Managing Type 2 Diabetes

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When you are diagnosed with diabetes, healthcare provider (doctor, nurse practitioner [NP], or physician assistant [PA]) will work with you to put together a diabetes care plan designed to control your blood glucose and reduce your risk for diabetes-related complications. Your diabetes care plan will typically involve monitoring your blood glucose level, lifestyle modifications (healthy eating plan and physical activity), and medication to improve glycemic (blood glucose) control and other parameters associated with diabetes risk (eg, weight, blood pressure, lipids), and approaches to decrease risk for cardiovascular complications (eg, quitting smoking, management of high blood pressure, and, in certain people, taking a daily low-dose of aspirin). While lifestyle modifications (healthy eating, weight control, and physical activity) are the core of any type 2 diabetes care plan, many healthcare providers will suggest that you start on the oral diabetes medication metformin when you are diagnosed or shortly thereafter. If a single medication is not sufficient for glycemic control, then your provider may suggested adding another oral or injectable medication or insulin.1,2

Blood glucose control. Your blood glucose treatment goal or target will depend to some degree on individual factors, including your age and health status. However, keeping hemoglobin A1C around or under 7% has been shown to decrease the risk of microvascular complications (these include complications where small blood vessels are affected, such as retinopathy and kidney disease). Keeping A1C levels under 7% is a reasonable goal for many non-pregnant adults. However, your healthcare provider may suggest an even lower A1C target of 6.5% or under, if you can achieve this goal without developing hypoglycemia or having side effects due to medication. Younger people who are diagnosed with type 2 diabetes sometimes use this lower A1C target. A higher A1C target of 8% or less may be appropriate for people who are affected by severe hypoglycemia, older people, or people with advanced cardiovascular disease, kidney disease, or other complications.1

Blood pressure control. People with diabetes (who do not have kidney complications) should maintain blood pressure below 140/80 mmHg. Blood pressure below 130/80 mmHg may be appropriate for certain patient groups. Talk to your doctor about what your blood pressure target should be.1

Lipids. If you have type 2 diabetes, you are at increased risk for heart disease. Therefore, your low-density lipoprotein (LDL) cholesterol level should generally be below 100 mg/dL, your triglycerides should be be below 150 mg/dL, and your high-density lipoprotein (HDL) cholesterol should be greater than 40 mg/dL (for men) and greater than 50 mg/dL (for women). If you have heart disease and diabetes, you should aim to keep your LDL cholesterol lower—below 70 mg/dL.1

Blood glucose monitoring. Ongoing monitoring of blood glucose is an important and necessary part of managing diabetes. If you have type 2 diabetes, your healthcare provider will monitor your glycemic control using hemoglobin A1C testing on a regular schedule during office visits. Since A1C testing gives shows you what your blood glucose average is over a period of 2 to 3 months, it is particularly useful for monitoring how well your treatment plan is working. The frequency of monitoring will be determined by how well your blood sugar is being controlled and other factors. Your provider may want to test you more frequently after a change in medication. If you use insulin therapy, your provider will have you do self-monitoring of blood glucose using a blood glucose meter.1,2

Self–monitoring of blood glucose may be recommended if you are taking insulin to control your blood glucose. Such monitoring allows you to check your blood glucose level at any time and enables you to make changes in treatment to fine-tune your blood glucose level.1

Self-monitoring of blood glucose typically involves using a lancet which inserts into a spring loaded device to get a tiny drop of blood from your finger and applying the blood sample to a test strip which you insert into the blood glucose meter. The blood glucose meter then within seconds displays the result of the test. The frequency of daily testing will depend on the specifics of your treatment plan. People with type 1 diabetes who depend on insulin injections typically need to test their blood glucose at least four times per day. For people with type 2 diabetes, the frequency of testing varies greatly depending on medication use and whether you take insulin or not.

There are many different blood glucose monitoring systems on the market today for self-monitoring of blood glucose. Your choice of a monitoring system may be determined, in part, by your health insurance plan. However, your healthcare provider and your diabetes educator will be able to offer guidance and training in using your monitor.

Learn more about different glucose monitoring devices and how to choose between different models.

Lifestyle modifications

If you have type 2 diabetes, lifestyle modifications will be the core of your diabetes care plan. It can be a challenge to make fundamental changes to the way you live. However, healthy changes, including losing weight and keeping it off, getting regular physical activity, controlling your blood pressure and lipids, quitting smoking, and healthy eating will make a big difference when it comes to protecting yourself from complications associated with diabetes. Reach out to your healthcare provider and your American Association of Diabetes Educators (AADE)-certified diabetes educator to help you make the behavioral changes that you’ll need for successful diabetes self-management.1

Changes in eating habits and food choices. Many factors affect blood glucose levels, including how much food and what types of foods are eaten, how active a person is, and the dosing of blood glucose-lowering medications. For a person with diabetes, getting a consistent amount of the right foods on a daily basis is very important for blood glucose control. It is also important in terms of reducing risk for common complications associated with diabetes and for weight control. Ask your healthcare provider to refer you to a certified diabetes educator who is also a dietitian to work with you to make changes in your eating behaviors and help you put together a food plan tailored to your individual needs and preferences.3

The American Diabetes Association (ADA) recommends an energy-appropriate, nutrient-dense, and culturally appropriate eating pattern for people with type 2 diabetes. A healthy eating pattern should be based on recommendations for the general public in the US Department of Agriculture’s Dietary Guidelines for American, 2010 and should include a high intake of fruits, vegetables, and dietary fiber and a low intake of total fat, saturated fat, and added sugars. For example, when it comes to carbohydrates, you should choose whole grains, legumes (peas and beans), vegetables, and fruits (especially those high in dietary fiber). For protein, animal- and plant-based source can be part of a healthy eating plan. However, some animal-based protein sources contain saturated fat, so low-fat, non-fat, or lean sources should be selected. For fats, monounsaturated and polyunsaturated fats, such as those found in seafood, nuts, seeds, and oils should be selected.1,4
Learn more about healthy eating and nutrition and diabetes

Physical activity.. Regular physical activity is a powerful tool that can contribute to your health whether you have diabetes or not. However, for people with diabetes regular physical activity is a must. The benefits of regular physical activity include cardiovascular fitness, weight loss, improved blood glucose control, decreased blood pressure, improved lipids, and improved sense of well-being.

Pre-exercise examination. Since physical activity affects blood glucose, you should get a sense of how an activity affects your blood glucose by measuring levels before, during, and after your exercise routine. This will allow you to know how you will need to adjust your insulin dose (if you take insulin) or to develop a strategy for eating foods that will keep your blood glucose at a normal level during and after physical activity. Make sure to drink adequate amount of liquids before, during, and after exercise to avoid becoming dehydrated. In people with diabetes, dehydration can have a direct impact on blood glucose levels.6

Special considerations.Since physical activity affects blood glucose, you should get a sense of how an activity affects your blood glucose by measuring levels before, during, and after your exercise routine. This will allow you to know how you will need to adjust your insulin dose (if you take insulin) or to develop a strategy for eating foods that will keep your blood glucose at a normal level during and after physical activity. Make sure to drink adequate amount of liquids before, during, and after exercise to avoid becoming dehydrated. In people with diabetes, dehydration can have a direct impact on blood glucose levels.6

Learn more about physical activity and diabetes

Medications and insulinAt the time you are diagnosed with type 2 diabetes or shortly thereafter, your healthcare provider may recommend that you start on an oral diabetes medication in combination with lifestyle modifications for control of blood glucose. If your blood glucose is extremely high (A1C of 10% to 12%), your provider may start you on insulin alone or in combination with another diabetes medication.

Many people who are diagnosed with type 2 diabetes will be started on an oral medication (take as a pill) called metformin (brand names: Glucophage, Gumetza, Riomet, Fortamet). Metformin is an insulin sensitizer. This means it helps the liver and the muscle use excess glucose. By sensitizing your tissues, metformin helps your body make better use of the insulin you continue to make. If the maximal dose of a single medication is not sufficient to lower blood glucose, your healthcare provider may suggest you add another medication to metformin. There are many different kinds of medications, both oral and injectable, to help you control blood glucose.

When it comes to medications to control type 2 diabetes, the ADA recommends using an approach of adding medications (including insulin) in a stepwise fashion as needed to achieve blood glucose control. As mentioned, most people will start with the drug metformin. If this drug is insufficient for blood glucose control after a 3-month period, another oral or injectable diabetes medication or insulin is added to treatment. If this combination is insufficient for blood glucose control after a 3-month period, then another medication or insulin is added. Options for second and third diabetes control medications include sulfonylurea, thiazolidinediones (also known as glitazones), dipeptidyl peptidase 4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and insulin. If a three-drug combination is not sufficient, your provider may recommend a more intensive program of insulin treatment, with or without other diabetes medications.1,2

Learn more about diabetes medications and insulin.

Decreasing risk for diabetes complications

Diabetes is associated with a range of serious health complications, including cardiovascular disease (heart attack and stroke), kidney disease, vision problems, and problems affecting the feet. Therefore, strategies for preventing diabetes complications are an important part of every person’s diabetes care plan. Keeping blood glucose under control is an important key to reducing risk for complications. Additionally, there are a range of other preventative strategies that you can use to protect yourself from diabetes complications.

Learn more about preventing and treating diabetes complications.

view references
1. American Diabetes Association. Standards of Medical Care in Diabetes—2014. Diabetes Care 2014;37:S14-S80. -- 2. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2012;35:1364-79. -- 3. Delahanty LM, McCulloch DK. Patient information: Type 2 diabetes mellitus and diet (Beyond the Basics). Nathan DM, Mulder JE, eds. UptoDate. Wolters Kluwer Health. Accessed at: www.uptodate.com. 2013. -- 4. Evert AB, Boucher JL, Cypress M, et al. Nutrition Therapy Recommendations for the Management of Adults With Diabetes. Diabetes Care 2013. -- 5. Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and Type 2 Diabetes: The American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care 2010;33:e147-e67. -- 6. McCulloch DK. Patient information: Diabetes mellitus type 2: Alcohol, exercise, and medical care (Beyond the Basics). Nathan DM, Mulder JE, eds. UptoDate. Wolters Kluwer Health. Accessed at: www.uptodate.com. 2013.
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