Type 1 Diabetes

Moving from teenage years to adulthood can be stressful for teens with diabetes and their families. Teens and young adults need to take on more diabetes tasks and make more judgments about their health care needs. At the same time, young adults face more pressure in their social lives and at school or work. Young adults living away from home for the first time may have a new doctor and health care team—or no doctor at all.

These challenges can result in poor diabetes care and medical problems that young adults will need to handle on their own. As more young people develop diabetes, their ongoing health care needs will need to be addressed by the adult health care team.

There is good news. New tools can help young adults with diabetes manage their diabetes and health care. The National Diabetes Education Program (NDEP)—a program of the National Institutes of Health, the Centers for Disease Control and revention, and more than 200 public and private partners—has created an online tool, “Transitions from Pediatric to Adult Heath Care,” with resources to help the young adult, their family, and their health care team who provide them with health care.

Tips for Success

How can parents prepare their teenagers to manage their diabetes care as they go off on their own? Here are several tips for success:

1. Start getting ready at least one to two years in advance. The NDEP tool has a “Transition Planning Checklist” that helps the health care team, the young adult, and the family prepare.

2. Help young people become active partners in their health. As young adults take on a bigger role when it comes to their health and wellbeing, they need to be prepared to manage their diabetes in many types of situations such as when they travel or during an illness. They must know how to prevent and/or manage any diabetes crises.

3. Prepare a summary of the teen’s health status. NDEP provides a “Clinical Summary” resource that their current health care team and the family can fill out and provide to the new health care team.

4. Encourage your child to seek support from other young people with diabetes. NDEP’s online tool provides a list of online discussion groups, forums, and message boards.

5. Find support for yourself. Parent support groups and resources can help you cope with the changes while you learn to support your child.

6. Locate adult health care professionals and insurance options. NDEP’s tool contains information on how to find a doctor, dietitian, or education program. In addition, you can find local health clinics that are either free or not costly.

Parents play a key role in helping their older teenagers get ready for life as adults. With thoughtful planning, your child can live independently with diabetes—and thrive.

For more information, visit the National Diabetes Education Program (NDEP) website, www.YourDiabetesInfo.org/Transitions.

You sit in your new diabetes doctor’s waiting room. Your name is called and you are ushered into the examination room. The doctor walks in and before he sits down he asks you: “What type of diabetes do you have?” Panic sweeps you; first question and I flunked already! You manage a meek: “How many types are there? I didn’t realize there is more than one.” No one has asked you that question before.

The doctor tries to reassure you that this is not the first time he sees a patient who didn’t know. So, you try to relax and listen to his explanation.

There are actually several types of diabetes mellitus. The three most common ones in the U.S. are so-called type 1, type 2 and gestational diabetes. The last one is easy, that is diabetes diagnosed during pregnancy. All types of diabetes are diagnosed the same way: glucose (“sugar”) levels in the blood are high (over 126 mg/dl in the fasting state and/or over 200 mg/dl two hours after you eat or drink the “Glucola” in the lab; it is recommended these numbers are obtained on two separate days before the diagnosis is made).

So, what is the difference between types 1 and 2? Type 1 diabetes is a so-called autoimmune condition. That means your own body produces antibodies against parts of the only cells which can make insulin in humans (that is beta cells of the pancreatic islets of Langerhans), eventually destroying them. As a consequence, patients with type 1 diabetes need to administer insulin for the rest of their lives (people cannot live without insulin, so important is the hormone for many functions of your cells and tissues).

Type 2 diabetes, by the way, is that condition in which persons cannot make sufficient amounts of insulin and on top of it the insulin they do manage to make does not do a very good job taking care of things, resulting in high blood glucose levels. There are perhaps twenty times as many people with type 2 than with type 1 diabetes in our country.

Back to type 1 diabetes. A long time ago, it used to be called “juvenile-onset” diabetes because it was thought that it affected only children and adolescents. We know better now. Type 1 diabetes can occur at any age; it’s just that it tends to be more aggressive (there are more antibodies destroying those beta cells quicker) in young people. Also, since it might take five to eight years before the job of destroying those insulin-producing cells is done, it is quite unusual to see type 1 diabetes in infants or very young kids. The other confusing thing is that, thanks to our current lifestyle, people with type 1 diabetes tend not to be skinny any longer. Add to it that because of childhood obesity and physical inactivity we now see many kids being diagnosed with type 2 diabetes, thus blurring the distinction between the diabetes types even more. Type 1 diabetes does not tend to “run in the families” as much as type 2 does even though there are specific genes identified with giving you the increased chance of coming down with type 1 diabetes. However, it is clear your genes alone don’t result in the disease. The unanswered question is what else happens that triggers the onslaught which kills off those insulin-making cells? It has been noticed that the frequency of type 1 diabetes has increased everywhere in the world over the past 100 years. What is it in the environment which might trigger that autoimmune attack in those genetically predisposed individuals? There have been many speculations (you have probably heard of different viruses, cow’s milk, possibly some pollutants or toxic substances in the air) but no definite answers are in. The problem is that even though we could predict type 1 diabetes years before it happens (just by drawing blood for those darn antibodies and measuring how much insulin people make after being given sugar) we can’t screen the entire population every year (imagine how much that would cost!). And since you need to destroy probably as many as 90 percent of those pancreatic cells to see blood sugar go up into the diabetic range, by the time the diagnosis is made it is too late to prevent it.

So, we are stuck (literally) treating type 1 diabetes after it wipes out most of the beta cells; and, the patients then need to take insulin for the rest of their lives. So, the management of type 1 diabetes typically revolves about figuring out the best way to deliver insulin so that glucose (and A1c) levels are as close to normal as possible while minimizing the number of hypoglycemic (low sugar) reactions. Anyone who has tried it will testify how difficult that tightrope walk is. Clearly, educating the patient about the importance of the right diet, physical activity, stress management, proper techniques for checking the blood glucose levels and insulin injection technique, etc. has to be placed on top of the agenda since the tasks can get overwhelming and no one can expect the newly diagnosed patient to know those things right off the bat. The family and community support is essential for successful overall management of this lifelong condition.

Even though every type of insulin will lower blood glucose levels (that is its job after all) in the 21st Century, there are essentially two ways offered to patients with type 1 diabetes: multiple daily insulin injections or continuous insulin infusion by an insulin pump. In both cases, the idea is to copy Mother Nature as closely as possible. In a healthy individual, those beta cells in the pancreas make about half of the insulin continuously— 24 hours a day, 7 days a week, and the other 50 percent come in short bursts to appropriately cover your meals so blood glucose levels always stay normal.

For the multiple insulin shot routine, the “base” is covered by one of two insulin “analogs” (made by changing the structure of human insulin to behave differently), insulin glargine or detemir. Their job is to make sure blood glucose is OK overnight and before each meal. The remaining insulin is provided by mealtime injections of “rapid-acting” analogs (there are three on the U.S. market, insulin LisPro, aspart, and glulisine). Patients usually take as much as needed to “cover” their meals. Most are taught to count carbohydrate content of the meal and match that with the quick-acting insulin (for example, take one unit for every starch exchange or 15 grams of carbohydrate). Insulin pumps provide insulin only in the rapid acting variety. They are worn externally (much as your favorite PDA or cell phone) and push insulin under your skin through a skinny plastic tube all the time. The user programs the pump so it delivers about half as a “basal” rate (that rate varies according to the need), and the remainder gets activated by a push of a button to give bursts (“bolus”) of insulin again to cover the meal. Patients usually change the infusion site every three days. Much progress has been made into making insulin delivery as painless and convenient as possible but it still takes an injection through the skin. Other ways to deliver insulin (into the lungs, through the nose, inhaling into the mouth, skin patches, etc.) have been tried but to date none of them has been judged to be as reliable.

The recent advance has come from using continuous glucose sensors, which give the user real-time information not only about glucose levels but also directions of changes in glucose numbers, history, and can sound alarms for very high or very low readings. Those sensors are placed on the skin and again plastic tubing is inserted under the skin to provide the information.

What about the cure for type 1 diabetes? While many scientists have been working on it for decades, currently, there is none available. The closest we have come is to use pancreas transplant (either whole from a cadaver or a part from a living relative donor) or pancreatic islet cell transplant (in which only the insulin producing cells are injected and they settle around the liver where they start producing insulin normally). Both types of transplants require use of anti-rejection medications by the recipients to avoid rejection of those foreign cells.

As you can see tremendous progress has been made in dealing with type 1 diabetes, but we still have a ways to go…

George Grunberger, MD, FACP, FACE, is chairman of the Grunberger Diabetes Institute in Bloomfield Hills, Michigan, and a Clinical Professor of Internal Medicine and Molecular Medicine & Genetics, Wayne State University School of Medicine in Detroit, Michigan. Dr. Grunberger has published over a hundred original peer-reviewed manuscripts, in addition to review articles, abstracts, book chapters, and letters to journals. His research interests have spanned the spectrum of subjects related to diabetes and its complications, from very basic studies on molecular underpinning of insulin action and insulin resistance to clinical research studies on many aspects of diabetes and its management.

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Diabetes mellitus occurs when the pancreas (an endocrine gland in the abdomen) cannot make enough insulin to satisfy the demands of the body. We currently recognize two types of diabetes. Type 1 is due to destruction of the cells in the pancreas that make insulin. These individuals, usually, must take insulin injections for the rest of their life. Type 1 generally occurs early in life and is of sudden onset. This type of diabetes happens at a level rate and does not seem to be increasing. In our country, only 1 of 25 people with diabetes has type 1 diabetes.

Type 2 diabetes is much more common than type 1. We now have about 25 million people in the US with type 2 diabetes, and the number of people affected is rising rapidly. Type 2 diabetes seems to have a more gradual onset, and is often treated with pills early in its course. This type of diabetes seems to be tied to the epidemic of overweight and obesity around the world. We used to think of it as starting at an older age, but now it is more frequently diagnosed in younger people, including children and teenagers. The US has the third largest number of people in the world with diabetes, surpassed only by India and China. The increased incidence of diabetes is a worldwide epidemic, and no country is spared.

Both types of diabetes are associated with similar complications. They are generally split into microvascular and macrovascular complications. Microvascular means small blood vessels such as the blood vessels in the eye and the kidney. Macrovascular means large blood vessels such as the blood vessels of the heart and the brain, as well as the large blood vessels of the legs. We’ll start out with the small blood vessels.

Let’s start with diabetic retinopathy, which refers to disease of the small blood vessels of the retina caused by diabetes. Diabetic retinopathy usually starts out with small areas of bleeding in the back of the eye (the retina). The retina is the area responsible for our eyesight, and if it becomes seriously damaged eyesight becomes impaired. The result of untreated retinopathy can be blindness. Diabetic retinopathy is the leading cause of blindness in adults. Early diagnosis and treatment can prevent blindness from occurring. Everybody with diabetes should have what we call a dilated eye exam once a year. This means that the pupils are dilated with eye drops and the eye doctor can get a good look at the retina in the back of the eye. If there are early changes of retinal disease, the person can be treated. Early treatment usually consists of laser therapy to the retina. Tight control of diabetes will often keep the retinopathy from getting worse, and may even reverse the effects.

Diabetic nephropathy is another microvascular complication that refers to disease of the small blood vessels of the kidney. If nephropathy continues to progress, it can ultimately lead to kidney failure, which may have to be treated by dialysis or kidney transplantation. The early stages of nephropathy can be picked up by laboratory testing of the blood and urine. Medicines are available to prevent the kidney disease from getting worse. Tight diabetes control also helps. Diabetes, however, is the leading cause of kidney failure leading to dialysis in the adult population. Renal failure is serious and can dramatically worsen quality of life of the person with diabetes, and also shorten the lifespan of the person who has it. Once again, it is important to pick up kidney disease early and institute treatment as soon as possible. Kidney disease also makes it difficult to treat the person for other diseases because kidney failure can change the action of many drugs that we prescribe.

Diabetic neuropathy refers to a complication involving the nerves of the body, perhaps by interfering with the small blood vessels supplying these nerves. The feet are usually the first to suffer and common symptoms include numbness, pins and needles feelings, pain, and eventually loss of sensation. With severe neuropathy of the feet, one cannot feel cold, heat or even touch. Under these circumstances, it is easy to produce damage to the feet. For example, if you had a nail in your shoe and couldn’t feel it, you could damage your feet.

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This special issue of EmPower Magazine is focused on The Changing Face of Diabetes Management. New research and new medications are forever changing the way that doctors and their patients approach the disease. Over the next several pages, you will see just how those changes can impact you or your loved one who is living with diabetes. You will also get a chance to see how regular people have lived extraordinary lives in spite of, or in some cases, because of their diabetes.

Starting on page 5, we will take a closer look at these medical breakthroughs, and what they mean for your treatment. That is followed by an up to date listing of the available medications so you can be informed as to just what treatment options are available to you. Of course, avoiding the complications of diabetes is one of the most important aspects of a patient’s diabetes management, so we will take a closer look at these complications and how to avoid them.

Our comprehensive review of the diabetes states begins with prediabetes. With an estimated 54 million Americans living with prediabetes, it is the largest healthcare epidemic in the United States. We will discuss the diagnosis and potential treatment of the condition, and how early intervention can delay or even prevent the onset of type 2 diabetes.

Type 2 diabetes is the most common form of diabetes. We will take a detailed look at the impact of weight management on type 2 diabetes, and give you a chance to take the 5 Pound Challenge! You’ll also hear from a patient who has taken his struggles with type 2 diabetes and weight worldwide. We’ve even included a special report specifically on nutrition for the diabetes patient. And finally, we take a frightening look at the growing number of children being diagnosed with type 2 diabetes.

Next, we discuss type 1 diabetes. We will discuss the different approach to management from type 2. We will also hear from a patient who has decided to fight her type 1 diabetes, literally!

Finally, we will give you some insight on how you can take this knowledge and make a difference. We start with an organization that is taking the power of prevention to the streets, enlisting volunteers to give free health screenings. We will also show you how to put together your own Diabetes Disaster Plan, to make sure you are prepared when disaster strikes.

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Window of Opportunity: A Patient Story
By Sarah Senn

Nothing could stop Sharon from enjoying life. From her budding career to her passion for hiking, Sharon was at the top of her game. But at 34, Sharon’s life changed. She was diagnosed with type 1 diabetes.

For Sharon, the active lifestyle of Santa Monica, California, is exciting. Before her diagnosis, Sharon was a true career woman. She worked for an education company coordinating inner-city education programs nationwide. Although the job was often stressful, she enjoyed the day-to-day challenges and traveling for her job. Sharon has always been driven and was searching for other ways to expand her career. With a background in holistic health, Sharon was excited to be given an opportunity to open a wellness center with a local physician. The strain of juggling the two jobs sent Sharon’s immune system over the edge.

During a business trip in May 2009, Sharon noticed something different. On the first day of the trip, her vision was blurry and by the end of the trip, she could not see well enough to drive. When she got home, Sharon’s mother, who has type 2 diabetes, suggested that Sharon test her blood sugar level. Her blood sugar level was more than 320 mg/dL.

Sharon made an appointment with the doctor right away. Blood tests showed that Sharon’s pancreas was not functioning properly. She had type 1 diabetes.

“At 5 ft 8 ½ in and 120 lbs, I thought I was healthy. I was eating right and staying fit. I didn’t know I could get type 1 diabetes,” she said.

Sharon’s diagnosis was heartbreaking to her at first. She went from diagnosis to denial. Sharon thought she was doing everything right. She went to yoga classes weekly and ate nearly a vegetarian diet. When she wasn’t working, Sharon was hiking, her favorite pastime.

At age 34, Sharon and her husband, Lou, were thinking about starting a family, but when she was diagnosed with diabetes, she was unsure if this would be possible.

“Emotionally, I felt like I was damaged goods,” she said.

About a month after being diagnosed, while on a typical hiking venture in Sequoia National Park, Sharon met a group of hikers from Stanford who told her about a study related to diabetes and stem cell research. Sharon has always been passionate about research and understanding her health. She contacted Stanford about enrolling in the study. However, if she was accepted as a study participant, Sharon would have to put the plans for having a family on hold for at least two years. Although it was a tough decision, and uncertain of whether they would still be able to have children in a few years, Sharon and her husband, Lou, decided it was best for her health to participate in the study.

She went through various levels of study screenings, but during the final screening she was removed from the study because she had something wrong with her lungs, but it was unrelated to diabetes. Another setback—Sharon was devastated, but now she was even more determined not to let diabetes slow her down.

“You have to take responsibility for what happens to you,” she explains.

In just over two months after being diagnosed, her blood sugar levels were under control and her A1c level had fallen to 5.7. Sharon decided to focus on her health and managing her condition. Inspired by her diabetes, she stopped working full time and decided to become certified as a yoga instructor. She now teaches yoga every morning and she hikes three times a week.

Sharon has been working with her endocrinologist [en-doh-cri-NA-lo-jist] to determine the treatment that is best for her. At first, Sharon managed her condition through individual insulin injections multiple times daily. But with an active lifestyle, she found an insulin pump works best. Admittedly, Sharon was concerned about using an insulin pump to control her condition.

“At first I thought that the pump would be like being on life support, but now it has become second nature,” she said. “It’s helped me find my new normal.”

She has turned to others who have type 1 diabetes for advice on nutrition and management techniques.

Sharon has also found new hope for an old dream. Shortly after learning that she would not be able to take part in the Stanford study, she found out about a study with the Sansum Diabetes Clinic for women with diabetes who are trying to conceive. Sharon qualified as a study participant, and she is looking forward to starting a family within the next year.

While she calls her journey over the last year an “emotional rollercoaster,” Sharon finds comfort in what she’s learned about herself.

“I can’t say that I’m glad I was diagnosed; I roll with the punches,” she admits. “But if I have to find the silver lining, it’s the realization of how precious our lives are. Diabetes opened a window for me.”

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On Pens and Needles:
What you Need to Know about Injectable Diabetes Medications
By Etie S. Moghissi, MD, FACP, FACE

Have you been told that you need to start an injectable diabetes medication? Are you afraid to even think about it? Are you thinking that injections are painful, inconvenient, and those needles are really scary? Plus, what might others think if they see you inject? Are you worried about what it means to need insulin injections? Do you know people who started insulin and ended up with other problems?

This is all understandable, and you are not alone. The truth is that there is a lot of confusion and misunderstanding about injectable medications, such as insulin or other kinds of medication.

Why Insulin?

Many people with diabetes believe that insulin therapy means that their condition is worsening or they consider it as a personal failure. They are afraid of low blood sugar and weight gain, or that their injection may be painful. It is important to know that one of the main problems of diabetes is that the pancreas does not produce enough insulin. Insulin is the natural hormone that is needed to keep blood sugar under control, and only insulin can replace insulin! So you may ask, “Who needs insulin?” All persons with type 1 diabetes need insulin to survive, and many people with type 2 diabetes eventually need insulin to control their blood sugar. And, many pregnant women with diabetes, or who have diabetes during pregnancy, need to be on insulin for a healthy baby. The bottom line is that insulin can be lifesaving for many people with diabetes.

Yes, insulin therapy can be associated with low blood sugar and weight gain if you are not careful with your meal plan and your physical activity. Newer insulins have a lower rate of hypoglycemia [hy-po-gly-SEEM-ee-ah] (low blood sugar) than older insulins. Also, newer insulin delivery devices (such as insulin pens) are more convenient than the traditional insulin vial and syringes.

If you have been told that you need to start insulin, or if you are already taking insulin, you should know about the insulin pens. They give accurate doses, are very convenient (can be carried around in your pocket or purse), and are covered by many insurances and prescription plans. The pen needles are so thin and so small that they are almost pain free. To get over being scared of needles and injections, you should give your first insulin injection into the skin of your abdomen (belly) or thigh while you are in your health care provider’s office. You will see for yourself that the pain of the injection is nowhere close to the pain of finger sticks that you do all the time to test your blood sugar. The reason for less pain is that there are far less pain fibers in the skin of your abdomen and thighs than there are in your finger tips. So, there is no need to live in fear. Experience the first injection in the safety of your health care team’s presence.

To avoid experiencing low blood sugar, learn to prevent it in the first place. You should monitor your blood sugar and you should not skip meals. Know what to do with the amount and the timing of your insulin injections relative to your physical activity.

The New Injectable Diabetes Medications That Are Not Insulin

There is a new class of diabetes medications (called incretins [in-KREE-tins] or gut hormone-like) that need to be injected but are not insulin. These medications stimulate your own body to make insulin to keep your blood sugar under control. The good news about this new class of medication is that they almost never cause low blood sugar (hypoglycemia) by themselves. The better news is that they actually can lead to weight loss instead of weight gain. They are easier to use because they are all administered by pen injectors, which are almost pain free, and can be carried around. Currently, there are 2 types of these medications available, exenetide [ex-EN-ah-tide] (Byetta) and liraglutide [lir-AH-gloo-tide] (Victoza). And, more are on the way.

Another injectable medication for diabetes is pramlintide [PRAM-lin-tide] (Symlin) which is used with insulin to control post-meal blood sugar and is also taken with a pen injector.
In summary, only you and your health care team can decide which medication is right for you. Remember that these are tools to help you get you to your blood sugar goals. You should focus on your goal (optimal blood sugar control). The goal is the most important. How to get there may be less important. Work with your health care team to find the right option for you. For some people, the best option may be pills. For others, the best option might be an injection. Do not let fear or false ideas prevent you from reaching your destination! (Your good health!)

Dr. Etie Moghissi is board certified in endocrinology, diabetes and metabolism and is in private practice in Marina del Rey, California. She is a Clinical Associate Professor of Medicine at UCLA. Dr. Moghissi is a recognized expert in the field of diabetes and is actively involved in direct patient care, as well as in professional medical education. She has published in peer-reviewed medical journals including Endocrine Practice and Diabetes Care. She serves as Treasurer of the American Association of Clinical Endocrinologists, and is Secretary/Treasurer of the American College of Endocrinology.

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The Good News About Preventing Diabetes Complications

By Faramarz Ismail-Beigi, MD, PhD

Every now and then, patients with diabetes ask me: “Doctor, even though most of my blood sugar numbers are high, I feel good. I don’t understand why I should take all these pills and insulin injections.” This is a great question. The main reason to have control of your blood sugar (glucose) is to prevent complications of diabetes. Diabetes, during its early years, produces no major symptoms unless the blood sugar gets very high. Then, the person will make a lot of urine, become thirsty, and not feel well. This is true in all types of diabetes.

So, you may ask,

“What are the complications we should prevent?”

We classify diabetes complications into two categories:

1) Complications that damage small blood vessels in your body

Diabetes can damage small vessels in the eyes, nerves, and kidneys. These can lead to blindness, loss of sensation in hands and feet, and kidney failure. These complications are serious, and can have a very negative effect on a person’s well-being.

2) Complications that damage the large blood vessels

Complications that damage large blood vessels cause “hardening of the arteries” that feed your heart, brain, and body. These complications are also very serious and can lead to heart attack, stroke, loss of arms or legs, and even early death. It is important to know that all these complications can happen, even if you feel healthy.

“How can I prevent these complications?”

The answer to this question can vary depending on whether you have type 1 or type 2 diabetes. However, no matter which type of diabetes you have, good blood sugar control is the most important way to prevent damage to small blood vessels. Also, as described further below, you can do many things to prevent the complications related to the large blood vessels.

“What is type 1 diabetes and who gets it?”

This type of diabetes (previously called juvenile diabetes) often starts in children and young adults, but it can start at any age. It begins after damage and loss of cells that produce insulin. For this reason, people with this form of diabetes do not produce insulin, and their health and wellness depends on taking insulin on a regular basis.

Two important studies (called DCCT and EDIC), which involved more than 1,400 volunteers with type 1 diabetes, have shown that good blood sugar control plays a very important role in preventing small vessel complications in the eyes, nerves and the kidneys. The results were so dramatic that doctors and patients all over the world started to aim for better blood sugar control. The studies have also shown that good blood sugar control can help prevent large vessel disease that can lead to heart attacks and strokes in people with type 1 diabetes.

“What is the best way to get good blood sugar control? Which insulin regimen is best?”

These are questions that each person should discuss with their health-care team. Today we have better insulins and better tools and technologies to help people get their blood sugars under control.

Like everyone else, people with type 1 diabetes can develop a rise in blood cholesterol and fats (lipids), high blood pressure, and “hardening of the arteries” with increasing age. Attention should be given to controlling the harmful effects of these changes, as well as stopping smoking.

“What is type 2 diabetes and who gets it?”

This form of diabetes (previously called “adult-onset diabetes”) is the most common form of the disease. Currently, more than 20 million people in the United States have it. Type 2 diabetes is on the rise, and it is estimated that millions more people in the USA and across the world will be affected in the next 20 to 30 years. Type 2 diabetes can run in families and is increasing in children and young adults. We often see this disease in people who are overweight. Type 2 diabetes is not just a problem of blood sugars. It also affects blood pressure, cholesterol, and fats, inflammation in the body, and blood clotting.

Normally, cells in the pancreas release proper amounts of insulin. This helps sugar enter into cells throughout the body for energy. One main problem of type 2 diabetes is the “resistance” of cells to insulin. This means that it takes more insulin to produce the same effect. On top of that, people with type 2 diabetes do not make enough insulin for what their body needs. In other words, there is also a problem with the cells that produce insulin. The tie-in with obesity comes from the fact that there is higher “resistance” to insulin with higher body weight.

This brings us to the important role of nutrition and physical activity, and their critical effect on the prevention of type 2 diabetes. We all agree that the best way to prevent complications of diabetes is to prevent the disease in the first place. The Diabetes Prevention Program (DPP) and other studies done in Europe and China have shown that type 2 diabetes can be prevented in about 50% of people that are highly likely to get type 2 diabetes. These people prevented type 2 diabetes through a healthy meal plan and moderate physical activity that resulted in moderate weight loss. I suggest to my patients that they should include physical activity as a part of their daily life, and not just as an add-on. There should be a time of the day that is devoted solely to your personal health and well-being. The positive effects of a healthy diet, weight loss, and exercise can add to each other.

You can lose weight by working with your health-care team and having a meal plan that contains adequate amounts of fiber, fruits, and vegetables, and has the appropriate amount of calories. Losing weight and keeping it off it is not easy and requires a lifestyle change in both attitude and behavior. As the author Thomas Paine once said, “The harder the conflict, the more glorious the triumph.”

“What about medications, and how can I prevent the complications of type 2 diabetes?”

Again, you need to talk to your health-care provider about this. Here our goals and targets for sugar control are more complex, because type 2 diabetes is different in different people. Your goals may depend on many factors, such as your age, how long you have had diabetes, and your overall health. It is important to know that managing diabetes is more than just controlling blood sugar. Controlling blood pressure and cholesterol levels

are also very important. You may have to take a daily aspirin, and stopping smoking is a must. An important study named Steno-2 showed that doing all of the above at the same time can reduce heart attacks and death by close to 50%. So, each one of these factors plays an important role in the development of large vessel disease.

Aim to get your blood sugar values close to normal especially if you are young or middle-aged and your diabetes is new. This recommendation is based on results of a large study conducted in England (the UKPDS trial) in patients who were recently discovered to have type 2 diabetes. The study showed that good control of blood sugar and blood pressure reduces the risk of damage to both small and large blood vessels and their complications. We try to reach this goal while avoiding frequent episodes of low blood sugar.

Three very large studies related to this topic have been carried out with the help of more than 22,500 participants with type 2 diabetes (the ACCORD, ADVANCE, and the VA Diabetes Trial). The results suggest that in people who have had type 2 diabetes for many years, trying to get their sugar levels very close to normal (or normal) does not always reduce the risk of complications associated with large vessel disease. However, they did show benefits in preventing small blood vessel complications. This is why the goal for blood sugar control is not the same for every person and must be tailored to each patient.

To reduce the risk of large vessel disease in type 2 diabetes, we should always pay attention to blood pressure, blood cholesterol, and fat control. I have listed the targets recommended for most patients with type 2 diabetes in the box. Remember that getting to these goals at the same time makes a very large difference in preventing complications.

The great news is that diabetes complications can be prevented. Today we have many new therapies, tools, and technologies to treat diabetes to prevent complications. The first step is to know your goals. Staying informed and engaged in your own care, and working closely with your health-care team will ensure that you will remain healthy!

Dr. Faramarz Ismail-Beigi is a professor of Medicine, Endocrinology, and Physiology and Biophysics at Case Western Reserve University, University Hospitals of Cleveland, and the Cleveland VA hospital. He received his doctoral degree and post-graduate training at Johns Hopkins School of Medicine in Baltimore. He also serves as the Medical Director of Joslin Diabetes Clinic at St. Vincent Charity Hospital in Cleveland. He conducts basic and clinical research in diabetes.

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