We’ve talked a bit about why people get Type 2 Diabetes- it’s closely linked to weight and it often runs in families. We know that it happens because of a combination of factors. Insulin resistance is when the body doesn’t respond to insulin as well as it should and is related to obesity. Additionally fat deposited in the pancreas can lead to problems with it’s function and can be a reason that the amount of insulin it produces reduces.
We’ve also talked a bit about weight loss, and how significant weight loss can, in certain circumstances allow Type 2 Diabetes to go into remission, or if that doesn’t happen it can reduce the number or dose of medicines required. We discussed carbohydrates and how reducing carbohydrate in the diet can have a positive impact on Type 2 Diabetes control, and potentially also in allowing remission to occur.
Moving on from remission, today’s blog focuses on those who perhaps have had had Type 2 Diabetes for a long time and in whom the aim may be good control rather than remission.
If remission is not going to happen for whatever reason, what are the other options?
In this situation there are two goals:
- The best diabetes control possible. We know from large trials that people with good diabetes control are less likely to develop complications in relation to their diabetes.
- Paying careful attention to what we call cardiovascular risk factors. It may surprise you to learn that rather than diabetes specific complications like kidney failure, death in people with diabetes is more likely to be related to heart disease. Cardiovascular risk factors is a posh phrase for the various other factors that increase your risk eg. high blood pressure and smoking.
Today I’ll stick to good diabetes control.
Firstly, just because remission isn’t on the horizon doesn’t mean that all the focus is taken way from lifestyle. Absolutely not – it is, without doubt, the most important thing, wherever you are newly diagnosed with Type 2 Diabetes, or you’ve had it for forty years.
In most people, weight loss and paying careful consideration to your intake of carbohydrate containing foods makes more difference to overall diabetes control then any tablet or injection can. I’ve seen people whose sugars are so high I’ve thought to myself they will undoubtedly need insulin injections. After discussion about their dietary habits it’s become clear that they are drinking large quantities of Lucozade or Irn Bru, or another sugary drink. They’ve gone away and cut out the sugary drink, their sugars has normalised completely and no drug treatment has been necessary. That’s an extreme example, but people often just don’t realise how much carbohydrate they are taking, or how big their portion sizes are. It’s vital that people with diabetes have the opportunity to discuss their diet with a knowledgeable health care professional. The job of the diabetes dietitian is not to criticise and make people feel bad – it’s to educate and provide support.
Physical activity also plays a vital role in improving blood sugar control. When you are active you need less insulin. Physical activity doesn’t need to consist of doing a full-on work out – treadmill and weights at the gym 5 times a week. Anything achievable will be better than nothing. Walking to work, going for a walk at lunch time, going up and down the stairs at home, some armchair exercises from you-tube. Anything you can manage will be of benefit.
There are other important lifestyle factors which are often forgotten about. We know that poor sleep increases blood sugars, as does stress. We know that people that are socially isolated are more likely to develop Type 2 Diabetes. We’ve spend some time in previous blogs talking about each of these issues, although not specifically in relation to Type 2 Diabetes. Have a look at our old blogs for ideas if you think any of these issues apply to you.
Having said all that, in many cases medication may also be needed – although alongside lifestyle changes rather than as an alternative. There are a number of different groups of medicines, they all have their pros and cons, and are suitable for different groups of people. I’m going to run through them briefly.
Metformin – an old favourite – it’s been around for decades, it’s cheap and does a great job at reducing insulin resistance. The main problem with Metformin is that some people find it upsets their stomachs a bit and can increase flatulence and cause loose stools. Often that can be avoided by starting at a low dose and gradually increasing the dose. Usually people will be on something between 500 mg twice daily and 1g twice daily. It should be taken with breakfast and evening meal. It doesn’t cause weight gain. There are some people who can’t take it, for instance people that have very poor kidney function. Usually, however it would be our first choice of medication. We also usually suggest continuing it if a second drug is needed.
Gliclazide is another old favourite – again it’s cheap and it’s been around for ages. It works by helping the pancreas produce more insulin. The main issues with Glicazide are that some people find they put on weight with it. Also if your dose is too big, or if you take it and don’t eat your meal – because of the way it works you can potentially end up with hypoglycaemia – a low blood sugar. For a few people eg. elderly and confused patients this may mean that Gliclazide is not appropriate, or it’s use may need to be monitored carefully. Dosage is usually anywhere between 40 mg once daily to 160 mg twice daily. Again it’s usually taken with breakfast and evening meal.
The Gliptins are a family of drugs – Sitagliptin, Alogliptin, Linagliptin, Saxagliptin – the list goes on. They have a complicated way of working – they prevent the breakdown of a hormone that encourages the production of insulin. They are useful in that they don’t cause weight gain or low blood sugars and they are relatively free of side effects (although you can never say never!), but they don’t have a big an impact on blood sugar as some of the other medicines. They may be useful in elderly, frailer patients.
The next group are the SGLT-2’s – I won’t bother you with the full title but essentially any drug that ends in gliflozin – eg. canagliflozin, empaglifozin. These are newer drugs on the market and work by making the kidneys pass out some of the excess sugar in the urine. The way that they work has pros and cons – on the plus side people usually lose weight with them as well as improving diabetes control, on the down side the most common side effects are thrush and urinary infections. Big trials of these drugs have shown that they reduce risk of heart attacks so they should be considered in anyone who has Type 2 Diabetes and a history of heart attacks or similar. They do have a potential very serious but very rare side effect – they can be associated with a condition called Diabetic Keto-Acidosis (DKA), usually when someone continues to take them while unwell. If you are on one of these drugs and are unwell, if you are admitted to hospital or are having a medical or dental procedure you should stop them until you are better.
GLP-1 agonists are a group of injectable drugs, the most common ones being dulaglutide, liraglutide and semaglutide. They help the body increase it’s insulin production and by doing that can improve diabetes control. They can also reduce appetite and therefore can potentially help with weight loss so are very useful in obesity. They often make people feel nauseous when they initially start treatment, so most of them start at a low dose and build up to the full dose. Otherwise they don’t have much in the way of side effects and they don’t cause low blood sugars. Some people benefit from them greatly in terms of diabetes control and weight loss but other people find they have no effect at all. In view of this they are often trialed for a period of time and stopped if they are not helping. Again these drugs have been shown to protect against heart attacks and are suitable for people who have had heart related problems previously.
There are other groups of drugs which are used less commonly which I haven’t discussed, and a lot (but not all) of these drugs can be used in combination. Drugs have a trade name as well as what’s called a “generic” name so if the medicines you are on aren’t mentioned here, have a closer look at the packet and see if there is another name.
Of course insulin is used as well in the management of Type 2 Diabetes, often after multiple other drugs have been tried and diabetes control is still an issue.