TYPE 2 DIABETES – MANAGEMENT AND MEDICATION
This section is designed to help patients understand in summary the treatments available and the on-going management of their Type 2 diabetes. The idea is to give an understanding of the condition and reduce the risks of developing long term complications.
Patients often do not receive adequate support from their healthcare professionals and are left with a lack of education about the progressive nature of the condition. Type 2 diabetes usually progresses slowly and once diagnosed with Type 2 diabetes a patient will within 7 years (on average) need treatment with insulin. Different types of treatment are available and different types of medication work in different ways such as tablets and/or insulin. Insulin can work as long-acting or short-acting in different ways with treatment delivered by pens and syringes to insulin pumps.
What causes Type 2 diabetes?
- Type 2 diabetes affects over 3 million people in the UK alone and probably there are an equal number of people living with the condition who are currently undiagnosed.
- There is a tendency for Type 2 diabetes to run in families but a sedentary lifestyle and being overweight or obese are also main causes the condition.
- Type 2 diabetes occurs mainly in people over the age of 40. With increasing levels of obesity it is becoming increasingly common in younger people including children.
- In Type 2 diabetes the insulin-producing cells in the pancreas either do not produce enough insulin or the insulin they do produce cannot be used properly by the body leading to insulin resistance. This means that the body cannot control blood sugar levels properly and gradually blood sugar levels rise causing hyperglycaemia.
- Because the onset is gradual, Type 2 diabetes can remain undiagnosed for several years. During this time the blood sugar levels are too high and this causes physical damage to the body and some of the complications of diabetes. People with Type 2 diabetes are often diagnosed as a result of having complications rather than because they suspect they have Type 2 diabetes.
SYMPTOMS OF TYPE 2 DIABETES ARE:
- feeling very thirsty
- urinating frequently, particularly at night
- feeling very tired
- weight loss and loss of muscle bulk
- itchiness around the vagina or penis, or regular bouts of thrush (a yeast infection)
- blurred vision that is caused by the lens of your eye becoming very dry
- skin infections
A Simple Test – Am I Type 2?
Can I see clearly now?
No! Oh! Why?
Could I be Type 2?
Oh dear! What do I do?
Echo ……………. Go see your GP
Yes you! Do it now!
I need to empty my bladder!
Echo ……………… OK – Do it now!
Echo again ……….. Go see your GP
Why do you say this again?
I’m too tired!
Echo ……………… You have three symptoms of Type 2
Please for me, for your family, go see your GP
OK – I’ll go!
Echo ……………… Summary your Symptoms are:
Blurred vision, Need to go to the toilet, Tiredness.
Next day at GP –
Doctor: I need a fasting glucose blood test, do not eat or drink anything after your evening meal tonight, bring me an early morning urine sample, and come to the surgery at 8.30am tomorrow for a blood test. I will see you again the following day when I have the results of your tests. We will work together and with your family to keep you healthy, develop for you a suitable diet, and if required prescribe you appropriate medication. I want you as a fit and well patient and not a tired and unhealthy one always needing to go to the toilet!
I recommend you contact the local Diabetes UK Support Group or other local group and attend their regular meetings for further information.
Follow me and my team and let us give you a healthy future!
Why do blood sugar levels need to be controlled?
Blood sugar levels that are too high can cause long-term complications. The risk of developing complications is reduced by treatment of the condition and lifestyle changes. Early diagnosis is also very important as this means that treatment of the condition can begin sooner rather than later. Good control means trying to keep blood sugar levels consistently as close to a normal level as possible. Once somebody has been diagnosed
they may be prescribed medications to improve the body’s sensitivity to insulin and to increase the amount of insulin the body produces. Some of these medications can cause the opposite problem and make blood sugar levels drop too low (hypoglycaemia or “hypo”). It is equally important to avoid this as not having a hypo is a major, daily concern for
many people with diabetes.
The complications of diabetes commonly affect several areas:
- The Eyes – diabetes can affect the blood vessels at the back of the eye (retinopathy) and can lead to visual impairment or blindness.
- The Heart and Vascular System – diabetes makes people more susceptible to heart disease and stroke. It can also cause blood clots in the blood vessels in the legs, which may result in amputation.
- The Kidneys – diabetes can cause damage to the kidneys or kidney failure (nephropathy).
- The Nerves – diabetes can cause loss of sensitivity to the nerves especially in the feet
How is Type 2 diabetes treated?
Treatment for people with Type 2 diabetes consists of a combination of three elements:
- Medication and/or Insulin
- Sometimes Type 2 diabetes can be treated with diet and exercise alone
Often, other medications are also necessary and if this still fails to reduce blood sugar levels sufficiently, then treatment with injections of insulin becomes necessary. On average, people with Type 2 diabetes will need to start taking insulin seven years after diagnosis as the body’s ability to produce its own insulin lessens. It is a combination of these three elements that is used to achieve target blood sugar levels and to reduce the risk of complications.
Diet and Exercise alone
When people are first diagnosed it may be that a combination of a healthy, carbohydrate-controlled diet, together with exercise, will have the desired effect of lowering blood sugar levels. However, this may not be appropriate for everyone, for example, those who are not able to take exercise due to other health problems, so other medications may have
to be used. Your doctor will be able to advise you what type of exercise is safe for you.
It is recommended that we all take at least 30 minutes of exercise, 5 days a week. Exercise is defined as any activity that makes us slightly out of breath and may be something as simple as a brisk walk. There are several benefits to taking exercise:
- Exercise reduces the risk of heart disease.
- Exercise raises HDL (good) cholesterol levels.
- Exercise lowers blood pressure or can prevent it from developing.
- Exercise helps us to reach and maintain a healthy weight.
There are two types of exercise:
Aerobic exercise – is good for your heart, increasing the body’s demand for oxygen and making the heart and lungs work harder and more efficiently. Some examples are walking, running, swimming, cycling and dancing.
Isometric exercise – increases muscle tension without moving a joint, for example pushing against a wall. It does not help the heart and circulation and should be avoided by people with heart disease or high blood pressure because it can increase blood pressure and put the heart under stress.
When people are first diagnosed with Type 2 diabetes, often one of the first and arguably most important pieces of advice they are given is to eat a healthy diet. The recommended diet for people with diabetes is the same standard ‘healthy diet’ also recommended for the general population, one which is high in carbohydrates, low in fat and with plenty of fruit and vegetables. To follow this diet to the best of their ability, people need to have an understanding of the basic food groups and the effects that these will have on their blood glucose levels/diabetes.
‘Food groups’ – refers to a method of classifying foods that are eaten on an everyday basis according to their nutritional properties. There are five basic food groups, proteins, carbohydrates, fats, fibre, vitamins and minerals.
- Proteins – They help your body to grow and repair itself. They are found in meat, poultry, fish, dairy products, eggs and beans.
- Fats – They provide energy and help your body to grow and repair itself. They are found in red meats, dairy products, some poultry and fish, Ready meals, cakes and pastries also contain fats.
- Fibre – It helps your body to digest food is found in cereals, bread, fruit and vegetables.
- Vitamins and Minerals – They are good for keeping your body healthy. Vitamins are mostly found in dairy products, fresh fruit and vegetables. Minerals are found in lots of foods but especially in fresh fruit and vegetables.
- Carbohydrates – They give you energy. They are sugars and starches and are found in bread, potatoes, rice, pasta, cereals and sugars. Eating carbohydrates directly affects the amount of glucose in the blood.
People who have Type 2 diabetes either do not produce enough insulin or the body does not use correctly the insulin it does produce. So when people with Type 2 diabetes eat carbohydrates their blood glucose levels rise. Because of this, it is important for people with Type 2 diabetes to keep a check on the amount of carbohydrate they eat. It is not just the amount of carbohydrate that is eaten that is important but also the type of carbohydrate.
Quick-acting carbohydrates – Some carbohydrates are quick-acting for example; sweet foods such as cakes, puddings, chocolate and some fruits. Sugary foods will raise blood sugars more quickly and higher in people with diabetes compared to those without diabetes.
Sugary carbohydrates tend not to last as long in the body so blood sugars may drop before the next meal. Sugary carbohydrates tend to make blood glucose levels peak and trough.
Slow-acting carbohydrates – Some carbohydrates are slower-acting and last longer, for example bread, potatoes and high fibre cereals. These carbohydrates do not raise the blood sugars as quickly or as high after eating. They last longer and therefore tend to give more even blood glucose levels.
Drugs used to treat Type 2 diabetes
There are a range of drugs that are used to treat Type 2 diabetes and these should be used alongside diet and exercise wherever possible. There are three main groups of drugs and they work in different ways.
• Biguanides (Metformin/Glucophage)
This reduces insulin resistance, which means that it improves the body’s ability to use the insulin that is still being producing. Because it does not increase the amount of insulin the body is producing, it does not cause low blood sugar levels (hypoglycaemia or “hypos”). Its main side-effects are stomach upsets. If Metformin on its own does not control blood sugar levels, then another drug may be added from the range known as Sulfonylureas. Metformin was first identified as a treatment for diabetes in the 1920’s but did not become widely available till the 1940’s – 1950’s.
• Sulfonylureas (Glibenclamide, Gliclazide, Glimepiride, Glipizide, Tolbutamide)
These drugs increase the amount of insulin the body produces. This means that they have the effect of lowering blood sugar levels and can cause hypos. Their side effects can also be stomach upsets and skin reactions.
• Glitazones (Pioglitazone)
This can also be added to the treatment regime. This drug works by reducing insulin resistance in fat tissue, muscles and the liver. There has been some recent research that shows that it can cause fluid retention.
Newer drugs that can be used to treat Type 2 diabetes include
Exenatide (Byetta/Bydureon) and Liraglutide (Victoza)
These are injected but they should not be confused with insulin. They work in several ways; they stimulate the body to make insulin, they slow down the rate at which glucose passes from the gut into the bloodstream, they cause cells in the body to remove glucose from the blood and finally they act on the brain to produce a feeling of fullness that reduces appetite and therefore food intake. They are used together with tablets and because they lower blood sugar levels they can cause hypos. Different people can experience different side effects but the most common are stomach upsets. However, the main advantage of these drugs is that they can help people to lose weight.
This list is not exhaustive and there are a wide range of drugs available that can be used to treat Type 2 diabetes. Some of the newer drugs work by filtering through the kidneys and by doing so put glucose into the urine which can lead to urine infections. Always remember that if you are taking any medication that can cause hypos then you should check your blood sugar levels regularly, particularly if you drive.
If these medicines still don’t control blood sugar levels well enough then the doctor may prescribe insulin. Treatment with insulin usually begins when the tablets you have been
taking are no longer able to control your blood sugar levels sufficiently well. There are risks and benefits to insulin therapy and your doctor or nurse should discuss these with you before you start using insulin.
The main risk is the increased possibility of low blood sugar levels (hypoglycaemia or hypos), whereas benefits include more stable blood sugar levels and an improvement in general well-being. It is important to remember that if/when a person starts to take insulin they do not become a person with Type 1 diabetes, they become a person with Type 2 diabetes who takes insulin.
Before starting on insulin most people will have been taking tablets, commonly metformin, which increases the body’s ability to use the insulin it still produces and a sulphonylurea, which increases the amount of insulin it produces. Because of the way sulphonylureas work, they can lower blood sugar levels and cause hypos. When you start taking insulin, you may need to continue taking these tablets but you are further increasing the amount of insulin in the body, presenting the possibility of an increased risk of hypos.
Your doctor or nurse should show you how to gradually increase your insulin dose until your blood sugar levels are stable at a level agreed at the start of treatment. Regular blood testing and recording is important to avoid hypos and to stabilise your blood sugar levels as quickly as possible. If you do find you are having frequent hypos then you should discuss this with your doctor or nurse and it is likely that they will reduce or discontinue the sulphonylurea.
There are lots of different types of insulin available and they work in different ways.
- Long-acting or background insulins are designed to be absorbed gradually, over a long period of time.
- Short-acting insulins are designed to work quickly and are used to deal with the sharp increase in blood sugar levels that happens after eating a meal.
- Intermediate-acting insulins fall between the two.
Usually, a doctor or nurse will advise starting by taking a long acting insulin which should be used once or twice a day, depending on the brand of insulin prescribed.
- Mixtures of long-acting and short-acting insulins are also available.
These are called pre-mixed insulins. These help your body cope with mealtimes as well as having a longer-lasting effect to help throughout the day. These are designed to be used twice a day. If you and your doctor or nurse think that one of these insulins would suit you then this should be discussed and they should tell you how often and when to inject.
Another option is to inject several times a day. This is called the “basal bolus” or “multiple dose” regime and it works by taking a long-acting insulin once or twice a day and a short-acting insulin at mealtimes.
There are several different devices that can be used for injecting insulin, the most commonly used being an insulin “pen” but other delivery devices such as insulin syringes are available and each have their own advantages and patient preference.
Diet Reverses Type 2 Diabetes – A Different Approach
Professor Roy Taylor qualified in medicine at the University of Edinburgh and is now Professor of Medicine and Metabolism at Newcastle University & Newcastle Hospitals NHS Trust. Professor Taylor has been conducting research on Type 2 diabetes since 1981 and has used a wide range of methods to understand the condition. He founded the Newcastle Magnetic Resonance Centre. This new facility aims to further medical and scientific knowledge by direct study of how the body works. This has led to an understanding of how food is handled in the body in health and disease. Prof Taylor demonstrated that Type 2 diabetes can be reversed to normal by decreasing liver and pancreas fat content.
Professor Taylor has authored over 200 scientific papers and has given over 100 invited lectures internationally including the 2012 Banting Memorial Lecture of Diabetes UK and recently the Betsy Sinclair Memorial Lecture to Diabetes UK members in Edinburgh.
Initial results were from a small sample of patients when compared to the numbers who have Type 2 diabetes however this fascinating work has demonstrated the usefulness of magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) and identified a very clear and specific clinical opportunity to use these expensive imaging and biochemical magnetic tools to show a possible solution to a major worldwide medical problem.
The first medical combined MRI and MRS magnet in the UK was installed in the mid 1980’s at Addenbrookes Hospital, Cambridge, when under the direction of Prof Laurie Hall (deceased) some of the first combined MRI / MRS brain images and spectrums were obtained in whole body format. At the same time MRI and MRS research was pioneered in London by Prof Ian Young OBE at Hammersmith Hospital, London, Prof Peter Mansfield, Nottingham, Donald Longmore, London, heart images, and Prof David Gadian at Imperial college London. These early magnets operated at 0.15, 0.5 and 1.5 tesla and at the time produced good but grainy images. The research presented by these UK teams has led to worldwide acclaim and acceptance of MRI as a significant diagnostic tool which has re-shaped radiology worldwide. It is a tribute to British science that Professor Taylor and his team have succeeded in using the powerful techniques of MRI and MRS to research and address a possible solution to aspects of the worldwide Type 2 diabetes problem.
An MRI scan can provide a biochemical analysis in diabetes by a separate signal comparing fat to water. The research wanted to know the percentage of fat in the liver and to see whether by losing weight the liver is changed and diabetes goes away. Results have shown that by decreasing liver fat diabetes goes away and by decreasing pancreas fat diabetes goes away.
With a low calorie diet hunger decreases after 36 hours.
The study was of 11 people over an 8 week period.
After 1 week 3.9kg weight loss was reported. A 60% fat loss and a 40% water loss was reported.
After 8 weeks a 15kg weight loss was reported.
After 1 week blood glucose returned to normal range by fasting glucose test.
13.5% liver fat became 4.6% liver fat in the period.
In Type 2 diabetes beta cell function in the pancreas is not good, after 8 weeks the pancreas was stable.
Fixed ideas about type 2 diabetes are a challenge however the hypothesis is true and Type 2 diabetes can be reversed with weight loss.
A restudy of the patients after 3 months fasting glucose was very similar based on normal diet and lifestyle from 8 to 5.5 mmol/l and weight loss from 97 to 82 kg. Patients have now been non diabetic for 18 months.
The patients selected had a short duration of diabetes of 4 years. The diet used was a low calorie liquid diet, eg Nestle type diet A larger study in Scotland and Northern England and over 8 years is now proposed.
The study has shown that Type 2 diabetes is a simple condition of excess fat in the liver and pancreas. Type 2 diabetes is reversible. . Applying magnetic resonance to Type 2 diabetes, especially tracking the return of metabolism to normal, is an exciting challenge.
For further information www.ncl.ac.uk/magres