Type 2 Diabetes

Introduction

When the body does not produce enough insulin or does not use it properly, type 2 diabetes (or insulin resistance diabetes) develops. Type 2 diabetes is most often diagnosed in overweight adults over the age of 40 with a family history of diabetes. However, type 2 diabetes is becoming increasingly common in younger people, especially adolescents. Certain racial and ethnic groups, African-Americans, Asian-Americans, Latinos and Native Americans are more prone to developing diabetes in their lifetime. Often, type 2 symptoms develop gradually, so people may have the disease for months or even years before it is diagnosed. Most people who develop type 2 diabetes first exhibit signs of pre-diabetes, with blood glucose levels elevated but below the diabetes range.

Insulin is the gatekeeper of the body that assures that blood glucose, or blood sugar, is handled properly. When the response to insulin in the body is ineffective, glucose builds up in the blood and accumulates. As diabetes develops, other health problems, such as high blood pressure and high cholesterol are also likely to occur. Recent research on obesity in children also indicates there is an increased risk of hybrid or double diabetes. People with type 1 diabetes who become overweight and have high blood pressure are at risk of developing type 2 as well.

What Happens When You Have Diabetes?

With type 2 diabetes, a number of systems may be functioning poorly. It takes 5-10 years for type 2 diabetes to develop. It is a slow progression of the following issues:

1. Your pancreas, particularly the beta cells, is not able to make enough insulin to control blood glucose levels. Your fasting blood glucose slowly creeps up over the years (pre-diabetes) until the insulin can no longer keep the levels in check and diabetes is diagnosed.
2. Insulin resistance is also a factor; the body resists the normal functioning of the insulin because of chronic inflammation related to excess weight and inactivity. There then is an increased demand for more insulin since it is less effective. This is called impaired glucose tolerance.
3. Hepatic glucose output—the liver, with its storage bank of glucose, begins to release more glucose than it needs to. The result is fasting blood glucose rises.

With type 1 diabetes, there is an autoimmune disease action that destroys the beta cells of the pancreas. These cells make insulin, so that the body no longer has a mechanism to lower blood glucose effectively. People with type 1 diabetes must take exogenous insulin (from outside the body) to stay alive.

In order to stay healthy by managing your diabetes well, you have a number of tools to help. Diet, exercise and medications are your arsenal of control. But first, you need to know your numbers by testing your blood sugar.

Questions Newly Diagnosed Type 2 Diabetes Patients Might Ask

Why Me?

Genes and environment play a role in whether a person gets diabetes or not. Diabetes is not your fault. You have done nothing to cause it to happen; but what you can do now is learn how to take control of your health as best you can. At first, you may not really believe the diagnosis—and you may bargain with the doctor for a few more months so you can lose some weight or start exercising. Denial is common, but when reality sets in, you may feel the anger of being burdened with a disease. Anger may turn to feeling overwhelmed, or depressed. These feelings are natural coping mechanisms. You will come to a stable point, where you will be open to learning how to manage your health and diabetes. With knowledge and a positive attitude, you can lead a long, high-quality life.

There Must Be Some Mistake?

The lab results could be repeated, for your peace of mind. There are very definitive standards for the diagnosis; it is not a judgment call by your doctor. A fasting blood test of 126mg/dl or higher on two occasions, or a HgA1c test of 6.5 percent or higher.

What Went Wrong?

You may have certain higher risks for developing type 2 diabetes, some of which are genetic. If you have a parent or sibling with diabetes, are over the age of 45, and of African American, Asian, American Indian or Pacific Islander descent, you are at higher risk genetically. A female is at higher risk if she has had gestational diabetes or a baby over nine pounds at delivery. Additional risk factors are: being overweight, waist circumference higher than 35 inches in women, 40 inches in a man; high cholesterol; inactivity and if you smoke.

How is Type 2 Diabetes Treated?

By the time you are diagnosed with diabetes, your pancreas may have lost 50 percent or more of its insulin-producing capability. This may slowly decline overtime. Changes happen over time that determines your treatment plan. The four major changes are:

1. The body’s cells become resistant to the action of insulin
2. The pancreas first makes more insulin, but then less and less over time
3. Less insulin is released with meals and blood glucose remains high
4. The liver isn’t releasing glucose correctly

Your treatment plan is based on what changes are happening. You need to work on your food intake and physical activity, and may also need an oral medication. (The first medication that is typically prescribed is metformin for type 2 diabetes.) You may need additional oral medications as time passes. You may eventually need insulin injections or other injectable medications. You may have a different “mix” of diet and medications than another person with diabetes, this depends on your unique body. You may also need blood pressure medication and blood fat medication as part of your prevention plan.

What Can I Eat?

A nutrition plan for a person with diabetes is a healthy diet that has less than 50 percent of calories from carbohydrates. Carbohydrates should be selected from three major food groups:

1. Starches: preferably high fiber, grains, cereals, breads, pasta, rice, legumes, starchy vegetables like potatoes, and corn
2. Fruits
3. Low fat diary such as milk and yogurt

Added sugar is not recommended, but a person with diabetes who has well-controlled blood glucose can work small amounts of sugar into their diet. The major selection of food needs to be lean proteins and vegetables. The diet should be low in saturated fats, to prevent heart disease. Use of nuts, olive or canola oil, avocado, and fatty fish, are preferred. Eat three balanced meals a day at regular times, select the healthiest foods, and achieve or maintain your healthiest possible weight.

Do I Have to Give Up Sugar?

A simple directive you may have heard is: “people with diabetes can’t have sugar.” But this is not true! What is true is that many people do consume too much simple sugar in sodas, sweetened teas, fruit juice, other sweetened beverages, candy, and desserts. These foods do not have a regular place in a diabetes friendly diet, especially if this person needs to lose weight. Simple sugars raise blood glucose levels quickly and quite high, so are not helpful to controlling blood glucose. A small amount of sugar however, when eaten with a meal, will have a lesser impact on blood glucose. The total amount of carbohydrates eaten at a meal, and for the entire day, is more important in managing blood glucose levels.

Can Diabetes Be Cured?

To date, there is no cure for type 2 diabetes. However, when some people lose weight, exercise more often, and improve their nutrition, their blood glucose returns to normal without the need for medication. Some persons with diabetes who have had bariatric surgery eliminate their need for medication to manage blood glucose. However, even with lower blood glucose and diminished symptoms, the disease is still present.

Do I Have to Test My Blood?

Self-monitoring blood glucose is an important tool in controlling your diabetes. Your doctor will instruct you how often and when to test your blood glucose, as well as your target goals pre and post meals. You may need to improve your dietary or exercise habits to manage your numbers to an optimum range.

What Should My Blood Glucose Numbers be?

Your fasting blood glucose, as well as before a meal, should be 80mg/dl to 130mg/dl. Two hours after a meal, no higher than 180mg/dl. Before bed, blood glucose targets range from 110-150 mg/dl.

What is A1c?

A1c is short for Hemoglobin A1c which is a measure of blood glucose that reflects the average blood glucose for the past 60-90 days. A1c is also used to diagnose diabetes. An A1c of 6.5 percent or higher is an indication of diabetes.

Can I Just Take a Pill?

Oral medications are usually an important part of your treatment plan, but first lifestyle changes may be recommended. Weight loss if necessary, increased exercise and controlling carbohydrate intake are important ways to manage your diabetes without medication. These recommendations may be the first prescribed step by your doctor. Lifestyle changes may reduce the need for oral medication, and provide better blood glucose control with medication.

Do I Have to Take Insulin?

Diabetes is a progressive disease, and there may be a point in time when lifestyle changes and oral medications aren’t enough to give good glycemic control. Trust your doctor’s clinical judgment in making the right decision for your diabetes treatment. Many people who feared using insulin find they feel better and have better control over their disease. People with type 1 diabetes must take insulin because their pancreas produces none.

What Happens if My Blood Sugar Goes Too Low?

Low blood sugar or hypoglycemia is a blood glucose below 70 mg/dl which occurs when someone takes blood sugar lowering medicine and doesn’t eat, or exercises too much, or delays or skips a meal. Symptoms are light-headedness, shakiness, sweating, blurred vision and labored speech, confusion and could lead to unconsciousness.

What Happens if My Blood Sugar Stays too High?

Hyperglycemia is before meal blood glucose over 130 mg/dl and over 180 mg/dl 2 hours after meals. If blood glucose is occasionally high but not over 250 mg/d, you may not have any symptoms. Symptoms to watch for are extreme thirst, frequent urination and hunger. Even without symptoms, the elevated concentration of glucose in your blood is damaging tissues. Unchecked high blood sugars will eventually lead to serious conditions including seizures, unconsciousness and coma. If your blood glucose levels are high, be sure to avoid dehydration by drinking adequate fluids.

Do I Have To Exercise?

Think of it as increasing your physical activity. Moving more will lower your blood sugar, help you control your weight and improve your fitness level. It is a part of the recommended treatment plan for nearly every person, especially those with diabetes.

Who Can Help Me With This?

Expect to be more connected to your primary care physician, and maybe an endocrinologist who specializes in diabetes care. There are certified diabetes specialists who are nurses, dietitians or pharmacists who can help you. Call your local hospital for information about support groups.

How Do I Prepare for Sudden Illness?

This is a good topic for your doctor to discuss with you. If you have been sick for 24 hours and your blood sugars are high, call your doctor. If you have ketones in your urine, call your doctor. Avoid dehydration by drinking plenty of fluids, and keep track of the medications you take. You will want to review which cold relief medications are safe for you to take when you are under the weather. Keep a record of your blood glucose to show the doctor.

11 Essential Things You Must Do (As a Newly Diagnosed Person with Type 2 Diabetes)

1. Test Your Blood Glucose

Your doctor will give you a glucometer and test strips and have a nurse show you what to do, so you can demonstrate enough knowledge to test blood glucose yourself. The strips and meters should not be left in any places where extreme hot or cold temperatures could occur, like a car. Be sure the test strips are coded with the meter and not expired.

2. Control Your Carbohydrates

Carbohydrates are converted to glucose by digestion. Insulin carries the blood glucose into the cells to provide energy for living. If the insulin is lacking or ineffective, the glucose piles up in the blood, causing problems for the body. Limiting carbohydrates to a level that the insulin can manage is one treatment of diabetes. Carbohydrates are sugar, fruit, lactose in milk and yogurt, and starches such as grains, bread, crackers, pasta, rice, legumes, and starchy vegetables such as potatoes, sweet potatoes, peas and corn. Your dietitian or certified diabetes educator can plan an individualized carbohydrate plan for you. Typically, women consume 45 grams of carbs per meal, and men 60 grams per meal. Keep snacks to 25-30 grams of carbohydrate.

3. Get Moving

Exercise lowers blood glucose. This is a second treatment for high blood glucose. Physical activity is important for everyone, even those without diabetes. It will improve your mood, help with weight loss, build muscle, strengthen bones, and improve your sleep. Try to get 30 minutes of exercise most days. Be sure to check your blood glucose before you exercise. If it is lower than 90 mg/dl, eat a light snack, and if higher than 250 mg/dl, do not exercise until within a more normal range.

4. Become Educated and Know Your Numbers

What are your target blood glucose goals? Your doctor may give you individual instruction, but these are the ADA recommendations:

• Fasting and before meals: 70-130 mg/dl
• 2 hours after start of a meal: 180 mg/dl
• A1C: <7%( tested every 3 months or more)

5. Build Your Support Team

Your team should consist of your doctor or an endocrinologist, a certified diabetes educator, a registered dietitian, a foot doctor (podiatrist), a dentist, an eye doctor and an exercise professional.

6. Take Your Medicine as Directed (and know how it works)

Diabetes is a progressive disease and there may come a point where diet and exercise, called lifestyle changes, aren’t enough to keep your glucose under control. There are quite a few oral medications that help lower blood glucose in different ways. Be sure you understand how to take the medication, what side effects to watch for, and how the medications work. There are also injectable medicines, and insulin by injection that are very effective in managing blood glucose. Our Diabetes Video Library has an extensive section on diabetes medicines.

7. Know How to Treat Low Blood Sugar

The signs of hypoglycemia are shakiness, sweating, weakness, blurred vision, hunger. A quick ingestion of simple carbohydrate is necessary to bring your blood sugar back up.

8. Lose Weight

Most people with type 2 diabetes start out overweight-above their ideal body weight. Weight loss, of even just 10 percent, can make a huge difference in blood glucose levels. Some people see their blood glucose go back to normal with lifestyle changes alone.

9. Get an Annual Physical with Blood Work to Prevent Complications

There are large and small vessel problems that might occur over time, so make it a habit to get a good check-up annually. Your eyes, kidneys, nervous system, heart, skin, teeth and feet are all susceptible to injury from diabetes and high blood glucose.

10. Know What to Do If You are Sick

Talk with your doctor about sick day plans. Call your doctor If you have been having vomiting or diarrhea for 6 hours, your blood sugars are over 240 mg/dl for 24 hours even with medicine, and if you show ketones in your urine. Remember to stay well hydrated.

11. Watch Your Blood Pressure and Cholesterol

Diabetes is closely related to heart disease. You need to control your blood pressure within 120/80 mmHg to reduce stress on blood vessels and kidneys. Protect your heart by lowering your LDL cholesterol <100mg/dl, and triglycerides <150 mg/dl and HDL cholesterol men >40 mg/dl and women >50 mg/dl. You may be prescribed prophylactic statins and blood pressure medicine to reduce your risk of complications.

Your Diabetes Emergency Plan

Prepare a diabetes emergency kit in which you can keep critical information and supplies in case of an emergency. A kit you can grab in a hurry with all you need to take care of your medical health. Choose a container that is insulated, waterproof and portable.

Information for Your Kit:

• Your type of diabetes
• List of all your medications
• Contact information of your doctors and Certified Diabetes Educator, as well as family members
• Most recent lab results
• Letter from your healthcare providers describing your medication and food regimen. If you are on insulin, your current insulin to carb ratio and correction factor, or typical dosing routine.

Kit Supplies:

• A supply of all your oral and injectable medications
• If on insulin, a glycogen kit, as well as glucose tablets or gels to treat low blood glucose. Also, some juice boxes, candy or sugar packets
• Blood glucose testing supplies and extra batteries
• Empty plastic bottle for safe disposal of sharps
• Non-perishable food supply such as peanut butter crackers, meal replacement shakes or bars, raisins, nuts
• Bottled water
• First aid kit with bandages, band-aides, cotton swabs, antibiotic ointments
• Money for unexpected cash-only needs
• Extra set of clothes and undergarments, socks; mini bottles of toothpaste, shampoo, etc.
• Prepaid cell phone and important numbers

How Much Do You Know About Diabetes Care?

1. In general, what effect does exercise have on blood glucose?

• A. Raises it
• B. Lowers it
• C. Has no effect
• D. Not sure

Answer:  B. Check it out yourself. Test your blood glucose, note the number, take a 30-minute walk and test again. Most often, it will drop. If you have eaten recently, you may not see a change.

2. Which item should NOT be used to treat low blood glucose?

• A. Three glucose tablets
• B. 1 cup of skim milk
• C. 1 cup of diet soft drink
• D. 1/2 cup of orange juice

Answer:  C. When your blood glucose is too low and you have symptoms of shakiness, sweating, and light-headedness, you need a quickly digested sugar source to raise your blood glucose. Diet soda has no calories or sugar and would not help. The glucose tablets are most efficient, since the glucose is absorbed in the mouth. The other foods will also work.

3. Which of the following food is a major carbohydrate source?

• A. Spinach
• B. Apple
• C. Egg
• D. Cheese

Answer:  B. Fruits are mostly carbohydrate, and will raise your blood glucose. It is best to eat the whole fruit, because the fiber causes the carbohydrate to be released more slowly. Refrain from drinking fruit juice, which raises the blood sugar quickly. Fruit provides essential nutrients like vitamin c and potassium, and a few servings can fit into a diet for people with diabetes. Other foods with carbohydrate are starches such as bread, cereal, rice, pasta, corn, legumes, and potatoes. There is also carbohydrate in dairy products such as milk and yogurt, but almost none in cheeses.

4. What is the best meal plan for people with diabetes?

• A. Balanced diet–like the Plate Diet
• B. Low in carbohydrate choices only
• C. High protein diet
• D. Not sure

Answer:  A. The American Diabetes Association recommends a balanced diet with 45 percent carbohydrate, 20 percent protein and 35 percent fat.

5. The A1c blood test measures a persons average blood glucose level for the past ______.

• A. day
• B. week
• C. month
• D. three months

Answer:  D. The hemoglobin A1c is an average of the last three months blood glucose levels.

6. True or False?

• An infection will mostly likely decrease my blood glucose.
  False:  Infections and other stressors increase your blood glucose.
• People with diabetes have an increased risk of heart disease.
  True:  Keep your cholesterol and blood pressure under control along with your blood glucose to avoid complications.
• As a person with diabetes, I should call the doctor if I have been vomiting or have diarrhea for more than six hours.
  True:  Your blood sugar may be harder to control, and you will need instructions on what medication to take. Check your blood glucose more often and stay hydrated. Watch for blood sugars over 240 mg/dl or ketones in your urine and report to your doctor.
• I can eat all the nuts I want because there is no carbohydrate and nuts are good for the heart.
  False:  Nuts are quite caloric, and so too much of a good thing could cause you to gain weight. A half-cup of nuts is about 400 calories, and contains some carbohydrate.
• Diabetes can affect my eyesight, kidneys and nerves.
  True:  Long term complications, due to uncontrolled blood sugar, can cause eyesight degeneration and blindness, kidney disease leading to dialysis, and nerve damage causing tingling, pain and numbness in fingers and toes. So, take good care of your diabetes and you will avoid these problems.

The Diabetic Diet – Your Choice

Diabetic Plate Diet

The Food Pyramid has been replaced with the Plate Method Diet by the UDSA and Department of Health and Human Services to describe a healthy diet for Americans (www.choosemyplate.gov). The Plate Method can be adapted for people with diabetes who want a simple, easy guideline on how to eat. With this visual tool, you can control your food portions and spread the carbohydrate evenly within each meal and throughout the day.

Using a 9 inch plate, divide it into 4 quarters for both lunch and dinner. Fill the plate like this:

• 1/2 plate with non-starchy vegetables (broccoli, green bean, leafy greens, salad, carrots, etc)
• 1/4 plate with starches (bread, rice, noodles, legumes, grains, cereal, crackers, rolls, tortillas, starchy vegetables like potatoes, sweet potatoes, winter squash, corn, peas and legumes)
• 1/4 plate with meat (lean beef, pork, poultry, fish, tofu, eggs, cheese)
• one cup low fat milk (on the side)
• one serving of fruit. (on the side) (one piece fresh, 1/2 cup unsweetened canned)

The breakfast plate will be arranged a little differently:

• 1/4 to 1/2 plate with starch
• 1/4 plate with protein
• One serving of milk and one serving of fruit.

Although a simplistic tool to plan your meals, be careful about preparation methods and added condiments like butter and salad dressings, which can add extra calories.

Exchange List for Diabetic Meal Planning

The Exchange List was created by the American Dietetic Association and the American Diabetic Association to provide a consistent approach to calculating a diabetic meal plan. Foods are divided into six groups (each group has common nutrient composition): Milk, Meats, Starch, Fruit, Vegetables, and Fats. A meal plan is created by defining a set number of servings from each group. The advantage of this approach is better calorie control, and manipulation of the nutritional quality of the diet.

Sample 1,500 Calorie Diet Using Food Exchanges

Carbohydrate Counting

Carbohydrate counting is a third option for better management of diabetes. The focus is to eat a prescribed number of carbohydrates at meals and snacks. A typical plan might be 45 grams of carbs at each meal, and one snack with 15 grams of carbs. This totals 150 grams of carbohydrates per day. For people with type 2 diabetes, the carb counting can be learned from the exchange lists. A serving, or choice, of starch, fruit, or milk group provides 15 grams of carbs. Once someone learns portion sizes, carb counting makes estimating a meal’s carbohydrate content quick and simple. People with type 1 diabetes who are on insulin, or even the insulin pump, must be exact about their carb counting since their insulin dose is based on the amount they eat at a meal. Advanced carb counting calculates for the smaller amounts of carbohydrate throughout all food choices, and may use such tools as carb listing booklets or online apps that track food intake. The disadvantage with only using the carb counting method is that other nutrients aren’t monitored and calorie intake is not controlled.

What You Need to Know About Diabetes and Medications

Insulin shots used to be the only treatment for diabetes for years. Insulin is a protein, and if swallowed would be digested. Therefore, it must be administered by injection. Scientists have been working to find oral medications to help control diabetes. There are many to choose from today, and each category of medication does something different to help manage the blood glucose. If you are on a medication, learn about how it works, be sure you take it when and how you should, and be alert to side effects.

Each drug belongs to a class, and each class of drugs works in specific ways. Some work on the pancreas, increasing its output of insulin. Another class works on the liver, decreasing the amount of sugar it releases. Another class works on the muscle, making it more sensitive to insulin. Even the GI tract (gastrointestinal) can be altered to decrease the absorption of carbohydrates and increase helpful hormones called GLP-1.

Some people may be on several oral medications, or oral and injectable. Some medications are also in combination pills. Injectables and insulin are now available in easy to use pens, with extremely tiny needles. Insulin is also used in insulin pumps. You need to check your blood glucose regularly to know how effective your medication, exercise and diet are keeping your blood glucose in range. You can make corrections if you know what is happening to your blood glucose.

The charts below give you an overview of all the types of medications that can be of help.

Medications for Type 2 Diabetes

Commonly Used Insulin