Before the discovery of insulin in 1921, treatment of type 2 diabetes consisted of a very low calorie diet–about 450 calories a day. It was called a starvation diet, and it ultimately did lead to starvation and death.
Today, most Americans with type 2 diabetes are overweight, and they benefit from losing weight–although not with a starvation diet. And there are other treatments now available that may or may not involve injection of insulin.
Insulin is essential for the metabolism of carbohydrates, allowing blood sugar to enter cells as a source of energy. Type 1 diabetics, who are unable to produce insulin, die quickly without an outside source. With type 2 diabetes, the body is able to produce insulin, but not in sufficient quantities, or the body resists the effects of insulin.
With either disease, cells are unable to get the energy they need and excess blood sugar circulates through the body, leading to serious complications involving blood vessels, nerves, bones and muscles.
At one time, type 1 was known as juvenile diabetes, and type 2, adult onset diabetes. Today, the incidence of type 2 diabetes among children and adolescents is increasing rapidly probably because of the rise of childhood obesity. Causes are not fully known, but the disease is most common among persons who have excess weight, are physically inactive and tend to have fat stored primarily in the abdomen rather than the hips and thighs. Hispanics, Native Americans, African Americans and Asian Americans have a higher risk than whites when they eat a typical American diet that is high in saturated fat and sugar.
Often Goes Undetected
The disorder often develops gradually and may go unnoticed for months or even years. In the later stages, symptoms include a cycle of increased thirst and urination, intense hunger and weight loss–despite eating more food than usual. Other signs include fatigue, slow healing sores, blurred vision, erectile dysfunction and areas of darkened skin in the folds and creases of the body. Type 2 diabetes may also show up when doctors notice a high blood sugar level on a blood test.
For a type 2 patient who is overweight, the first order of business is weight loss. As opposed to a starvation diet, this is best accomplished by a healthy eating plan that can be followed indefinitely. For extreme cases (a body mass index of 35 or greater), bariatric surgery may be the best way of achieving the weight loss that’s needed.
Contrary to belief, there is no special diabetes diet, although it should be well balanced and low in saturated fat, sugar and calories.
For good health, it’s important to focus on fruits, vegetables and whole grains. High fiber foods are generally low in glycemic index. They take longer to digest and are less likely to cause a spike in blood sugar.
Regular physical activity is the other part of the equation. With or without weight loss, exercise offers the best protection from the effects and complications of diabetes. It consumes calories, lowers blood sugar, improves blood flow and blood pressure and makes muscle cells more receptive to the effects of insulin.
For some patients, particularly those who have been diagnosed early in the course of the disease, these healthy lifestyle changes may be all that’s required to bring blood sugar under control and manage type 2 diabetes. To head off diabetic complications, it’s also necessary to monitor blood pressure and cholesterol and keep them under control. If you smoke, stop.
If lifestyle changes are not enough to keep blood sugar under control, medications may be needed.
The drug most commonly prescribed is metformin (Glucophage) which inhibits the release of glucose from the liver and improves the sensitivity of cells to the action of insulin. It can also cause slight reductions in weight and LDL cholesterol. Metformin can cause gas and nausea and, occasionally. lower blood sugar more than desired.
Other commonly prescribed drugs are sulfonylureas (Glucotrol, DiaBeta, Micronase, Glynase PresTab, Amaryl). They work by stimulating the pancreas to release more insulin.
And there are many others--Actos, Avandia, Precose, Glyset, Prandin, Starlix, Januvia, Nesina, Onglyza, Tradjenta, Farxiga, Invokana, Glucovance, Metaglip, Avandamet, Kazano, Oseri. They work in various ways with various side effect profiles.
For first-line treatment, a 2012 study found metformin associated with fewer heart attacks, strokes and deaths than sulfonylureas. In many cases, however, one oral medication is not sufficient. One or more other medications from various classes may be prescribed in order to control blood sugar in several ways.
Studies have found insulin to be very effective in controlling blood sugar and reducing the risk of complications such as kidney or eye disease. As a result, it is often prescribed as second-line (or even first-line) treatment, even if the pancreas is still capable of producing some insulin.
About 50 percent of type 2 diabetics experience what is called the “dawn phenomenon.” Their blood sugar rises at the end of the night, primarily because of a normal fluctuation of hormones and the increased production of growth hormone between 4:30 and 6:00 a.m. This is the body’s way of providing a burst of energy to start the day, but these hormones also raise blood sugar. When insulin production is curtailed because of diabetes, the result is a spike of blood sugar before breakfast and sometimes after breakfast as well.
It’s possible to deal with dawn phenomenon by
• eating dinner earlier in the evening,
• keeping the evening meal small or
• doing something active, such as going for a walk, after dinner.
In patients who are still unable to control the morning rise in blood sugar, some doctors recommend an early start to insulin therapy, since the dawn phenomenon is not well controlled by oral diabetes medications.
A recent study based on medical records of 42,000 type 2 diabetes patients in VA hospitals [Journal of the American Medical Association, June, 11, 2014] found that those taking a combination of metformin and insulin had a higher risk of heart disease and death than those taking a combination of metformin and sulfonylurea.
By definition, type 2 diabetes is non-insulin-dependent. Treatment depends on what best controls blood sugar and reduces the risk of complications.
REFERENCES:
Asres Berhan and Alex Barker, “Sodium glucose co-transport 2 inhibitors in the treatment of type 2 diabetes mellitus,” BMC Endocrine Disorders, 2013;13(58).
Terri D’Arrigo, “Rocky morni ng highs?” Diabetes Forecast, September, 2008.
Linda M. Delehanty, M.S., R.D., and David K. McCulloch, M.D., “Patient information: type 2 diabetes mellitus and diet (beyond the basics),” UpToDate.com, updated January 6, 2014.
“Diabetes and morning high blood sugar,” WebMD Medical Reference, reviewed by Ikimball Johnson, M.D., June 15, 2012.
“Diabetes, type 2 overview,” New York Times Health.
“Insulin use as a secondary treatment for type 2 diabetes linked to heart disease, death,” PR Newswire, June 10, 2014.
Mayo Clinic Staff, “Type 2 diabetes,” MayoClinic.com, January 25, 2013.
Lisa Nainggolan, “Dawn phenomenon affects half of type 2 diabetes patients,” Medscape Medical News, November 7, 2013.
Gregory A. Nichols, “Where is insulin’s place in the treatment of type 2 diabetes?” Medscape Diabetes; Endocrinology, May 15, 2013.
“Oral diabetes medications,” WebMD Medical Reference, reviewed by Michael Dansinger, M.D., June 4, 2013.
“Thirty years of research on the dawn phenomenon: lessons to optimize blood glucose control in diabetes,” Diabetes Care, December, 2013.
“Treatments for type 2 diabetes,” Patient.co.uk, last reviewed June 26, 2013.
Miriam E. Tucker, “Deaths higher when insulin is second-line treatment for type 2 diabetes,” Medscape Medical News, June 10, 2014.
“Type 2 diabetes overview,” WebMD Medical Reference, reviewed by Melinda Ratini, M.D., May 16, 2012.
Wenhui Wei, Ph.D., M.D., M.B.A., et al, “Real world insulin treatment persistence among patients with type 2 diabetes: measures, predictors and outcomes,” Endocrine Practice, 20 14;20(1):52-61.
08/25/2014
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