I'm Dr. David Hite, a member of the American Association of Diabetes Educators.
I provide Diabetes Education classes for a large non-profit healthcare organization in Sacramento, California. I know that most of you can't attend my diabetes class in person at the clinic, so I've created an educational DVD and this e-book "Type-2: Straight Talk About Diabetes Self-Care" to help you understand Type-2 Diabetes, and learn how you can Take Control of Your Diabetes or offer needed help to a friend or loved one who may be struggling to avoid the medical complications that often come with this disease. This information is also perfect for those of you who have pre-diabetes and want to reverse those symptoms and avoid progression to diabetes. If you have not already done so, I encourage you to get my complete Diabetes Basics-Take Control DVD presentation and learn even more about your condition. Good health. Live well.

Type-2: Straight Talk About Diabetes Self-Care

Diabetes is a chronic condition. It’s not yet curable. But we do know some secrets to help you stay healthy and avoid diabetic complications. Your doctor is a very important part of staying healthy, so visit and have blood tests 2-3 times each year so you can spot potential problems early and to make sure you're still on track. But also remember what you do for yourself when you leave the doctor is just as important as anything your doctor can do. The secret involves Taking Control of your diabetes by following my 5 M’s of diabetic care. Sounds simple, but you all know that diabetes is a complex and frustrating medical condition. There’s a lot to learn, but the more you know, the easier it will be to stay healthy. I hope this section specifically on diabetic medications will help to answer some of your questions and set you on the road to good health.

MEDICATION

I’ve just been diagnosed with type-2 diabetes; will I have to inject myself with insulin?

Probably not for many years, though you may benefit from some oral diabetic medications (pills). We will discuss diabetic medications later in this book. Ironically, most people with type-2 diabetes actually have elevated insulin levels in the years prior to diagnosis. During this time the body is over-producing insulin in an effort to keep blood sugars under control (Insulin has lost its effectiveness because of insulin resistance. Normal amounts of insulin can no longer get the job done). Excess body fat, stored in the omentum which surrounds organs in the abdomen, clearly plays some role in insulin resistance. Whether this abdominal fat is the cause or the result of insulin resistance is unclear.

What does seem clear is that a sedentary lifestyle, and years of eating diets loaded with sugar, refined carbohydrates, and unhealthy fats (animal and trans-fats), causes us to gain weight, especially in the abdomen. This accumulated fat may simply gum up the doors to the cells. This puts so much pressure on the pancreas that it wears out prematurely. Your pancreas has been working overtime, probably for many years, making extra insulin to keep your sugars down. It’s only after the pancreas tires and begins to slow down, a condition called "insulin fatigue," that blood sugars begin to rise and diabetes is diagnosed. Focus now on reducing insulin resistance to reduce the pressure on your pancreas. This may help preserve its function and prevent further damage.

I really don't want to take pills until I have to. Can I control my diabetes without them?

Yes, often you can, especially in the early stages of diabetes when blood sugars are only mildly elevated. It's even possible to get off Medications after you've started by working hard on the other aspects of blood sugar control. Understand that you're not ignoring your diabetes, but rather you're keeping Medication in reserve, as a safety net, and controlling sugars by employing your other tools: Monitor, Meals, Motion, and Motivation. Ultimately, with or without medications, success is measured by maintaining healthy blood sugar levels.

My blood sugar has been rising for the past few months and now my doctor says it's time to start taking medication to help. What do these pills do?

You may recall from the reading above how your pancreas was damaged by overwork in the years leading up to your diagnosis of diabetes. For many years it controlled your blood sugars by producing extra insulin, compensating for the fact that your cells weren’t responding to this chemical key. At some point, if a healthy diet, exercise and weight loss are no longer sufficient to keep blood sugars stable, you will need the additional help that diabetic medications offer. There are three main types of oral (pills) medications, each designed to work in a different way. One type stimulates your pancreas to produce a little extra insulin for mealtimes, another works by preventing your liver from inappropriately dumping unneeded sugar into the blood, while others sensitize the cells to respond better to the insulin you are producing.

Can you describe how each of these pills works to lower my sugar?

There are three classes of oral medications commonly used to treat high blood sugars (hyperglycemia). The first class of drugs is called secretagogues because they stimulate the pancreas to produce (secrete) extra insulin. These are best taken about 30 minutes before a meal to give the pancreas time to react and produce the extra insulin needed for the upcoming meal. Tolinase (tolazamide), Glucotrol (glipizide), Micronase (glyburide), Orinase (tolbutamide), Prandin (repaglinide), and Starlix (nateglinide) are examples of these. (Note – Drugs have two names and this may sometimes seem confusing. The capitalized word is the name the company gave it, their registered trademark. The other is the actual generic drug name). Of the medications mentioned in this class, Prandin and Starlix are shorter acting for those who tend to have after-meal blood sugar spikes that drop back into the normal range quickly. This shorter acting formulation lessens the risk of blood sugars being lowered too much in the hours after your meal.

The second drug commonly used is Glucophage (metformin). This medication slows the release of sugars that are stored in the liver. One of the many jobs of the liver is to store extra sugars and release them during emergencies (fight or flight reaction) and when blood sugars drop during the night. Many of you may experience this “Dawn Effect” and find that your morning sugar readings are higher then when you went to bed. Glucophage will help lessen this effect. Take this medication with food and start slowly to avoid the possibility of stomach distress. Most patients start with a single 500 mg (milligram) tablet once a day (dinner). If your doctor prescribes more than a single pill daily, wait until your body gets used to the lower dose before adding more. Usually add the second pill after one week (breakfast). If there is a third pill to take, wait until the third week then add it to your lunchtime/diner meal as your doctor directs. Glucophage also helps lower insulin resistance and sensitize the cells so they use insulin more efficiently by opening the “doors” that have been stuck shut. This sensitizing effect makes this drug an effective option for people with “metabolic syndrome” because of added abdominal body fat. It can also be used in combination with any of the medications from the first group of drugs mentioned above (e.g. glipizide) to help lower blood sugars even more effectively than using one class alone.

The third most commonly prescribed class of medications includes Actos (pioglitazone) and Avandia (rosiglitazone). These medications work as insulin sensitizers to reduce insulin resistance and make your insulin work better. These drugs tend to cause water retention, so they must be used with care in patients with congestive heart failure. Also make sure to have periodic liver function tests to monitor any negative reaction to your diabetic medications. For patients struggling to maintain stable blood sugars, this class can also be added to the others to make a triple combination therapy, though most often a patient will begin adding insulin injections at this point.

Note-Avandia (rosiglitazone) has been linked to heart attacks and heart failure and now requires a special "black box" warning label. Talk to your doctor about this before starting this medication. Check out this website to learn more about this drug and efforts to recall it and remove it from the market: Avandia Side Effects.

Newer drugs to hit the market attempt to control blood sugars by manipulating gastrointestinal hormones called incretins. Insulin is quickly released into the blood, even before blood sugar begins to rise, due to the action of two gut hormones called glucagon-like peptide-1 (GLP-1), and glucose-dependent insulinotropic peptide (GIP). Both of these hormones play a key role in blood sugar control by stimulating the release of insulin, inhibiting the release of the counter-regulatory hormone glucagon, and by slowing how fast food is released from the stomach. Two incretin analogs (drugs that mimic GLP-1 hormone), are now being used as a therapy in type-2 diabetes. Byetta (exenatide) and Victoza (liraglutide) are examples. One drawback with these two drugs is that they must be injected. Difficulties were encountered when trying to fully utilize these incretins however because in the body they are quickly inactivated by the enzyme dipeptidyl peptidase-4 (DPP-4). This has led researchers to create drugs like Januvia (sitagliptin), or Onglyza (saxaglyptin), which inhibit the action of DPP-4. These are taken in pill form.

One word of caution. DPP-4 enzyme is known to be involved in tumor suppression, which leads some researchers to fear that inhibiting this enzyme may spur the growth of certain cancers. Speak to your doctor about this if you're taking DPP-4 inhibitors or considering it.

One other drug worth mentioning is Symlin (pramlintide). This drug is an analog (chemically similar) to the natural hormone amylin which is made in the pancreas by the same beta-cells that make insulin. It is thought to partner synergistically with insulin to lower blood sugar. It is indicated only for those who use mealtime insulin, and is administered by a separate injection. Severe hypoglycemia is a major concern and a 30% reduction in the units of insulin is usually required. Because it has been shown to decrease appetite, it may also activate the satiety centers in the brain.

I encourage you to learn as much as you can about the drugs your take. Don't forget, what you do to control your blood sugars outside the clinic is just as important as anything that happens there. Work on your M's (Meals, Motion, Monitoring, and Motivation) first to lessen the need for medications. A good website to gather information about the medications you may be taking can be found at: Drugwatch. It features up-to-date information on the drug side-effects of prescription and over-the-counter medications and publishes alerts to aid in the protection of patients and consumers.

My doctor wants me to start insulin, but I'm afraid. My grandmother started insulin and ended up having kidney damage. Doesn't insulin cause complications?

No, it doesn't cause complications, in fact it will prevent them. All animals need insulin to survive (my neighbor's cat needs two shots of insulin each day). Your grandmother's kidney complication was the result of damage that occurred before she started insulin. When natural insulin production gets very low, and oral medications are no longer effective in controlling sugar levels, supplemental injections of insulin are necessary. This need for insulin shouldn't be seen as a failure on your part (any more than wearing glasses to compensate for weakening eyesight), and it doesn't mean that your diabetes is now "the bad type". In fact I believe that in many cases we wait too long to begin using insulin. Research indicates that intensive insulin therapy at the time of diagnosis may help to preserve the function of your pancreas and make it easier to control your diabetes later on. Have a frank discussion with your doctor about this and don't be afraid to try insulin therapy. You will be surprised to find that the injection itself hurts less than your daily finger stick. Good news on that front is that a new "oral" insulin is being tested. It isn't a pill, it's a spray that's absorbed in the mouth. Stay tuned, we should know about its effectiveness in the next few years. The important thing in any case is that blood sugars be controlled in as normal a range as possible.

Won't I gain a lot of weight when I start insulin?

Not necessarily. Often the use of diabetic medications means some added weight, but this effect can be reduced by making healthy changes to your portion size. Remember that some of the sugar in the blood that was not absorbed by the cell is then lost in the urine. The ancient Greeks wrote that honey bees were attracted to the urine of people with diabetes (diabetes mellitus translates "sweet urine"). It's a normal urge to begin eating more when you don't absorb all that you eat. Once you start taking diabetic medications you should re-evaluate your portion sizes at mealtime since now you will be absorbing your calories so much more efficiently.

Here are some other helpful books and websites that will help you stay motivated and on track.

Diabetes Burnout by William H. Polonsky, is a supportive guide to keeping you on track during tough times.

For healthy eating tips I think the Mayo Clinic Healthy Weight Pyramid is a good guide to follow, but remember you will have to limit your intake of fruit.

Michael Pollan's book In Defense of Food: An Eaters Manifesto is a fantastic book and will make you reconsider everything you thought you knew about food. His advice is simple: "Eat food. Not too much. Mostly plants." Follow his motto: "If it came from a plant, eat it; if it was made in a plant, don't."

The South Beach Diet is a lower carbohydrate diet that encourages eating lean protein, healthy fats, and high fiber natural "good carbs".

Check out Toma Grubb's website and new book Toma's Diabetic Diet - A Layman's Guide to Controlling Blood Glucose with Diet.

He includes a trial version of CyberSoft's Nutribase-7 Personal Plus Nutrition and Fitness Software that helps you make healthy eating choices and track the results.

One of the early pioneers of diabetes information online is David Mendosa. His website is an excellent source of information on all things related to diabetes. Toma and David are both living well with diabetes and are an inspiration to others wanting to control their blood sugars and avoid health problems by adopting a healthy lifestyle.

A good book and resource for understanding glycemic index and healthy eating is The New Glucose Revolution. by Jennie Brand-Miller.

I also think you should get a calorie-counting guide and begin to learn about the foods you eat. I recommend Allan Borushek’s The CalorieKing Calorie, Fat & Carb Counter. This book is full of great ideas and explanations about how to make healthy food choices.

For those of you who like to chat online, I will recommend a wonderful website where you can network with other people with diabetes, ask questions and get ideas and support at Diabetic Connect.

Finally, if you would like to get involved with community-based programs that increase awareness about diabetes, the American Diabetes Association website can help get you connected and active locally.

I hope my explanations in this e-book have been helpful. If you have not already, I encourage you to get my complete Diabetes Basics-Take Control DVD presentation and learn even more about your condition. Be your own advocate, your own best friend, and most importantly, don’t beat yourself up over small setbacks. Believe in yourself and in your ability to take control of your life and control your diabetes; then take the first step toward living a healthy life. Remember, knowledge is powerful only if it leads to positive change. If this e-book was helpful or if you have suggestions to improve it please email your comments to: Doc@healthdoc.org. Good health. Live well.

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