Shock, disbelief and outright denial are common responses to a new diagnosis of Type 2 diabetes (T2D). How did this happen? What can I do about it? I feel fine….for the most part. Can diabetes be reversed?
T2D is one of the most commonly-seen conditions in primary care medical offices and affects almost 10% of the US population or roughly 30 million Americans. Additionally, 79 million adults have impaired glucose tolerance or “pre-diabetes,” which is defined as elevated blood sugar that does not reach the mark for an outright diagnosis of diabetes.
Read below for a comprehensive guide to living with diabetes, including diagnostic criteria, symptoms, medication options, diet choices, physical activity recommendations, and more.
People with higher odds of developing diabetes usually have both lifestyle and genetic risk factors.
The most common risk factors include:
- Overweight or obese
- Sedentary lifestyle – physically active less than 3 times a week
- Poor eating habits
- Have a parent, brother or sister with Type 2 diabetes
- Ethnic groups – African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, Native Hawaiian, or Pacific Islander
- Age > 45
- Had gestational diabetes or had a baby weighing > 9 lbs.
The risks can be lowered through increasing physical activity, eating a diet lower in sugar and grains, and losing weight. Many diabetes prevention programs have led participants to successfully delay or completely prevent the onset of diabetes. While no prediction tool is 100 percent accurate, this calculator may be helpful in identifying your chances of developing diabetes or pre-diabetes.
Type 2 diabetes has some classic hyperglycemia symptoms to be aware of, but it’s also possible to experience none of these before being diagnosed. Many people are completely surprised when diabetes is discovered through routine wellness exams.
Common symptoms that may be experienced include:
- Frequent urination, including at night
- Increased thirst
- Excessive hunger and weight loss
- Blurry vision
The standard criteria for diagnosing diabetes is determined by the American Diabetes Association (ADA) and the World Health Organization (WHO). Normal blood glucose falls in the range of 70-120 mg/dL.
Diabetes may be diagnosed by:
- A fasting plasma glucose ≥ 126 mg/dL
- A random plasma glucose ≥ 200 mg/dL plus symptoms of hyperglycemia
- 2-hour plasma glucose ≥ 200 mg/dL during an oral glucose tolerance test (OGTT) with a loading dose of 75 gm, or
- A1C level ≥ 6.5%
It is recommended to confirm the diagnosis by testing blood sugar levels on a separate day, but the HbA1C (A1C) often tells the blood sugar story in enough detail to confirm the diagnosis.
What is an A1C?
Both the glucose level drawn in a lab and a fingerstick glucose level give an immediate snapshot of what the blood sugar is doing at that moment. However, the A1C provides a key measure of glycemic control over the lifespan of a red blood cell (120 days) and is affected little by day-to-day variations.
The A1C is similar to a blood sugar “report card” and may be done every 3-6 months to determine whether lifestyle changes or medications need to be adjusted. The ADA has set an A1C goal of <7% for most people with diabetes. The goal can be adjusted up or down, depending on the risk of hypoglycemia, age, and other medical conditions. Pre-diabetes is diagnosed when the A1C is 5.7%-6.4%.
Classifying Diabetes – Differences in Type 1 and Type 2
The primary types of diabetes are Type 1 and Type 2, although gestational diabetes and other subtypes exist. All forms of diabetes have high blood sugar as a common feature, but the root cause varies greatly between them.
Insulin is a hormone that is produced in the pancreas by beta cells. Its function is to unlock the door of the cells so that glucose from food can enter and provide energy to them. When insulin is absent or not detected by the cells, the normal regulation of blood sugar balance in the body is disrupted and glucose stays in the blood instead of moving into cells where it’s needed.
Type 1 Diabetes (T1D)
T1D accounts for about 5%–10% of all diabetes. It can occur at any age but is most commonly diagnosed in those less than 18. A family history of diabetes is not often seen in Type 1.
T1D results from an autoimmune disease where the body mistakenly attacks and destroys beta cells, leading to total or near-total insulin deficiency. The onset is sudden, with extreme thirst, frequent urination, weight loss and lethargy.
Up to 40% of Type 1 patients are diagnosed when they are admitted to the hospital in diabetic ketoacidosis (DKA), a life-threatening condition resulting from an absence of insulin plus an inciting event. Because Type 1’s do not make any insulin on their own, all of their treatment comes through multiple daily insulin injections or an insulin pump.
Type 2 Diabetes (T2D)
T2D makes up 90%-95% of all diabetes cases, most of them being in individuals who are overweight or obese. It is caused by a combination of defects but is primarily related to insulin resistance and insulin deficiency.
Insulin resistance develops when the skeletal muscles, fat tissue, and liver do not respond to the insulin made by the pancreatic beta cells. They have built up a tolerance to insulin, making it less effective.
Insulin deficiency develops when beta cells burn out from years of high production trying to overcome insulin resistance. The resulting hyperglycemia, or excess sugar in the blood, causes long-term toxicity to almost every organ system.
Type 2 most commonly occurs in people older than 40 who are usually overweight or obese. It is becoming more frequently diagnosed in children and adolescents due to the increase in obesity and sedentary lifestyle in our society.
Comparison between Type 1 and Type 2 Diabetes
|Type 1||Type 2|
|Onset||Sudden, severe||Gradual, over years|
|Age of onset||Any, most often <18||Any, most often >40|
|Weight status||Normal BMI||Overweight or obese|
|Cause||No insulin||Insulin resistance, obesity|
|Family history||5-15% of 1st degree relatives may have T1D||>50% of 1st degree relatives may have T2D|
|Prevalence||5-10% of all diabetes||90% of all diabetes|
|Treatment||Insulin||Weight loss, oral meds, insulin|
Role of Diet in Type 2 Diabetes
The vague instructions of “make lifestyle changes” or “eat healthy” are not helpful for most people diagnosed with T2D. There is so much conflicting information to be found on the “best” diet for people living with diabetes that one can stay completely confused by trying to discern what will lead them to controlled blood sugar levels.
What is clearly known is that carbohydrates break down into glucose in the body, and of all the macronutrients (carbs/fat/protein), carbs impact blood sugar the most.
What differs among people is how much a certain amount of carbs will raise your own individual blood sugar. This is known as carb tolerance and is unique to you. It is mostly dependent on your level of insulin resistance and genetic factors, but weight, activity level, and muscle mass also play a role.
Learning your own carb tolerance will answer the question, “How many carbs should I eat in a day?” and will empower you to make food choices that lead to improved glycemic control. Follow this guide which uses blood sugar monitoring to determine your own carb tolerance.
Key point – There is no “one size fits all” eating style for successfully living with diabetes, and the topic can become controversial rather quickly. Self-experimentation, continually learning, being open-minded to try new things when your method isn’t working will all contribute to finding the right eating plan for you. And that may not necessarily be what works for someone else with T2D.
Helpful tips for living with diabetes regardless of what diet is followed:
- Learn to identify the carb content of food. You may not be interested in a very low carb diet, but quickly knowing which vegetables contain the most carbs, the difference between high and low carb foods, and the number of carbs contained in one serving of a particular food will put you far ahead on any carb controlled eating plan. Find an app or website that has this information readily available and consult it often until you understand the basic principles.
- Learn to read a nutrition label. Nutrition labels tell you the number of carbohydrates, calories, fat, and salt (sodium), as well as specific ingredients that a food contains. The legal requirements for nutrition labels change occasionally, so this guide should help keep you up to date.
- Increase fiber intake. Make the carbs you consume high quality. High fiber foods do not cause the high blood sugar spike post-meal.
- Don’t fall down the sugar substitute trap – a controversial topic in its own right! Just because a sugar alternative has zero calories, doesn’t mean it will not cause a rise in insulin, which leads to your body storing more glucose as fat. Current research suggests that stevia does not impact blood sugar and can be a better sugar substitute choice, although some find the taste quite bitter.
- Don’t drink sugary drinks – sodas, juice, energy drinks, sweet tea, and some alcohol contain enough sugar to sabotage a low carb lifestyle. Pay attention to the carb count in beverages.
A meeting with a registered dietitian can be beneficial to living with diabetes as you find a sustainable style of eating that matches your preferences and goals.
Two leading nutrition philosophies which hold vastly different views are the ADA Diet (or any related modifications) and the Ketogenic Diet. The DASH diet, the Mediterranean diet, Paleo, and other ways of eating have also been recommended as options for individuals with diabetes.
ADA diet guidelines
The ADA has a well known eating plan based on the standard recommendation of 45 grams of carbs per meal and follows the plate method. The plate method suggests filling half of your plate with non-starchy vegetables, and the remaining portions of the plate should include 25% protein and 25% whole grains. No foods are strictly forbidden on this plan. Portion control, getting adequate fiber and consuming lower fat foods are key.
Critique: While a balanced and open-minded eating plan will be the least different from a standard American diet and possibly the easiest to follow, it is less likely to lead to well-controlled diabetes. The carb limit of approximately 150 g/day or more will be excessive for most people.
Low carb diets in general have become more mainstream in recent years, but the ketogenic diet specifically focuses on low-carb high-fat (LCHF) eating. The goal of the keto diet is to get the body to make ketones, a different energy source than the carbohydrates your cells typically use for energy. Most keto diets recommend 80% fat, 15% protein and 5% carbohydrate. Because of the feeling of fullness as a result of high-fat eating, the keto diet leads to weight loss more rapidly than a low-fat diet.
Keto diets have been studied for a variety of diseases, notably neurologic and metabolic conditions. The keto diet can restore insulin sensitivity, so doses of diabetes medication may need to be adjusted if you are following this low-carb way of eating. Consult your physician to ensure that you don’t have other medical conditions that would make keto eating unsafe.
Critique: One of the main criticisms of the keto diet is that many people tend to eat too much protein and poor-quality fats from processed foods, with very few fruits and vegetables. Patients with kidney disease need to be cautious because this diet could worsen their condition. Some argue that it is too restrictive and unrealistic to maintain long-term.
Blood Sugar Monitoring
Self-monitoring of blood glucose (SMBG) provides information regarding your changing blood glucose profile and should be part of a regular management plan in diabetes. The information learned can help with the appropriate scheduling of food, activity and medication.
There is debate over optimal frequency and timing of SMBG in those with T2D using only oral medication. Some health practitioners are skeptical about the effectiveness of SMBG as a self-management tool, although the real value is in the way the data is used.
The greatest benefit from SMBG is the way it helps you connect your behaviors or actions with the number you see. The more connections you can make between your glucose number and what may have caused it, the better you will become at living with diabetes.
There is no limit to the number of factors that can make blood sugar swing between highs and lows. You can use the knowledge gained from SMBG to make all kinds of decisions that can lead to better overall control. It’s not just writing down numbers or tracking them electronically that make a difference. It’s the way you use the information.
Continuous glucose monitoring (CGM)
Unlike a snapshot moment in time blood sugar reading, CGM provides continuous information on glucose numbers throughout the day, without fingerstick checking. Most CGM devices have a small sensor device that is worn for 7-10 days. They are usually approved by insurance in T2D for those who check their blood sugar 4 times a day and are on multiple insulin injections. The benefits of CGM are the valuable insight gained about your glucose levels and rate and direction of glucose change. The Dexcom and Freestyle Libre are two CGM devices available for personal use.
There is no doubt that a sedentary lifestyle contributes to T2D and that physical activity is a key element in the prevention and management of diabetes. A combination of aerobic and resistance training is considered more effective for blood sugar management than either type of exercise alone and is an important part of living with diabetes.
How much activity is needed?
The ADA recommends that people with T2D get at least 150 minutes of exercise a week, or 30 minutes a day on five days of the week. Aim to do resistance training at least twice a week when living with diabetes. Studies show that three 10-minute sessions may be just as effective as doing 30 minutes continuously. High-intensity interval training in 10 one-minute bursts of intense aerobic activity can lower blood sugar in people with type 2 diabetes for 24 hours afterward. Building muscle mass through resistance training will improve insulin sensitivity.
Start with what you can comfortably do, and build up from there. Progressively increasing the duration and intensity of exercise will safely build your endurance without discouraging you to the point of wanting to stop.
Safety during exercise
Checking your blood sugar before and after physical activity will show its effect on your body when living with diabetes. This will also let you know if you need to carry fast-acting carbs or eat a snack prior to the activity. Drink plenty of water and listen to your body if you are experiencing unexpected discomfort or are having alarming symptoms such as shortness of breath or chest pain. Wear proper footwear to avoid blisters or other injuries.
Once you have been cleared by a physician for exercise, the important thing is to get started. If you have never built physical activity into your life before, this can be one of the hardest habits to form. Set small goals, identify obstacles, and start breaking them down. A lifestyle that includes adequate physical activity is much more likely to achieve blood sugar goal and avoid progressive medication management of diabetes.
Type 2 Diabetes Treatment
Several distinct classes of drugs exist to treat T2D. Metformin is generally accepted as the first-line treatment and is currently the most commonly used oral agent prescribed for diabetes. It is usually recommended in combination with diet and exercise, but can also be used along with any other diabetes medicine. Metformin has many benefits, such as lowering the A1C by up to 2%, low risk of hypoglycemia, low cost, and no weight gain. Its main drawback is the GI side effects, primarily diarrhea. A complete review of metformin and how to improve tolerance can be found here.
If a goal A1C is not achieved through lifestyle changes plus metformin after 3 months, treatment is advanced and other classes of diabetes medications may be added. There is no exact algorithm to determine the next best drug that should be prescribed for everyone, but there are some general principles that can be applied to this decision. An in-depth discussion of this process can be found here.
Risk of hypoglycemia, cost, weight change, other side effects, cardiovascular protection and amount of A1C reduction are all important factors in medication selection. But the primary predictor of success with an oral medication is your acceptance and tolerability of whatever is prescribed. At the end of the day, the best and right medicine is the one that you are willing to take day in and day out to achieve control of blood sugar long-term.
Because of the prevalence of insulin resistance in T2D, over time, many people will require the addition of subcutaneous insulin to achieve their goal A1C. There are many myths around the topic of insulin which prevent people from agreeing to try it when living with diabetes. It can be a very scary step, but once adjusted, most insulin users report that it helps control their blood sugar without a significant decrease to their quality of life.
Insulin preparations are classified according to their duration of action – short acting and long acting. One unique thing about insulin dosing in T2D is that the time to peak hypoglycemic effect and insulin levels is not completely predictable among users, due in part by variations in the rate of absorption in the subcutaneous tissue.
Insulin may be delivered with a vial and syringe, through a pre-filled pen device or a pump. Pens are more simple to use than vials and syringes, and their differences are reviewed here.
Short-acting insulin is used to control mealtime blood sugar spikes. “Rapid-acting” insulin includes Novolog, Humalog or Apidra and are administered shortly before meals. Their onset of action is within 15 minutes, so they offer flexibility with regard to injecting tied to an eating schedule. Regular insulin (Novolin R, Humulin R, Relion R) does not start working quite as quickly as the rapid-acting insulin and should be injected about 30 minutes before mealtime. The main advantage of Regular insulin is a lower cost.
Basal insulin delivers micro amounts of insulin to the bloodstream all throughout the day. Most are designed to last about 24 hours, but some are slightly shorter (Determir/Levemir) while some basal insulin is longer acting (Deguldec/Tresiba). Newer formulations are more concentrated to allow a smaller volume of insulin to be injected, but the time-action profile of these does not change. Concentrated insulin can be beneficial when insulin resistance is high and larger doses of insulin are needed.
The cost of basal insulin can be quite high, but one form of glargine (Lantus) was approved in a less expensive form (Basaglar). The differences and similarities of Lantus and Basaglar are reviewed here. NPH is an intermediate-acting insulin that can be injected twice daily to serve as a less expensive basal or background insulin. Novolin N, Humulin N and Relion N are the three brands available.
In some instances, short-acting and long-acting insulin are combined in the same product in various ratios – 70/30, 75/25, 50/50. The ratio of long-acting insulin is commonly the highest of the two. These offer the convenience of both meal-time and basal coverage in one injection. The drawback is less control overdose adjustments and individualization of the components to meet blood sugar needs.
One of the most dangerous and downright frightening attributes of living with diabetes is the possibility of having a low blood sugar episode. This defined as glucose <70 mg/dL, although some sources use <60 mg/dL.
Hypoglycemia can occur for a variety of reasons, but most often happens when too much insulin is given or when dosing errors occur. Not eating enough or an increase in physical activity can also contribute.
Symptoms of hypoglycemia
Sweating, nausea, hunger, tingling, fast heartbeat, tremor, and anxiety are the first symptoms experienced when blood sugar drops too low. More advanced symptoms are difficulty in concentrating, confusion, weakness, drowsiness, a feeling of warmth, dizziness, blurred vision, and loss of consciousness. Severe hypoglycemia can lead to seizure and coma.
The goal of hypoglycemia treatment is bringing the blood sugar back to a normal range as quickly as possible. The Rule of 15 is an easy to remember process for treating hypoglycemia episodes. This rule says that you should consume 15 grams of fast-acting carbs. Wait 15 minutes and recheck your BG. If you’re still less than 70, eat 15 more grams of fast-acting carbs. Repeat that up to 3 times. If this isn’t doing the job of getting you to 100 or more, seek emergency medical treatment for more intense intervention.
Examples of 15g carbohydrate:
- ½ C fruit juice
- ½ C regular soda (Coke, Sprite, etc)
- 1 C milk
- 3 glucose tablets
- 1 tube glucose gel
- 5 hard candies
- 1 Tablespoon of honey, sugar or corn syrup
A comprehensive guide on the causes, prevention and treatment of hypoglycemia and “false lows” can be found here.
Type 2 Diabetes Complications
Many people with T2D feel “normal,” especially when diabetes is well-controlled. But chronic hyperglycemia (called glucotoxicity) can damage both large blood vessels throughout the body, called macrovascular disease, and small blood vessels throughout the body called microvascular disease.
Macrovascular disease results in an increased risk of heart attack, stroke and decreased blood flow to the lower legs. Aggressive management of cardiovascular risk factors such as smoking cessation, cholesterol management, and blood pressure control is needed to reduce the possibility of macrovascular disease.
1) Coronary Heart Disease (CHD)
The standard recommendations for reducing the chances of cardiovascular disease are important here. Treatment of dyslipidemia and high blood pressure, smoking cessation, and antiplatelet therapy (aspirin) when needed reduces macrovascular events.
2) Dyslipidemia (Cholesterol)
Statin therapy is recommended regardless of baseline lipid levels in 1) patients with existing CHD or 2) patients without CHD who are over the age of 40 or have CHD risk factors other than diabetes.
3) Hypertension (Blood Pressure)
The ADA recommends a BP goal <140/80 mmHg. Some guideline creators suggest a goal of <130/80 mmHg, especially in younger patients, those at high risk of a stroke, or if kidney disease is present. Medications such as ACE inhibitors and ARBs are recommended as initial treatment to reduce blood pressure.
4) Antiplatelet (Aspirin)
The recommendation of aspirin in those with T2D and no history of heart disease has changed over the years because of the risk of bleeding events with aspirin. The ADA still recommends aspirin in some diabetics with other risk factors for cardiovascular disease. The use of aspirin for primary CV prevention should be an individual decision between you and your physician. However, aspirin is still recommended for secondary prevention once a cardiovascular problem has occurred.
Aspirin or other antiplatelet therapy may be considered in peripheral arterial disease or foot ulcers to help with circulation.
Microvascular disease shows up in the retina (eyes), kidneys and nerves, called retinopathy, nephropathy and neuropathy. These complications are specific to diabetes. Early treatment of blood sugar to near-normal levels greatly decreases the risk of these problems.
- When caught early, retinopathy may reverse with improved blood sugar and blood pressure control. More advanced retinopathy will require laser surgery or other interventions to stop progression.
- Early stages of retinopathy are without any symptoms, but advanced disease can lead to spots in the visual field, blurry vision or loss of vision if untreated.
- An annual retinal photograph or dilated eye exam is recommended to allow quick action on any problems identified.
2) Neuropathy (Nerve disease)
- Neuropathy is one of the most common complications in patients with T2D and can take a significant toll on one’s quality of life. Tingling, numbness, or pain are the primary symptoms. The feet are usually affected more often than the hands. Improved blood sugar control is the primary treatment.
- Medications may be prescribed for severe neuropathy causing ongoing pain. Drugs such topical capsaicin cream, NSAIDs, gabapentin, low-dose tricyclic antidepressants, pregabalin (Lyrica), and others may provide relief.
3) Nephropathy (Kidney disease)
- Kidney disease is also without symptoms. Glucose and BP control are important for preventing and slowing the progression of nephropathy.
- A urine test called microalbumin should be performed annually to detect early kidney damage. If microalbumin is found, the ACE inhibitor class of blood pressure medicine is usually prescribed for kidney protection. If nephropathy has progressed, other measures of kidney function such as the glomerular filtration rate (GFR) and serum creatinine (SCr) will be followed.
Emotional Burden of Diabetes
Beyond the shock and denial of an initial diabetes diagnosis, the emotional difficulties of a chronic disease can be overlooked when medical care is the primary focus of treatment.
Discouragement and depression are common in diabetes and can lead to worse disease control when not addressed. The social, psychosocial and cultural aspects of living with diabetes are important factors that can impact the quality of life and health.
The hope available to a person with well-controlled T2D is not spoken of often enough. The gloom and doom statements of diabetes being the leading cause of blindness, kidney disease and amputations are well known. Less known but what should be loudly proclaimed is that well-controlled diabetes is the leading cause of NOTHING!
The Behavioral Diabetes Institute is a non-profit organization that focuses on addressing the social, emotional, and psychological barriers to living a long and healthy life with diabetes. They are actively engaged in research examining the psychological aspects of diabetes and evaluating innovative behavioral interventions. Print and video resources are available to offer help to patients and healthcare providers.
The isolation and heaviness of diabetes are well known. Be proactive in getting help from your primary care team or mental health professional when needed. Some specific ideas on how to deal with the stress of living with diabetes are offered here.
There is an overwhelming amount of information to know about T2D, which is a largely self-managed disease. The amount of incorrect information about living with diabetes that is passed on through word of mouth or unreliable sources is astounding.
Research has shown that people who have gone through diabetes education programs:
- Use primary care and preventive services
- Take medications as prescribed
- Control their blood glucose, blood pressure and cholesterol levels
- Have lower health costs
Through whatever means that work for you, find a trustworthy place to learn the basics of comprehensive diabetes care. This includes blood sugar control through diet, exercise and medications. It also includes treating conditions associated with diabetes, such as hypertension, dyslipidemia, obesity and cardiovascular disease. And finally, routine screening and management of diabetes-related complications should be a priority in order to ensure a high quality of life for years to come.
Follow www.mydiabetesvillage.com for ongoing support for living with diabetes.
Want some quick and easy diabetes-friendly snacks?
With this list, you won't have to wonder what to eat in between meals!
Download it to your phone or tablet and keep it handy, or print it off and keep it by your fridge.