Diabetes: Your Treatment Options

WebMD Live Events Transcript

Treatment of your diabetes is truly a team effort between you and your doctors. Balancing diet and drug approaches to best control your condition, plus evaluating new or complementary treatments, is a big job for everyone involved. We sorted though the options on Sept. 23, 2004, when JoAnn Manson, MD, from the Harvard School of Public Health, was our guest.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Support for this University course was provided by Medical Mutual.

MODERATOR:
Welcome to WebMD University: "Diabetes: Get the Advantage" Your instructor is JoAnn Manson, MD, from the Harvard School of Public Health. She joins us to look at treatment options.

Dr. Manson, how feasible it is to avoid medication if diet and exercise are able to keep levels in a healthy range?

MANSON:
It is possible for many people to avoid taking medications if you include regular exercise and have a hearth healthy diet.

However, it's important to be testing your blood sugar regularly and know that your fasting blood sugar is less than 126, and that your hemoglobin A1C is less than 7. If your numbers are running higher than that, you may need a combination of lifestyle and diet modification.

Exercise is probably the most important thing you can do to reduce the need for medication, regular moderate or vigorous exercise, including brisk walking up to 30 minutes daily, keeps blood sugar under control for many people and lowers the risk of cardiovascular disease.

For type 1 diabetes, which usually occurs in people under the age of 30, medication is essential and the use of insulin is required to keep blood sugars under control. When we're talking lifestyle modifications and controlling blood sugar, we're talking about type 2 diabetes, though lifestyle modification is important whether you have type 1, type 2, or don't have diabetes. Everyone should have 30 minutes of moderate or vigorous exercise daily.

MEMBER QUESTION:
I am 49 and a brittle diabetic with blood sugars that are way out of control. I was up to 200 units of insulin a day just to stay below 200. Would the insulin pump be useful versus daily shots?

MANSON:
The insulin pump may be helpful for you. Your doctor may also want to try a combination of insulin and oral medication that would lower insulin resistance. That could be helpful, especially if you have type 2 diabetes. I'm assuming you have type 1, however, in which case the insulin injections would be critical and an insulin pump may offer you better control than separate injections.

Fortunately there's been a lot of progress in the treatment of type 2 diabetes in the last decade with many new options available. Many people with type 2 diabetes may benefit from the TZD, such as Avandia and Actos. Also Metformin or glucophage are commonly used, both Metformin and TZD can be taken together. Occasionally insulin is used with one of these oral medications to control diabetes, especially in type 2. There are many more treatment options for controlling blood sugar and often a combination of medications can be most effective.

"Lifestyle modification is important whether you have type 1, type 2, or don't have diabetes. Everyone should have 30 minutes of moderate or vigorous exercise daily."

MEMBER QUESTION:
If blood sugar elevates due to stressors as in General Adaptation Syndrome, how high will it go and how fast is the reaction? For example, what is the chance of an elevated blood sugar in a clinical setting when the patient is uncomfortable in the doctor's office? If blood sugar elevates due to stressors, (for example, when the patient is uncomfortable in the doctor's office), how high will it go and how fast is the reaction?

MANSON:
Stress is a major cause of an increase in the blood sugar level and associated with higher levels of hormones, such as cortisol and epinephrine. These hormones can significantly increase blood sugar, even within 30 to 60 minutes of the stress-related event. Ways to reduce this stress include:

  • Walking. It's a very good way to reduce the stress.
  • Many find that concentration on deep breathing is helpful.
  • Of course, try to avoid situations that induce stress.

I found that exercise is one of the most helpful ways to reduce stress levels.

MEMBER QUESTION:
Is it ever possible for someone diagnosed with type 1 diabetes to get off of insulin therapy through diet and exercise?

MANSON:
Generally no, people with type 1 diabetes do not make sufficient insulin, and they usually require lifelong insulin treatment.

It is not safe to try to go without insulin. The risk can be life-threatening, such as going into ketoacidosis. For people with diabetes, the greatest risk is cardiovascular disease, so the most important thing you can do is to reduce your risk factors for heart disease and stroke. That includes:

  • Knowing your blood pressure level
  • Knowing your cholesterol level
  • Getting treated if you have hypertension or high cholesterol

It is very common to require medication to treat hypertension and high cholesterol for people with diabetes, and treatment can lower your risk of heart attack, stroke, congestive heart failure, and many other cardiovascular complications.

More than two thirds of people with diabetes die from cardiovascular events, so that's the most important outcome to avoid. Many people with diabetes benefit from statins to lower the cholesterol; medications such as Lipitor, Zocor, Pravachol, and others. For high blood pressure -- and even in the absence of significantly increased blood pressure -- ace inhibitors can be very helpful, such as Captotril, lisinopril, Ramipril. They reduce the risk of kidney disease and lower blood pressure.

MEMBER QUESTION:
Can diabetes cause high cholesterol in someone who has never suffered from it?

MANSON:
Yes, diabetes can lead to abnormalities in cholesterol. Also, the underlying risk factors for diabetes, such as metabolic syndrome, can increase the risk. It's a combination of diabetes leading to abnormal cholesterol, and the underlying conditions that heighten the risk of diabetes also leading to high cholesterol.

"More than two thirds of people with diabetes die from cardiovascular events, so that's the most important outcome to avoid."

MEMBER QUESTION:
Can coffee, regular or decaf, interfere with insulin absorption?

MANSON:
Coffee has been linked to a decreased risk of developing type 2 diabetes, but in someone who already has diabetes, it may have an adverse effect on blood sugar. Generally less than two or three cups a day, is fine. There's very little evidence it affects insulin absorption, so it's fine to indulge in coffee. But avoid the whipped cream and other high-caloric trappings that often go with coffee.

MEMBER QUESTION:
What is your opinion of the South Beach diet?

MANSON:
I think the South Beach Diet, which is high in fruits, veggies, and whole grains, is a very reasonable diet for people with diabetes, especially if it leads to weight loss. The Mediterranean diet, which is high in fish, fruits, veggies, nuts, and whole grains, is also a very good diet. The Atkins diet long-term may be a problem for people with diabetes because of the high saturated fat and meat. The real key for controlling blood sugars and preventing the long-term risks of diabetes is to:

  • Maintain a healthy weight
  • Be physically active
  • Get your cholesterol under control
  • Get your blood pressure and blood sugar under control

Any diet that's well tolerated, that can be maintained long term, and leads to weight loss and maintaining the weight loss can be very effective for these goals. A few things I think are very helpful in lowering the risk of cardiovascular disease for people with diabetes include:

  • Increasing your intake of fish (to one or two servings a week)
  • Increasing your intake of omega-3 fatty acids
  • Lowering the saturated fat in your diet (such as from meat and high-fat dairy)
  • Avoiding trans fatty acids (such as from baked goods and French fries) is very important for type 2 diabetes

The glycemic index is important in terms of avoiding the refined sugars that rapidly increase the blood sugar. So instead of white bread or white rice, have whole grain bread and wild or brown rice; foods that are higher in fiber and higher in whole grains. Also avoid sugar-sweetened beverages and foods that increase the blood sugar quickly.

MEMBER QUESTION:
Which fish are safe to eat; I hear so much lately about contaminated sources?

MANSON:
Certain fish are high in mercury -- such as swordfish, shark, and tile fish -- and should be eaten no more than once a month. However, most fish can be eaten at least once or twice a week, including:

  • Salmon
  • Herring
  • Sardines
  • Mackerel
  • Cod
  • Most shellfish

MEMBER QUESTION:
I've been on the South Beach diet, recently diagnosed type 2, and my dietician wants me to consume 225 grams of carbs a day, much more than I was eating. This sounds like the wrong thing to do, what do you think?

MANSON:
I think 225 grams of carbs per day sounds a little high. That's going to be 900 calories a day from carbs. Depending on your total caloric intake, that might be reasonable or it may be too much, if you're limiting calories. Usually we recommend 50% to 60% of calories from carbohydrates though this can vary and there isn't a firm recommendation. The greater issue is the type of carbohydrate, rather than the total amount. Lean toward whole grains, fruits, and vegetables as opposed to refined carbohydrates and simple sugars which rapidly increase blood sugar.

MEMBER QUESTION:
If I cannot eat more than 15 to 20 grams of carbohydrates per meal, do I need to be on medicine so that I may eat more fruits and grains?

MANSON:
Few people would have to restrict their carb intake to 15 to 20 grams per meal, especially if they're eating whole grains and high-fiber foods. I don't think you need to restrict yourself.

MEMBER QUESTION:
Do fruits need to be kept to a minimum because of their sweetness?

MANSON:
Certain fruits will increase the blood sugar level more than others. For instance, grapes and berries have a tendency to do that, but apples, pears, and most fruits are not a problem.

MEMBER QUESTION:
What exactly is a refined carb or a simple sugar?

MANSON:
It has to do with how quickly the blood sugar level increases after consuming the carbohydrate. Generally whole grains and fruits and vegetables tend to be fine, while refined carbohydrates very quickly increase blood sugar and include candy, sugar-sweetened sodas, cookies, and cakes.

"It's very important to see an eye doctor regularly, at least once a year, to check for retinopathy, because that can lead to vision loss and blindness."

MEMBER QUESTION:
Why does a diabetic person need excessive amounts of insulin if the body only makes so much insulin anyway?

MANSON:
Many people with diabetes have insulin resistance, leading to a requirement for more insulin than people without diabetes would normally make. Some of the insulin resistance is due to risk factors for diabetes, such as obesity or sedentary lifestyle; some is a hereditary predisposition to insulin resistance.

MEMBER QUESTION:
Where would one go for "state of the art" diagnosis and treatment of diabetes?

MANSON:
Many doctors of internal medicine, primary care physicians, are extremely skilled in treating patients with diabetes. You may want to check with your local medical center to find out which doctors specialize.

Endocrinologists benefit some patients who are having trouble controlling their blood sugar, who have brittle diabetes, or who are running into complications. Find out from your local and state medical society who is board certified in endocrinology.

There are many communities that now have a Joslin Diabetes Center, so if you live near one, that can be a valuable resource. It's very important to see an eye doctor regularly, at least once a year, to check for retinopathy, because that can lead to vision loss and blindness. Also have your urine tested to check for signs of protein in the urine, which is a marker for developing kidney disease.

MEMBER QUESTION:
I was diagnosed with gestational diabetes, at what level should I keep my blood sugar to avoid getting type 2 diabetes?

MANSON:
Gestational diabetes is a strong predictor of developing type 2 diabetes within 10-15 years, so it's important to have regular fasting blood sugars checked to see if diabetes is developing. The best ways to lower your risk are regular exercise (at least 30 minutes of brisk walking or other activity every day), maintaining a healthy weight (and that may mean losing weight for many people), and following the type of diet we discussed: higher in fish, fruits, and vegetables; and lower in fat and refined sugars.

MEMBER QUESTION:
My a.m. fasting levels are borderline -- when do you recommend starting medicine?

MANSON:
It's best to have a fasting blood sugar less than 126, so 125 is as high as you want to run on a regular basis. If you are consistently above that level, despite lifestyle modifications such as regular diet and exercise, then talk to your doctor about medication.

MEMBER QUESTION:
I have type 2 diabetes and am just starting with glucophage. Do the symptoms of nausea and stomach cramps decrease or disappear with time?

MANSON:
They very often decrease over time, so if you can tolerate the symptoms for a few weeks, it may be worthwhile to give the medication a longer trial period. However, you may also want to ask your doctor about starting with a lower dose and gradually increasing; you may tolerate that better. If you continue to have significant side effects, you could switch to one of the TZD-type medications, such as Actos or Avandia.

MEMBER QUESTION:
What might the long-term effects of hypoglycemic reactions be on the heart and brain?

MANSON:
There is less research on that subject than we'd like. There's a suggestion that repeated episodes of hypoglycemia may impair brain function and could have adverse effects on cognition. In terms of the heart, there's very little known, although it's certainly not good for it to be deprived of its fuel for long periods repeatedly. So hypoglycemic reactions should be avoided if at all possible.

"Lantus is absorbed more quickly than standard forms of insulin, so it can be more effective in lowering blood sugar after a meal."

MEMBER QUESTION:
I don't understand why my highest readings (160-180mg/dl) are early in the morning, when I haven't eaten in 12-plus hours. How can diet possibly cause such levels?

MANSON:
Sometimes medication can cause a low blood sugar while a person sleeps, then a rebound in the morning. It could be a sign that there was hypoglycemia during the night if the patient's on medication, if not, it may be because in the morning certain hormones are at their highest level, particularly cortisol, and that can increase blood sugar.

MEMBER QUESTION:
What are the advantages of Lantus insulin?

MANSON:
Lantus is absorbed more quickly than standard forms of insulin, so it can be more effective in lowering blood sugar after a meal. It is often worth trying if you tend to have high blood sugar after a meal despite your usual insulin regimen.

MEMBER QUESTION:
Can medicine -- steroids in particular -- cause diabetes?

MANSON:
Steroids can definitely cause diabetes, especially high doses of oral prednisone or other forms of cortisone. Also a blood pressure medicine called thiazide diuretics can increase blood sugar. There are many types of medications that can increase blood sugar and lead to insulin resistance, so if a person has been on steroids chronically that is a possible contributor to developing diabetes. Steroid inhalers usually do not significantly increase blood sugar.

MEMBER QUESTION:
Over time, is a person with type 1 diabetes (and a direct family history of type 2) at risk for their body resisting the insulin being injected?

MANSON:
A person with a predisposition to both types of diabetes can have insulin resistance, as well as a pancreas that is unable to make adequate insulin, leading to blood sugars that are very hard to control.

MODERATOR:
Dr. Manson, do you have any final words for us?

MANSON:
The good news about diabetes and complications from diabetes is that much of the risk can be prevented. It is within our control. A healthy lifestyle can substantially reduce your risk and I encourage everyone to exercise regularly, pay attention to diet, and see your doctor regularly. Keeping blood pressure and blood cholesterol under control, as well as self-monitoring of blood sugar, is tremendously important.

MODERATOR:
Thanks to JoAnn Manson, MD, from the Harvard School of Public Health, Harvard Medical School, and Brigham and Women's Hospital, for sharing her treatment tips with us today.



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