Treatment for Diabetes Mellitus

Treatment for Diabetes Mellitus Treatment for Diabetes Mellitus

How is type2 diabetes treated?

Type2 diabetes is treated commonly with oral anti-diabetic drugs along with intensive lifestyle modification. Some patients with type2 diabetes have very high blood glucose values - a diagnosis with HbA1c of greater than 10% and random blood glucose values of more than 300 mg/dL. These patients would require insulin therapy for a short duration before oral antidiabetic drugs are initiated. 

What is intensive lifestyle modification in type2 diabetes?

Intensive lifestyle modification refers to all measures taken by patients with type2 diabetes that can reduce or eliminate the need for concomitant medication. These modifications can also be used to prevent diabetes and they’re considered to be very effective. They’re in fact more effective in the elderly than in younger patients with type2 diabetes and everybody who is capable of doing lifestyle modification should pursue them.

What are the elements of lifestyle modification? 

Intensive lifestyle modification in type2 diabetes has two main components and several minor components.

Main components 

  • Physical activity or exercise
  • Diet

Minor components 

  • Getting adequate sleep
  • Adequate treatment of anxiety or depression, if present
  • Avoiding shift work if it is possible
  • Dental prophylaxis or treatment of periodontitis
  • Smoking cessation

Diet for type2 diabetes is individualized based on the body mass index and excess body fat of the patient. If there is excess body fat or obesity, losing weight would definitely improve type2 diabetes. For those who have normal body weight and do not have an Enlarged waist circumference, weight loss may not be a reasonable goal. In such patients, improving the body composition with the improvement of muscle mass will be the goal.

Diet with weight loss goals

Our dieticians at Magna usually recommend a calorie restricted diet. The goal will be to restrict your daily intake of calories by 500 cal over your usual intake. As a first step our dietician will assess your daily calorie intake during a follow-up of a few days. After that, they will modify their initial diet prescription to make sure that you are consuming less calories than usual with continuous monitoring of your weight. The calorie composition is also looked at to see that carbohydrate intake as part of total calories does not exceed 50%.

In order to improve type2 diabetes, regular physical activity is required. Doing physical activity once or twice a week will not be beneficial whereas doing physical activity at 24-hour intervals daily will be more beneficial. 

How intense should exercise be in type2 diabetes?

Doing any amount of physical activity will be of benefit in type2 diabetes, activity that is more intense will have the optimal benefit.  Typically we recommend patients with no symptoms, which are suggestive of the cardiac disease, to start an intensive exercise program. Guidelines recommend 150 minutes per week of moderate to high-intensity physical activity. Moderate-intensity physical activity usually will increase your heart rate to between 50 and 75% of your target heart rate. Your target heart rate is usually calculated as 220 minus your age. For example, a 40-year-old person will have a maximum target heart rate of 180 per minute, so physical activity in his case will be moderate if the target heart rate is between 90 and 135 bpm. This is achieved by brisk walking rather than strolling.

Many people who do not have adequate physical fitness and are totally sedentary may have higher rates with lower intensity of activity. They should do weight loss through diet and slowly increase the intensity of physical activity. We can also define physical activity in terms of the speed with which walking or running is done. Walking at 5 to 6 km/h is considered a moderate-intensity intensive activity for someone with average physical fitness. Jogging or running at more than 7 km/h is considered high-intensity physical activity.

Strength training

For those patients with type2 diabetes who have Sarcopenic obesity, a lower muscle mass with excess body fat, strength training becomes very imperative. Strength training refers to exercising muscles against a fixed resistance in order to improve muscle tone and strength. Usually, 30 minutes of strength training activity is recommended, at least three days a week under the guidance of a good physical trainer. In all our centers, we recommend strength training as part of our diabetes management for individuals who require the same.

Medications for the treatment of type 2 diabetes

  • Why are medications required in type2 diabetes?
  • Can medication be avoided in Type 2 diabetes?

Many people consider taking medication for type 2 diabetes as a form of dependency on medication and also a failure of their own lifestyle modification efforts. This is in fact not accurate. Studies have shown that despite optimal lifestyle modification, say diet to the prescribed extent and physical activity with the achieved goal of weight loss, diabetes does tend to progress in individuals over a 5 to 10-year period. This is because type two diabetes is a polygenic disease and the gene dysfunction leads to progressive loss of beta cell function.

Since lifestyle intervention is not uniformly successful in individuals with type two diabetes, we at Magna always recommend medication along with lifestyle modification. Another reason for starting medication early in the course of type two diabetes is that many long-term studies have shown that those individuals who control their blood glucose very well from the day of diagnosis tend to do better than those individuals who have higher HbA1c values over time. In fact, when patients ask us what can be the long-term side-effect of medication, we say that one of the important side effects is actually old age. Therefore, if you have type2 diabetes you must view oral medication as an ally and seek rational use of them in order to maintain your Hba1c at the lowest possible level without any over effects.

How do we decide which patient should get which medication?

If you have type two diabetes and have had a heart attack or stroke or if you have been admitted with heart failure to the hospital, then SGLT2 inhibitors have to be used in your treatment without other medication. This is because using these medications will increase longevity in patients who have such conditions. Apart from this, there are several new studies which show that using a combination of medications at the onset of diabetes treatment gives long-term success in terms of both control and avoiding complications.

After taking into account the severity of your diabetes and your comorbidities, a certified Endocrinologist will decide on your medical therapy. At the time of initiation, usually, the probable side effects of medication are also discussed. Fortunately, most of the medications that are used to treat type two diabetes have few or no side effects. There is also a diabetes educator or a nurse who is a part of all our care teams and all our patients have the phone number of these educators. In case of any symptoms that may emerge after initiation of oral antidiabetic drugs, this is addressed easily over the phone or via online chats. Our experience over the years has been that patients have been able to understand their medication better and follow the medication as per recommendations, if they have access to our diabetes educators.

What is the type of medications used to treat type2 diabetes?

There are 5 main classes of oral medication used to treat type two diabetes. In each of these classes of medication, there may be several different chemical entities or drugs which have slightly different properties. Within each class of medication, the medication would act with a similar mechanism.

  • Biguanide(metformin)
  • DPP 4 inhibitors
  • Pioglitazone
  • SGLT 2 Inhibitor
  • Alpha glucosidase inhibitors
  • Sulphonylureas

Patients who are on oral medication and where the doctor is confident that the HbA1c control will be optimal over a three-month period usually need not self-monitor their blood glucose. Self-monitoring of blood glucose is recommended more for patients who require insulin and for patients with pregnancy. However, we strongly recommend that all patients with type two diabetes monitor their HbA1c with a good quality AC every three months, and usually along with HbA1c the random blood glucose is also measured. In all our centers, we have a point of care HbA1c which can provide results within a few minutes. Typically, patients who visit our centers get their HbA1c done along with their usual vitals examination. This improves care because the planning and execution required for care reduces for the patient. We set a goal of HbA1c based on the age of the patient, the number of comorbidities that they have, and their cardiovascular risk as well.

Blood glucose is the only important thing to be looked at in patients with type2 diabetes?

Contrary to popular belief, our Endocrinologists focus on several other parameters of patients with type2 diabetes and his or her health. These are BP, LDL or lipid levels, need for antiplatelet therapy, renal function, Retina Pati, urine albumin excretion rate, and cardiac condition. This is also the reason why we recommend an annual physical examination for diabetes-related complications. Read more about our annual diabetes health checks here .

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