creatinine level which should be less than 1.4 if you are female and less than 1.5 if you are male, to start on metformin. If you have congestive heart failure, liver damage, alcoholism or severe chronic lung disease you shouldn’t take metformin.  Metformin doesn’t hurt the kidneys, liver, or heart, but if these organs are already damaged, metformin can build up in the system and cause a bad reaction.
     Tests of kidney and liver function should be done every 6 months while on metformin and the drug stopped if they become abnormal.  Metformin should also be stopped if a dye study is required (an x-ray where dye is injected into the vein) or hospitalization occurs. 
    Metformin is usually given once or twice a day.  It should be taken with a meal (or just after a meal) in order to lower the risk for gastrointestinal side effects.

Do and Don’ts For Taking Metformin
Do                                                                                          
  • Take it with food
  • Increase the dose slowly
  • Tell your doctor if you have diarrhea or nausea 
  • Stop taking it if you are having a test where dye will be injected into your veins 
  • Make sure you have regular tests of your kidneys and liver
Don’t 
  • Take it if your kidneys aren’t normal
  • Take it if your liver isn’t nearly normal
  • Take it if you have congestive heart failure
  • Take it if you drink more than 2 glasses of alcohol per day
  • Take it if you are sick in the hospital
  • Be needlessly afraid. This is a good drug.
In most cases the initial treatment for type 2 diabetes is diet and exercise to lower insulin resistance and metformin, an oral medication.

2.  Sulfonylurea Agents (glyburide, Micronase, Glynase, glipizide, Glucotrol, glimepiride, Amaryl)    
     These are the first oral agents used for treating type 2 diabetes and have been in use since the 1940’s.  There are many drugs in this class—glimepiride, glyburide, and glipizide are among them.  This medication can lower blood sugar levels rapidly, and increases the amount of insulin made by the body.  Because of this they are good drugs for lowering blood sugar levels.  However, the down side to increasing insulin levels all day long is that blood sugar levels can fall too low, especially true if one is trying to cut back on calories and increase exercise.  These drugs cause weight gain, in part because of the low blood sugar levels but also because people may feel hungrier on these agents.     
    There are a few contraindications to taking these drugs.  An allergy to sulfa drugs may lead to an allergy with these agents, and if the allergy to sulfa drugs was severe these drugs shouldn’t be used.  Patients who have reduced kidney or liver function or who are elderly should be started on the lowest possible dose of these drugs to prevent low blood sugar reactions.  In general these drugs are given once or twice daily, in the morning and/or evening.  Except with glipizide, timing relative to meals is not important. 
Do’s and Don’ts for Taking Sulfonylurea Agents 
Do                           
  • Take once or twice a day, as recommended by your doctor              
  • Eat less and exercise more to avoid weight gain but follow instructions provided by your health care team
  • Call your doctor if low blood sugar reactions occur
Don’t
  • Take them if you have a severe allergy to sulfa drugs
  • Skip meals and snacks because low blood sugar reactions can occur 

3.  Meglitinides (Prandin and Starlix) 
    These drugs are similar to sulfonylurea agents in terms of how they act (to increase insulin levels) but have a shorter half life (meaning their activity in the body is gone more rapidly than the sulfonylurea agents).  Because of their shorter half life they need to be taken before every meal, three times per day.  The brand names of these drugs are Prandin and Starlix.  They can cause low blood sugar reactions and weight gain, because they increase insulin levels.  However, if a meal is not eaten then the drug shouldn’t be taken, which allows a bit more flexibility in terms of lifestyle.
4.  Glitazones (pioglitazone, Actos, rosiglitazone, Avandia) 
    These drugs (and their related drug, Rezulin) may have received more media coverage than any other antidiabetes medication.  This does not, however, mean they are bad drugs.  When this class of medication first came on the market, in 1997, we had only metformin, sulfonylurea agents, and insulin for treating type 2 diabetes.  The glitazones, which reduce insulin resistance and lower blood sugar levels without causing hypoglycemia, helped many lower their blood sugar levels and achieve better blood sugar levels than they ever had before.  But, like all drugs, they have side effects, which are important to know about and monitor for.
Glitazones are a bit like “exercise in a pill,” reducing insulin resistance and decreasing insulin levels.  Because of their effect on insulin resistance, studies have shown that these drugs help prevent diabetes and might prevent the progression of beta-cell failure seen in most people with type 2 diabetes.  Although they do not seem to be able to restore the body’s insulin secreting cells back to normal, at least they help slow the loss of these cells.  This does not happen with any of the other drugs we use for treating diabetes (although some, such as Byetta, have not been around for long enough to know).  Therefore, this is an important benefit of these drugs.
Recently concern has arisen about Avandia increasing the risk for heart attack and stroke.  Although Avandia and Actos are similar in some ways, they are different in others.  In this regard, Actos does not seem to carry the risk of increasing heart attack and stroke and may even reduce the risk.  Therefore, Actos seems to be the safer drug although the real risk of Avandia is unclear.  The FDA added a black box (serious) warning to Avandia stating that it might increase the risk of heart attack and stroke (macrovascular events).  This warning was not added to Actos. 
     Both Actos and Avandia have long been known to cause a similar problem with the heart called congestive heart failure.  This happens, it is believed, because these drugs increase the fluid (water) in the body and in people whose heart can’t pump the extra fluid around their body effectively enough, it backs up into the lungs.  This is congestive heart failure.  It is relatively easy to treat; requiring medications to rid the body of the extra fluid, but is a serious problem.  Neither Actos nor Avandia increase the risk of dying due to this side effect, but it must be monitored.  The FDA has required that a black box warning for congestive heart failure be attached to both Actos and Avandia, but this concern is not a new one.
    To guard against serious side effects from the glitazones, the following rules should be observed.  First, do not use them if you have congestive heart failure.  Second, don’t use them if you have liver problems (except for fatty liver, a condition associated with type 2 diabetes that improves with glitazones).  Make sure your doctor tests your liver function before starting one of these drugs.  Third, although a little bit of swelling in the ankles and feet (known as edema) often happens with glitazones (because they increase the amount of fluid in the body), a lot of swelling in the ankles is something to notify your health care team about.  Additionally, feeling short of breath with exercise or needing to be propped up with pillows at night to breath can be signs of congestive heart failure and should be reported to your health care provider immediately. 
    The glitazones can cause weight gain, because they make the body use insulin more efficiently (as it should) and insulin helps with the storage of fat.  And the increase in fluid in the body also can add a few pounds.  To counter this effect, it is important to reduce the number of calories eaten every day and also to reduce other drugs that can cause weight gain (such as sulfonylurea agents and insulin).  The reduction in medications, however, should be done in conjunction with your health care team.  Additionally, starting with a low dose (for example, Actos 15 mg per day) and increasing to 30 mg per day after a month, may help reduce the weight gain and risk for side effects.  It takes up to 12 weeks to see the maximal effect of this drug, and often the maximal dose (45 mg) is not required to lower blood sugar levels into the normal range.
    Actos is given once a day.  Avandia is given once or twice a day.  It does not matter whether or not it is taken with meals.
Do’s and Don’ts of Glitazones

Do                           
  • Take them at any time of day you’ll remember, with or without food            
  • Eat less and exercise more to avoid weight gain                       
  • Increase the dose gradually                   
  • Call your doctor if you develop swelling in your legs or shortness of breath
Don’t
  • Take them if your liver is not normal
  • Take them if you have congestive heart failure
  • Take them if you have swelling in your legs
  • Expect a rapid fall in your blood sugars

5.  Alpha-glucosidase Inhibitors (Precose and Glyset) 
    These drugs work in the gut to lower the amount of carbohydrate consumed after a meal.  This reduces blood sugar levels after eating.  In theory these drugs seem as though they would be very helpful, but they only lower blood sugar levels a small amount compared with other antidiabetes drugs.  They also cause a side effect that most people dislike, which is flatulence.  What happens is that all of the undigested carbohydrate goes through the gut and when it reaches the colon the bacteria that live there ferment it.  Fermentation causes gas, and this gas can be quite disturbing to patients taking the drug.  Interestingly, although not used much in the United States, in places where the carbohydrate content of the diet is high, such as in Asia, these drugs are much more commonly used.  
    To take these drugs, check kidney function and be sure that creatinine level is less than 2 mg/dl, and make sure liver function is normal.  Do not use these drugs if there is a history of bowel obstruction or other gastrointestinal issues.  Start by taking a very small dose, usually 25 mg, before each meal and gradually increase the dose.  Do not take the drug if you don’t eat. 

6.    DPP-IV Inhibitors (sitagliptin, Januvia) 
   This is the newest type of drug for treating diabetes available on the market.  DPP-IV inhibitors work by inhibiting the enzyme known as DPP-IV.  This enzyme breaks down a variety of substances, one of them being GLP-1.  When DPP-IV is inhibited, GLP-1 levels increase.  GLP-1 is a hormone made in the L-cells of the intestine that helps the body’s insulin producing cells (the beta-cells) work better to produce insulin more normally.  It also reduces glucagon levels (glucagon is a hormone that raises blood sugar levels but in people with type 2 diabetes it is paradoxically increased after eating).   
    Januvia, the only drug in this class on the market in the United States, lowers blood glucose levels without causing weight gain or hypoglycemia.  It can be used in people with contraindications to other drugs (such as kidney disease and congestive heart failure).  Side effects are generally rare, but include skin rash and a stuffy nose.  Because these are new drugs on the market they are expensive and the full side effect profile is not known.
Januvia is a once daily pill, taken regardless of whether or not food has been taken.

7.    Incretin Mimetics (exenatide, Byetta)
      Byetta is another drug that impacts the GLP-1 system, but does so differently from Januvia.  It was initially derived from the saliva of the gila monster and it mimics the effect of GLP-1 on the GLP-1 receptors in the body.  It has a fairly powerful effect on these receptors, causing an increase in healthy insulin secretion, a decrease in after eating glucagon levels, a slowed emptying of the stomach (which is accelerated in patients with type 2 diabetes), and acts on the brain to promote a feeling of fullness or satiety.  Therefore, with Byetta there is an improvement in blood sugar levels, weight loss, and no hypoglycemia. 
     Byetta, unlike the other drugs mentioned, is an injection that is taken twice daily, before breakfast and dinner.  It comes in an easy to use prefilled pen and the needles are very tiny.  The most common side effect is nausea, so the drug is started at a lower dose (5 mcg) and increased to 10 mcg after one month.  Many patients will have a little nausea for the first few days, which goes away on its own.  There is the rare patient who may have severe nausea and/or vomiting and must stop taking the drug.  Byetta should not be used in patients with severe kidney damage or in people who have problems with their stomach and/or intestinal track.

Do’s and Don’ts of Taking Byetta

Do                           
  • Take within 60 minutes of a meal            
  • Start at a low dose and increase in 1 month       
  • Report any serious nausea, vomiting, or abdominal pain to your health care team       
  • Expect to feel fuller and eat less, which can lead to weight loss                
  • Follow your diet and exercise plan to further enhance the benefits of this drug
Don’t
  • Take if your kidneys are seriously damaged
  • Take if you have had serious problems with your stomach/intestinal track
  • Worry that it is an injection—the needle is small and easy to use
  • Be surprised if there is mild nausea at first; it usually goes away after a few days 
For many the use of insulin is simply another step in the treatment of their diabetes.

8.    Insulin (many types)
      Patients often fear the use of insulin, but for many it is simply another step in the treatment of their diabetes.  There are many different types of insulin, and the type of insulin basically means how long it will last in the body.  Some are short or rapid acting insulins, to give before meals (Humalog, Novolog, Aphidra) and others are longer acting (NPH, Levemir, Lantus).  Most are available in easy to use insulin pens.
When a patient with type 2 diabetes starts on insulin, the oral medication is generally continued and long acting insulin is added at bedtime.  This lowers the fasting blood sugar level so that the pills can work in the daytime.  If this doesn’t work, then insulin needs to be given before every meal to mimic the action of a nondiabetic pancreas. 
     The side effects to insulin include having a low blood sugar reaction and weight gain.  Local injection site allergies can also occur.
How should treatment be monitored? 
    When starting on a medication it is important to know the following: What is the reason for the medication?  How should the effect of the drug be measured?  And what should be monitored to be sure this drug is safe?  When it comes to treating diabetes it is really easy to know whether or not a medication should be added or increased.  The information comes from laboratory tests and home glucose monitoring.  If the before-eating blood sugar levels are 90 –130 most of the time and the two-hour after eating blood sugar levels are less than 160 most of the time, it is likely that the medication is working.  This can be confirmed with a measurement of an HbA1c to get a sense of overall control.  The HbA1c should be less than 7% and ideally within the normal range (4-6%).  
     Drugs should be adjusted to avoid too many low blood sugar reactions, although mild reactions, especially after missing a meal or a snack, may occur occasionally.  The symptoms (hungry, shaky, sweaty) go away as soon as sugar is consumed.  Metformin, glitazones, sitagliptin, exenatide, and alpha-glucosidase inhibitors will never cause the blood sugar to go too low on their own, but can cause low blood sugar reactions when taken along with drugs such as sulfonylurea agents and insulin.

    Generally people with diabetes require the gradual addition of one pill to the next, making sure the blood sugar stays at target.  Often people will need three or more medications to control their blood sugar levels, in addition to the medication needed to control cholesterol levels and blood pressure.  Although this may seem like a lot of medication to take, the risks associated with not treating the disease far outweigh the risks of taking the medications.  And the treatment of type 2 diabetes is always enhanced by a healthy diet and exercise, so efforts in this area should always continue.
Combination Pills    
     Many drugs come as combination pills, which are pills that contain two different types of drug in one tablet, in a fixed combination of the two.  When adjusting medications it is often easier to adjust each component independently, so that side effects of one can be separated from side effects of another.  Once a successful dose of two drugs is reached that matches an available combination pill, it may make it easier to take the combination pill.


What are the complications of diabetes? 

     In general, there are two types of diabetes complications.  These are considered the microvascular (small blood vessel) complications and the macrovascular (large blood vessel) complications.  The microvascular complications are the complications that involve the eyes, the kidneys, and the nerves.  The macrovascular complications are the complications that involve the blood vessels.  These complications include coronary artery disease, stroke, peripheral vascular disease, and heart attack.  There is a different approach used for preventing each type of complication, although often strategies to avoid the microvascular complications will help the macrovascular complications, and vice-versa. 
     The microvascular complications appear to be almost entirely caused by high levels of blood sugar.  It is not known exactly how it is that high levels of blood sugar cause these complications, although it is clear that high blood sugar levels cause damage to the fragile lining of blood vessels and other tissues that over time can result in their malfunction.  The single best way to avoid the microvascular complications of diabetes is to maintain blood glucose levels as close to normal as possible.  If this happens, the risk of these complications is markedly reduced.   
    Diabetic retinopathy means damage to the back of the eye, the retina, which is where vision occurs.  The blood vessels in the back of the eye are extremely sensitive to the effects of glucose.  In ways that are not currently understood, high levels of glucose make these blood vessels leak fluid into the back of the eye.  When this happens, the delicate nerve cells that are involved in the transmission of vision can be damaged, and ultimately destroyed.  The amazing thing about diabetic retinopathy is that you can have terrible damage to the back of the eye, but if it does not involve the center of vision, there may be no visual loss until one catastrophic day when vision is impaired.  At that point, it may be too late to do much preventive care.  Therefore, long before there is any change in vision, it is important to see an eye doctor.  The American Diabetes Association recommends going to the eye doctor for a dilated eye examination at least once a year.  In this way early, asymptomatic changes to the back of the eye can be identified and treated to prevent progression to visual loss and blindness. 
     Kidney damage is equally insidious.  Patients with diabetes often have no idea they have any damage to their kidneys until their kidneys are seriously injured.  The good news is that there is a warning signal, the leakage of small amounts of protein in the urine that happens early.  If this is detected, there are medications that can be used to help prevent kidneys from failing.  Therefore, patients with diabetes should have a yearly urine test for microalbuminuria (early kidney damage).  Unfortunately, many physicians do not know about doing this test.  They tend to do what is called a urine test for protein, but this urine test for protein is a later sign of kidney damage. 
    Diabetic neuropathy, or damage to the nerves, is a process where there are no early warning signs.  The most common form of diabetic neuropathy is numbness, tingling, or pain in the feet on both sides.  Diabetic nerve damage, at least of this sort, tends to be in both feet.  Back and disk injuries are often on just one side, which helps differentiate these from diabetic damage.  There are many other forms of diabetic neuropathy; it can involve the stomach, the intestines, the heart, sexual function, and the movement and function of individual groups of nerves.  Once these events occur, they either resolve by themselves, or are treated with pain medications.  Some of the most miserable and inconsolable patients are those with painful peripheral diabetic neuropathy.  The best way to prevent neuropathy from happening is to keep blood sugar levels as close to normal as possible.  If this is done, then the complication does not occur.  Many researchers are working on ways to help reverse and/or more effectively treat neuropathy; but thus far, the best approach is prevention.
The macrovascular complications are generally best treated by traditional means for lowering risk of heart disease and stroke.  However, having diabetes increases the risk for macrovascular complications by two- to four-fold over that which is seen in the general population and although not proven, it is believed that there is an influence of high blood sugar levels on these complications as well.  In general, most patients with elevated cholesterol and triglyceride levels need to be on treatment to lower these levels, and they also need to be on treatment to lower their blood pressure.  The best treatment for an elevated cholesterol level tends to be a statin drug (such as lovastation, pravastatin, simvastatin, atorvastatin, or rosuvastatin) and most people with type 2 diabetes above 40 years of age should probably be on a statin.  Similarly, drugs known as ACE-inhibitors (and the related drugs known as ARBs) help protect the heart as well as lower blood pressure and slow kidney damage in patients with type 2 diabetes.  Most people with type 2 diabetes above the age of 55 years and anybody with type 2 diabetes and high blood pressure or early kidney damage below age 55 should be on one (or both) of these agents.   
     Finally, most patients with diabetes, particularly those over the age of 40, should take an aspirin a day (81 to 325 mg) to help lower the risk of heart attack and stroke.

Conclusion

     Type 2 diabetes is an increasingly common disease, but not an untreatable one.  Weight loss and physical activity can help prevent diabetes in high-risk individuals.  If diabetes (elevated blood sugar levels) develops, the disease can be controlled with a combination of diet, exercise, oral, and possibly injectible medications.  The key is to add new treatments as soon as the blood sugar levels become elevated much above target, which means above an HbA1c level of 7%.  All too often there is a lag between rising blood sugar levels and adding new treatments, and this lag can increase the risk for complications developing. 
    People with diabetes must be their own advocates.  It is up to each individual to track their numbers, to make sure that quarterly and annual tests are done, and to ask questions in order to fully understand their own treatment plan.  Treating diabetes is in essence about prevention - the blindness that doesn’t happen, or the leg that isn’t amputated.  Preventive health care isn’t exciting; there are no magical cures, no great drama to it.  But it is the practice of good health over time.  For people with a chronic disease such as diabetes, spending the time and effort to pay attention to the details of their health care can make a huge difference in both the quantity and quality of life.  Treating diabetes is not just about treating blood sugar levels.  It is every bit as important to treat the abnormal cholesterol levels, the elevated blood pressure, and the high risk for heart attack and stroke.  This may seem like a lot to do and require a handful of pills everyday, but at least there are options.  People with type 2 diabetes can live long, healthy, complication free lives.  It just takes a little extra effort.
Finger stick blood sugar testing is usually more frequent when starting or adjusting a new medication.

Appendix #1 - Tests for monitoring type 2 diabetes


     The best way to keep track of the laboratory tests is to make a chart (or use a preprinted form) and enter the date each test was drawn and what the results were.  Many doctors now keep electronic medical records.  It is very important to notice whether the tests are worsening.  Early damage can often be treated, but late damage is generally irreversible.
 
  • Finger stick blood sugars:  blood sugar testing at home should be based on the schedule given to you by your health care team.  Usually testing is more frequent when starting or adjusting a new medication.  Often it is helpful to test in the morning, before eating (called a fasting blood sugar level which should be 90 – 130 mg/dl) and 2 hours after a meal (ideally this should be <160 mg/dl).  Once on a stable dose of medication testing may only be recommended once or twice a week.  Patients taking insulin may need to test 4 times a day, before meals and at bedtime, based on the insulin regimen.
  •  HbA1c levels:  The HbA1c should be measured every 3 months if for people on insulin or in poor control.  People on oral medications or diet and exercise, and who are at target (below 7%, although ideally in the normal range of 4 – 6%) may only need to have this measured every 6 months.  This test does not require fasting.
  • Cholesterol Panel:  The cholesterol panel is made up of several very important parts.  The total cholesterol level is the first number and should be less than 200.  The LDL (or bad) cholesterol should be less than 100.  The most important number to remember is to be sure that the LDL is less than 100.  The HDL (or good) cholesterol should be more than 40 if male and more than 50 if female.  Finally, the triglyceride level should be less than 150.  This lipid panel test should be done every year if all of the targets above are met, and more often as there are adjustments in diet, exercise and medication.  This test should ideally be done fasting, which means nothing but water for the past 10 – 12 hours.  
  • Kidney Function Tests:  Two tests for kidney function should be done at least every year.  One is a blood test and one is a urine test.  Neither need to be done while fasting.  The blood test is called a creatinine level.  This test shows how effectively the kidneys are eliminating waste products from the blood.  If this level starts to increase AT ALL above normal it could mean that there has been some possibly permanent damage done to the kidneys.  This is very important to know, because it is important to prevent further damage from happening to the kidneys so they don’t stop functioning. The other test is a spot urine sample.  This means that urine is collected into a cup and sent for analysis.  This test is called the albumin to creatinine ratio (A/C ratio or microalbumin) and measures whether or not protein is leaking from the kidneys.  Protein leaking out of the kidneys is the first sign of diabetic kidney damage.  If this happens medications such as ACE-inhibitors and/or ARB’s should be started.
  • Foot Examination
    At least every year a comprehensive foot examination should be performed, where the health care provider checks pulses, sensation, reflexes, and overall health of the feet.  At each visit to the health care provider’s office shoes and socks should be removed so that the feet can be inspected for abnormalities.  People with diabetes should check their feet daily at home and the health care provider contacted immediately if unusual redness, ulcers, or nonhealing sores develop.
  • Dilated Eye Examination
     This should occur yearly, by an eye care specialist knowledgeable in the diagnosis and treatment of diabetic eye disease.
     
Appendix #2 Treating and Preventing Type 2 Diabetes:  Diet and Exercise 
     There are eleven basic points that should be followed to create a healthy lifestyle.  These were formulated by an expert diabetes dietitian, Meg Werner Moreta, RD, CDE.
  1.  Understand the three basic food groups and how to balance meals. 
  2.  Engage in daily physical activity. 
  3.  Learn about portion sizes.
  4.  Use the plate method. 
  5.  Keep food records.  
  6.  Clean up your environment.
  7.  Learn to know your hunger.
  8.  Eat and drink often, so you never feel too hungry.
  9.  Don’t be a slave to the scale.
10. Plan your meals for a week. 
11. Eat your fruits and vegetables.
1.  Understand the three basic food groups and how to balance meals.  
    The three food groups are carbohydrate, fat, and protein. All three are necessary for survival. Carbohydrate is the primary source of sugar in the blood.  It is the only fuel the brain can use.  Additionally carbohydrates fuel muscles and other organs.  Carbohydrate comes in many forms.  The simplest and obvious forms are table sugar and candy.  More complex forms are the starches such as breads and cereals, pasta, rice and potatoes.  Fruits, vegetables, milk and yogurt are mostly carbohydrates as well, although dairy products contain a mixture of protein and fat.  
     All of these carbohydrates are broken down in the intestines and enter the blood stream as a form of simple sugar.  The more fiber a food has, such as uncooked fruits and vegetables, the slower the sugar is absorbed.  Your body stores sugar mainly in the muscle and liver.  It also collects in fat (but in a different form).  Because sugar is vital to the functioning of the body, sugar created from protein carbohydrate isn’t eaten.  If you don’t eat enough protein or carbohydrate to keep your glucose levels high, your body will break down muscle to make glucose—muscle is a storage form of protein.  Fat can never be reconverted to sugar. 
    Protein is a building block for muscles, skin, and hair, and basically all of the major organs.  Protein comes from animal sources (beef, lamb, poultry, fish, and pork), vegetable sources (soybeans, lentils, split peas, grains), nuts (the best are walnuts, almonds, peanuts), dairy (milk, cheese yogurt), and eggs.  Depending on the source of the protein it is accompanied by more or less saturated fat and cholesterol.  Fatty meats taste succulent and good (like a well-marbled steak) but this is probably the worst form of protein to eat.  Poultry, fish, vegetable, nut, low fat dairy, and eggs without the yolk are all healthier sources of protein for people with diabetes or prediabetes who are at increased risk for heart disease. 
    Fat is everywhere.  It lines the nerves, it is needed to make normal hormones and it is a way to store energy.  Muscles use free fatty acids (from fat) for fuel during exercise.  There are several problems with eating fat—it is very high in calories (9 calories per gram compared to 4 calories per gram of protein and carbohydrate) and it tastes good, especially when it is found in cookies, cakes, and ice cream.  The two types of fat in food are unsaturated and saturated.  The two unsaturated fats are called monounsaturated and polyunsaturated fats. These help lower cholesterol levels.  Monounsaturated fats are found in olive, canola, almond, and peanut oils and avocados.  Most vegetable oils are high in polyunsaturated fats such as corn, safflower, sunflower, soybean, and cottonseed.  Saturated fats, which are found mainly in animal products such as meats, whole milk, cheese, butter, lard, shortening, and tropical oils, should be limited in the diet.   Trans-fatty acids are also something to watch out for.  They are known to be chemically altered making them hydrogenated, creating a more solid fat, but also a more dangerous fat which can also lead to heart disease.  
    Meals should contain approximately 40% carbohydrate, 30% high quality protein, and 30% healthy fat (avoiding saturated and transfat).  Foods lower in glycemic index, with more fiber and a slower absorption, should be consumed frequently.  Fat also slow the absorption of food and by eating adequate amounts from all three groups the body remains well fueled, and feels sated, which is helpful when attempting to lose weight.

Choose an enjoyable activity—it can be aquacise, or any activity that you will do with a group or by yourself.
2.  Engage in habitual physical activity. 
     The goal for exercise is to exercise 45 to 60 minutes five days per week, although any exercise can help.  An exercise program should not be started too quickly.  First, it is important to be tested for any underlying heart disease or diabetic complications that need to be treated before exercise is started.  Therefore, a pre-exercise evaluation by a physician is required for anyone with type 2 diabetes.  Once that is accomplished, exercise should be gradually integrated into existing patterns of activity.  Many people make the mistake of starting an exercise program too fast. They jump into some activity, get tired – then sore, and decide that it was a bad idea. A better way is to start with 5-10 minutes per day and increase by 5 to 10 minutes each week to 45 minutes, five times per week.  Exercise doesn’t have to be done continuously—exercising in two shorter blocks of time is just as good as exercising in one longer block.  Choose an enjoyable activity—walking, bicycling, swimming, working-out on a treadmill or on an exercise bicycle.  Some people benefit from working out with a partner or in a class, while others prefer to exercise alone.
  3.  Learn about portion sizes.
     Work with your dietitian or other nutrition expert to find out how much to eat at each meal or snack.  Read food labels to determine what an actual portion size is meant to be.  Often it is necessary to measure food quantities at first in order to visualize how much to eat.  By reducing portion sizes it is often simple to lose weight, and allow for diversity of food choices.
4.  Use the plate method. 
     After learning portion sizes, assemble a healthy meal in your mind each time you eat.  To do this visualize a 9” plate.  Half of the plate should be vegetables and/or salad.  The other half is divided in half again, 1 part is protein (3-4 ounces) and the other part is one cup of carbohydrates (the less refined the better).  A dessert of fresh berries or other fruit and be added afterwards. 
5.  Keep food records. 
    The conscious act of writing down everything that is eaten is surprisingly effective.  Food should be logged within 15 minutes of eating.  This helps reveal areas in which changes need to be made, as well as to reinforce healthy behaviors. 
6.  Clean up the food environment. 
If food is not easily available it is less likely to be eaten.  Don’t keep foods at home that are unhealthy and tempting.  Throw out all the junk food.  If food is purchased for a party or friends, throwing it out is better than eating it.  Have healthier foods on hand for snacks and meals—it facilitates making healthy food choices.
7.  Learn to characterize hunger.
     Understanding the difference between physical and emotional hunger.  Learn to determine if hunger is because of not having eaten recently or because of an emotional need to eat.  For example, late night snacking usually fills an emotional need.  It is important both to identify times of vulnerability to emotional eating and develop strategies, in advance, to deal with it.  Walking on a treadmill or working out on an exercycle in the evening instead of eating is often helpful for bringing down morning blood sugar levels.  If the desire to eat is overwhelming, have food prepared that is low in calories and high in fiber (such as raw vegetables or fruit) or takes time to eat (such as raw peanuts in the shell).  And even if there are times when unhealthy foods are consumed, it is important to be self-forgiving and start the next day with a new resolve to eat more wisely.

8.  Eat and drink often, so you never feel too hungry. 
    Eat three meals and two snacks each day.  The best meals are combinations of fat, carbohydrate, and protein.  Ideally, limit the carbohydrate intake to less than 40% of total calories.  This generally means eating 60 grams of carbohydrate or less per meal.  Use food labels and buy a carbohydrate-counting guide.  Avoid processed carbohydrate, eating more fiber instead.  For instance brown rice is better than white rice.  Whole grain bread is better than white bread.  Additionally, the more cooked or mashed a food is, the more quickly the sugar is absorbed.  For instance a whole, fresh apple with the skin is better than a baked apple, which is better than applesauce.  Apple juice is even worse, since it is absorbed very quickly into the blood stream and a large amount can be consumed quickly.
9.  Don’t be a slave to the scale. 
    Weigh yourself once a week.  Establish a routine—time of day, clothes you are wearing (or not wearing).  Be sure your scale is on a flat surface and calibrates to zero.  If you have had a week of eating wisely don’t get discouraged if you haven’t lost any weight.  Weight loss is slow and your goal is to establish new habits that allow you to gradually lose weight and be healthier. It is not a race to have some sudden, extraordinary weight loss.  It took a while to gain the weight so it will take a while to lose it.

10.  Plan your meals for a week. 
    Here are some time saving ideas that can allow you to enjoy your other activities:
  • Limit grocery shopping to once a week.  The more often you go to the store, the more tempted you are to buy   extra items you just do not need. 
  • Clean and chop up your fruits and vegetables in advance, for easy access.  Have them in sealed plastic bags or containers in your refrigerator.  That way they will be staring you in the face when you’re rummaging around looking for food.  And once you’ve spent the time chopping them up, you may be motivated not to let them go to waste and will eat them instead of less healthy choices.
  • Buy skinned and boneless chicken for easy preparation. 
  • Keep staples in the house to make a quick healthy meal.  If you dislike cooking, you can always double the recipe and freeze half for a later time. 
  • Learn to read labels.
11.  Eat your fruits and vegetables.
    Two servings of fruit and three of vegetables are recommended everyday.  This may be impossible to achieve, but a consciousness about increasing intake of fresh produce will help. For example, eat raw carrots and celery as appetizers at a dinner party instead of eating the little quiches and puff pastries.  When ordering at a restaurant, get a side of fresh fruit or a small salad (light dressing) instead of fries.  This can save several hundred calories.   

Two servings of fruit and three of vegetables are recommended everyday.

References

  1. ADA Clinical Practice Guidelines (released in January of each year): http://care.diabetesjournals.org/content/vol31/Supplement_1/
  2. Becker, G.  “The First Year Type 2 Diabetes:  An Essential Guide for the Newly Diagnosed.”  Marlow and Company, New York City, NY, 2001. 
     
  3. Beaser RS, Campbell AP.  “The Joslin Diabetes Manual, 2nd Edition:  A Program for Managing Your Treatment”, Fireside, New York City, NY, 2005.
     
  4. Clegg, H.  “Trim and Terrific Diabetic Cooking.”  American Diabetes Association Press, Alexandria, VA, 2007.
     
  5. Edelman S.  “Taking Control of Your Diabetes, 3rd Edition.”  Professional Communications, 2007.
     
  6. Holzmeister LA.  “Diabetes Carbohydrate and Fat Gram Guide, 3rd Edition.”  American Diabetes Association Press, Alexandria, VA, 2006.
     
  7. Peters AL.  “Conquering Diabetes.” Hudson Street Press/Penguin Publications, New York City, New York, 2005. http://www.conqueringdiabetes.com/ 
  8. Rubin AL.  “Diabetes for Dummies.”  For Dummies, Wiley Publishing, Hoboken, New Jersey, 2004.


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