The ABCs of diabetes management

This column is dedicated to Dr. Augusto D. Litonjua, my diabetes doctor, eminent physician, pioneer Filipino endocrinologist, and founder of the Philippine Society of Endocrinology and Metabolism (PSEM), now known as the Philippine Society of Endocrinology, Diabetes, and Metabolism (PSEDM), who is celebrating his birthday today.

In 2013, there were more than 382 million people with diabetes worldwide, with one person dying of the disease every six seconds.  In the Philippines, in that same year, there were 3.2 million people recorded to have diabetes, accounting for 6.01 percent of the country’s 54.5 million adult population.  It is estimated that by 2030, there will be 7.8 million Filipinos with the disease, which will give the Philippines the distinction, by then, of having the ninth largest diabetes population in the world!

The prevalence of diabetes, a disease marked by high levels of sugar in the blood, has more than quadrupled in the past two decades.  More than 90 percent of these cases are type 2 diabetes, when the body becomes resistant to the effects of insulin (the hormone that enables cells to take in sugar and other nutrients for energy and growth) and not enough insulin is produced to overcome the resistance.  Although the exact cause of type 2 diabetes isn’t clear, one thing is certain: Excess body fat is the No. 1 risk factor.  Type 1 diabetes, a disease that usually first appears during childhood or adolescence, is far less common.  In this column, the term diabetes will refer to type 2 diabetes unless otherwise specified.

Not only are more people being diagnosed with diabetes, they’re also developing the disease at younger ages.  That’s worrisome because the risks of complications from this common disease  which include heart attack, stroke, blindness, and kidney failure  become greater the longer you have diabetes.  These serious events underscore why it is so important to follow your treatment plan as closely as possible.  There’s good evidence that rigorous blood sugar control can delay or even prevent the development of debilitating long-term complications. Such tight control is now possible  thanks to innovations such as high-tech monitoring devices, improved medications, and nearly painless insulin injectors.

Lifestyle as medicine

With diabetes of any type, keeping your blood glucose levels in control is important over the long term, as excess glucose in the bloodstream damages blood vessels and nerves, leading to problems such as heart disease, stroke, kidney disease, eye damage, amputation, and nerve damage.

Since good control  as measured by a glycated hemoglobin (HbA1c) test  is associated with a decreased risk of diabetes-related complications, it’s important to tackle blood glucose control seriously.  Improvements in diet and physical activity  with an additional goal of modest weight reduction  is the foundation of type 2 diabetes therapy.  A commitment to these changes may allow some people to delay drug therapy or forgo it altogether.  Research suggests that lifestyle changes have an important effect on long-term blood glucose control.  This is especially true for adults older than 60.  Even if you do need medication, lifestyle improvements still provide a major boost in terms of blood glucose control, helping you keep the use of medication to a minimum.

 Mainstays of drug therapy

The hormone insulin is probably the drug most commonly associated with diabetes. And for people with type 1 diabetes  in which the pancreas produces little or no insulin naturally  injections of insulin are the only way to help the body use and regulate digested food energy in the form of blood sugar (glucose).

With type 2 diabetes, it’s a different story. The pancreas produces insulin, but cells throughout the body become resistant to insulin’s ability to unlock cellular gates that allow blood glucose to enter cells. Insulin unlocks portals on cells that allow passage of glucose energy from the bloodstream.  With type 2 diabetes, the body still produces insulin, but cells become resistant to it, making it difficult for glucose to enter cells. Drugs for type 2 diabetes work in several ways to address this problem, including reducing spikes of glucose in the bloodstream, increasing insulin production, or making cells more receptive to insulin. People with type 2 diabetes may require insulin injections. However, the disease often can be successfully managed with changes in diet and exercise  and with one or more drugs that help your body to better utilize and regulate blood sugar.

Drug choices for diabetes control

If lifestyle changes aren’t adequate or can’t be sustained, drug therapy is typically initiated. Usually, metformin is the first line of choice for keeping blood sugar levels in check with type 2 diabetes. Metformin works by reducing glucose release between meals. An important advantage with metformin is that it doesn’t cause low blood glucose (hypoglycemia).  In addition, it may promote weight loss and improve cholesterol and triglyceride levels. Side effects of metformin include nausea, upset stomach, and diarrhea. These often get better with time or with dose adjustments. Although rare, lactic acid buildup (lactic acidosis) is a serious side effect that’s more common in older adults and those who regularly drink alcohol.

Which medication comes after metformin is more of a difficult choice and depends on a number of factors such as cost, side effects, and the person’s risk factors. Drugs in the sulfonylurea class are often the primary second-line choice for controlling blood glucose because they’re effective, have a predictable track record, and are relatively inexpensive.  These drugs stimulate insulin release. Sulfonylureas include glimepiride, glipizide, and glyburide. They may be added to metformin therapy or sometimes used alone. A disadvantage of sulfonylurea drugs is they can cause hypoglycemia, particularly in those who have liver or kidney disease.  However, short-acting versions of the drugs are less likely to cause this.  Another potential disadvantage is that taking a steroid drug reduces sulfonylurea effectiveness. 

Newer medications

A number of newer oral or injectable drugs have also come on to the market to further improve blood sugar control.  These new diabetes medications can help your body produce more insulin, control glucose levels, or improve your body’s ability to use insulin.  Most diabetic drugs are taken orally, but a few can be injected.  Among the new oral and injectable drugs for diabetes are the following:

• Alpha-glucosidase inhibitors = slow the absorption of glucose from digestion (oral). E.g. acarbose, miglitol.

• Thiazolidinediones = make tissues more sensitive to insulin (oral). E.g. pioglitazone, rosiglitazone.

•  Meglitinides = stimulate production of a quick burst of insulin (oral). E.g. nateglinide, repaglinide.

•  Dipeptidyl-peptidase 4 (DPP-4) inhibitors = stimulate insulin production when blood sugar rises (oral). E.g. alogliptin, saxagliptin, linagliptin, sitagliptin.

•  Sodium glucose cotransporter 2 (SGLT-2) inhibitors = cause excess blood glucose to be excreted in urine (oral). E.g. canagliflozin, dapagliflozin.

• Incretin mimetics = mimic the gut hormone incretin, causing insulin release with high blood glucose (injectable). E.g. albiglutide, exenatide, liraglutide.

• Amylin mimetics = mimic action of pancreas hormone amylin, slowing digestion (injectable). E.g. pramlidine.

Lifestyle strategies

A diagnosis of type 2 diabetes doesn’t mean an end to the food and activities you love.  What it does require is a commitment to a healthy lifestyle, one that can have a big impact on your current and future health.  The same strategies that help prevent type 2 diabetes are also the best ways to treat the disease.

As with diabetes prevention, weight loss is an important treatment strategy.  Even a modest weight loss of five to 10 percent of your weight can improve your body’s ability to use insulin properly and help keep your blood sugar levels in check.  Similarly, what you eat  and how much you eat  matters.  Focus on centering your diet on healthy foods.  These include high-fiber, low-fat foods such as vegetables, whole grains, and smaller servings of lean meat and low-fat or fat-free dairy products.

Physical activity can also improve glucose control and decrease insulin resistance.  The recommendation for adults is to get at least 150 minutes of aerobic exercise a week and to do strengthening exercises at least two days a week.  If you haven’t exercised for a while, you may want to start slowly.  Other lifestyle strategies for managing your diabetes include reducing stress and restricting how much alcohol you drink.  Both stress and alcohol can negatively affect your blood glucose levels.  And if you smoke, consider stopping.  People with diabetes who smoke are at least twice as likely as nonsmokers with diabetes to die of cardiovascular disease, such as heart attack or stroke.  People with diabetes who smoke are also more likely to develop circulation problems in their legs.

Type 2 diabetes is a serious disease, but it can be prevented or managed if you’re going to do your part. The choices you make about your weight, diet and physical activity can have a significant impact on your life. By taking an active role in your health, you can make the most of your todays and tomorrows.