INTRODUCTION — Diabetes mellitus is a chronic condition, but people with diabetes can lead a full life while keeping their diabetes under control. Lifestyle modifications (changes in day-to-day habits) are an essential component of any diabetes management plan.
Lifestyle modifications can be a very effective way to keep diabetes in control. Improved blood glucose control can slow the progression of long-term complications. Multiple small changes can lead to improvements in diabetes control, including a decreased need for medication.
Diabetes requires a lifelong management plan, and persons with diabetes have a central role in this plan. Lifestyle modifications are an opportunity for diabetics to take charge of their health. Therefore, it is important to learn as much as possible about diabetes and to take an active role in making decisions about health care and treatment.
DIETARY CHANGES — Healthcare providers may recommend specific dietary changes for people with diabetes, depending upon the patient's therapy goals. Dietary changes can help with weight loss, improve blood glucose control, and lower blood cholesterol levels and blood pressure.
Calories — Lifestyle changes that promote weight loss are the primary lifestyle treatment for people with type 2 diabetes who are overweight. Improving caloric balance (eating fewer calories than are used by the body) should be consider the primary goal of lifestyle modification.
Weight loss can improve blood glucose control by decreasing insulin resistance and partially restoring the normal insulin-producing function of the pancreas. Weight loss can also lower blood pressure; high blood pressure and obesity are both risk factors in the development of cardiovascular disease. Weight gain can be a problem in patients who take insulin stimulators (like sulfonylureas, or meglitinides), thiazolidinediones (like pioglitazone and rosiglitazone) or who take insulin.
A sensible and sustainable diet, which may include reducing the number of calories eaten each day, allows for gradual weight loss over time. A healthcare provider or nutritionist can discuss an ideal weight goal with help to plan a safe and effective overall weight-loss program. While reducing calories and increasing activity are beneficial to anyone who is overweight, a focus on carbohydrate counting may also be useful for patient using insulin stimulators (like sulfonylureas and meglitinides) and insulin.
Carbohydrate counting — It is possible to adjust an insulin dose based upon the amount of carbohydrates eaten. The number of carbohydrates can be determined using nutrition labels or carbohydrate calculators (show figure 1). The dose of insulin needed based on carbohydrates eaten varies from one patient to another, and can be determined with the help of a healthcare provider (show table 1).
Post-meal blood glucose management — Blood glucose levels can rise sharply after meals. Increasing the amount of soluble fiber in the meal may slow and/or lessen this rise, and may decrease the dose of insulin needed. Soluble fiber is found in fruits, vegetables, and beans. A high-fiber diet can also lower levels of low-density lipoprotein (LDL) cholesterol (sometimes called "bad" cholesterol).
Eating foods with a low glycemic index is another approach for controlling post-meal blood glucose levels. A diet of low-glycemic index foods may also decrease LDL cholesterol levels. The glycemic index of some foods is shown in the Table (show table 2).
Increasing the dose or changing the timing of very rapid or rapid-acting insulin before meals can help control post-meal glucose levels. Very rapid-acting insulin (lispro [Humalog®], aspart [Novolog®], or glulisine [Apidra®]) should be given within 15 minutes of eating, while rapid acting insulin (Regular or R) should be given 30 to 60 minutes before a meal (show table 3).
Other approaches that can help to reduce the rise in blood glucose levels after meals include the use of alpha-glucosidase inhibitors (like acarbose or miglitol) which can be taken as a pill with the first bite of a meal. These drugs slow down the rate at which starch is broken down into glucose and so delay the absorption of glucose into the blood after a meal. These drugs are effective in some people although they can cause flatulence and diarrhea as a side effect.
Two new injectable therapies (pramlintide [Symlin®], and exenatide [Byetta®]) can also decrease the rise in blood glucose after a meal. They can also increase satiety and decrease hunger which can lead to weight loss in some patients. However, both of these drugs can cause significant nausea in some patients. In addition, patients who are taking insulin will need to reduce their insulin dose if pramlintide or exenatide are added.
Dietary guidelines — The ratio of carbohydrates, protein, and fat is important to long-term health. Current recommendations are as follows: Carbohydrates: 45 to 65 percent of total calories Protein: 5 to 20 percent Fat: 25 to 30 percent (mostly monounsaturated or polyunsaturated, not saturated fat)
Clinicians may recommend different nutrient ratios for persons with other health conditions, pregnant women, and growing children.
A low carbohydrate diet has shown favorable results in short-term studies for persons trying to improve blood glucose control, cholesterol, and lose weight. Persons with type 2 diabetes may consider a low carbohydrate diet, but should work with their healthcare provider to individualize a plan.
A moderate-salt or low-salt diet is often recommended; a low-salt diet is especially useful for lowering high blood pressure.
Timing of food intake — Consistent timing of food intake is not necessary for all people with diabetes. However, people using intensive insulin treatment may find it easier to control their blood sugar levels when they eat approximately the same amount of carbohydrates at the same time each day.
Establishing healthy dietary habits — To get started with healthy eating habits, a patient may be asked to keep a food diary, discuss current eating patterns, attend a dietary class for people with diabetes, or meet with a dietitian. Eating habits should be changed slowly, making it easier to adopt new habits.
ALCOHOL USE — The recommendations for alcohol use in persons who are diabetic are similar to those for non-diabetics. On a daily basis, no more than two alcoholic beverages for men or one alcoholic beverage for women are recommended. One alcoholic beverage is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits (all of which contain 15 grams of alcohol).
Alcohol can cause either low or high blood glucose, depending upon the amount of alcohol consumed, if food was eaten at the same time, and the history of prior alcohol use or abuse. Persons with diabetes who choose to drink alcohol should drink moderately.
A moderate intake of alcohol may lower blood pressure and decrease the risk of coronary artery disease and stroke. However, excessive use of alcohol can increase the risk of neurologic and liver disease and high blood pressure.
QUITTING SMOKING — Over 25 percent of people newly diagnosed with diabetes are smokers. Quitting smoking is one of the most important things a patient can do to improve their health.
Smokers with diabetes have an increased risk of the following: Death, especially from heart attacks and strokes High "bad" cholesterol levels Worsened blood glucose controlled, compared to non-smokers Neurologic complications from diabetes Kidney disease leading to dialysis Foot ulcer and amputation of toes, feet or legs caused by peripheral vascular disease
Diabetics who quit smoking can decrease their risks. Most people who smoke find it difficult to quit; assistance is available from a number of sources. Healthcare providers have access to self-help materials, and can help select a quit date, provide contact information for local support groups, and prescribe nicotine replacement treatment, if needed.
EXERCISE — Exercise is beneficial for all individuals, with or without diabetes. Even persons with longstanding diabetes or diabetic complications can benefit from exercise.
For diabetics, exercise promotes cardiovascular fitness and weight loss, lowers high blood pressure, improves lipid profiles, improves blood glucose control in some cases, and leads to an overall sense of well-being. It may even help prevent type 2 diabetes in some people.
General exercise precautions — It is important to balance enthusiasm and common sense when beginning an exercise program. These precautions encourage patients to stay safe and ensure that exercise is productive. Wear well-fitting, protective footwear (See "Patient information: Foot care in diabetes"). Drink adequate liquids before, during, and after exercise to prevent dehydration, which can upset blood glucose levels.
Diabetics who use insulin should also: Measure blood glucose before, during, and after exercise to determine their body's typical response to exercise. If the pre-exercise blood glucose reading is 250 mg/dL or higher, exercise should be postponed until the level is under control. Consider a decrease in insulin dose by about 30 percent during exercise. Choose an insulin injection site away from exercising muscles (for example, avoid the legs if running) Keeping rapidly absorbed carbohydrates on hand (glucose tablets, hard candies, or juice). Eat a snack 15 to 30 minutes before exercise, and again every 30 minutes during exercise. Eat a source of slowly absorbed carbohydrates (dried fruit, fruit jerky, granola bars, or trail mix) immediately after exercise. This will counter a post-exercise drop in blood glucose levels.
The pre-exercise examination — People with diabetes who want to start an exercise program should consult with their healthcare provider first. A pre-exercise examination, including a supervised exercise stress test, may be needed for persons over the age of 35 and those who have had diabetes for more than 10 years.
Type of exercise — Gentle aerobic exercises, which increase the heart rate for a sustained period of time, are often the best choice for diabetics. Examples of aerobic exercise include walking, cycling, swimming, or rowing. Diabetics with well-controlled blood glucose levels and no complications can usually participate in most any type of exercise.
Choose exercise that is enjoyable and can be performed comfortably, making it easier to stay motivated and stick with a program over time. People who are accustomed to a sedentary lifestyle may find it particularly challenging to start and continue with an exercise program. Talk with a healthcare provider about any barriers that stand in the way of exercise; he or she may be able to suggest solutions.
People with diabetic eye complications (proliferative retinopathy) may be advised to avoid high-impact activities and strenuous weight-lifting, which can increase blood pressure and cause bleeding in the eye. People with neurologic complications (peripheral neuropathy) are usually advised to avoid traumatic weight-bearing exercises such as running, which can lead to foot ulcers and stress fractures although this depends on the severity of the nerve damage.
Intensity — Exercise does not have to be intense to be beneficial. Persons who want to increase the intensity of exercise should do so gradually, and should stop if he or she experience worrisome symptoms, such as chest discomfort or nausea.
Duration — A reasonable exercise session consists of 10 minutes of stretching and warm-up, followed by 20 minutes of gentle aerobic exercise. Eventually, you may wish to exercise for more than 30 minutes at a time. You should increase the duration of exercise gradually.
Timing — People who take insulin should try to exercise at the same time of the day. This practice can help to maintain predictable blood glucose levels.
Frequency — Most of the benefits of exercise for people with diabetes require a regular, long-term exercise program. Patients should commit to exercising 30 minutes a day most days of the week.
MEDICATIONS AND BLOOD GLUCOSE MONITORING — The day-to-day management of blood glucose levels can be complicated. Management may require a schedule of oral medications and/or insulin, frequent blood glucose monitoring, and carefully planned meals and snacks.
However, successful management of diabetes does not have to take the enjoyment out of life. It can be difficult to establish a routine that incorporates all aspects of diabetes care, though many people find that the routine becomes second nature once established. Written schedules may help patients to remember the details of a routine until they are committed to memory. It is also important to carefully manage situations that can complicate blood glucose control, such as sick days and vacations.
People with diabetes may need to take several medications throughout the day. Medications to lower high blood pressure, lower cholesterol levels, and low-dose aspirin may be used to manage and prevent complications. Each prescription should be taken exactly as directed on a daily basis. If the medication schedule is complex, a pill organizer or written outline may be helpful in remembering to take specific medications at specific times.
ROUTINE MEDICAL CARE — Making lifestyle changes is an excellent step towards diabetes management. However, routine medical care is important for people with diabetes; this may include frequent medical appointments and screening tests. Your healthcare team will periodically reevaluate the diabetes management plan, and can work to detect health problems that do not cause symptoms in the early stages.
Finally, it is important to listen to your body and seek care if questions or problems arise. This may require calling and seeing a clinician between scheduled appointments. Even persons who have had diabetes for many years have difficulty some times, and clinicians are skilled in helping to solve problems.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institue of Diabetes and Digestive and Kidney Diseases
(www.niddk.nih.gov/)
American Diabetes Association (ADA)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
The Hormone Foundation
(www.hormone.org/public/diabetes.cfm, available in English and Spanish)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Close, EJ, Wiles, PG, Lockton, JA, et al. The degree of day-to-day variation in food intake in diabetic patients. Diabet Med 1993; 10:514.
2. Pan, XR, Li, GW, Hu, YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT study. Diabetes Care 1997; 20:537.
3. American Diabetes Association. Nutritional Recommendations and Principles for People with Diabetes Mellitus. Diabetes Care 1994; 17:519.
4. Torjesen, PA, Birkeland, KI, Anderssen, SA, et al. Lifestyle changes may reverse development of the insulin resistance syndrome. The Oslo diet and exercise study: A randomized trial. Diabetes Care 1997; 20:26.
Tuesday, October 16, 2007
Lifestyle modifications in type 2 diabetes
INTRODUCTION — Diabetes mellitus is a chronic condition, but people with diabetes can lead a full life while keeping their diabetes under control. Lifestyle modifications (changes in day-to-day habits) are an essential component of any diabetes management plan.
Lifestyle modifications can be a very effective way to keep diabetes in control. Improved blood glucose control can slow the progression of long-term complications. Multiple small changes can lead to improvements in diabetes control, including a decreased need for medication.
Diabetes requires a lifelong management plan, and persons with diabetes have a central role in this plan. Lifestyle modifications are an opportunity for diabetics to take charge of their health. Therefore, it is important to learn as much as possible about diabetes and to take an active role in making decisions about health care and treatment.
DIETARY CHANGES — Healthcare providers may recommend specific dietary changes for people with diabetes, depending upon the patient's therapy goals. Dietary changes can help with weight loss, improve blood glucose control, and lower blood cholesterol levels and blood pressure.
Calories — Lifestyle changes that promote weight loss are the primary lifestyle treatment for people with type 2 diabetes who are overweight. Improving caloric balance (eating fewer calories than are used by the body) should be consider the primary goal of lifestyle modification.
Weight loss can improve blood glucose control by decreasing insulin resistance and partially restoring the normal insulin-producing function of the pancreas. Weight loss can also lower blood pressure; high blood pressure and obesity are both risk factors in the development of cardiovascular disease. Weight gain can be a problem in patients who take insulin stimulators (like sulfonylureas, or meglitinides), thiazolidinediones (like pioglitazone and rosiglitazone) or who take insulin.
A sensible and sustainable diet, which may include reducing the number of calories eaten each day, allows for gradual weight loss over time. A healthcare provider or nutritionist can discuss an ideal weight goal with help to plan a safe and effective overall weight-loss program. While reducing calories and increasing activity are beneficial to anyone who is overweight, a focus on carbohydrate counting may also be useful for patient using insulin stimulators (like sulfonylureas and meglitinides) and insulin.
Carbohydrate counting — It is possible to adjust an insulin dose based upon the amount of carbohydrates eaten. The number of carbohydrates can be determined using nutrition labels or carbohydrate calculators (show figure 1). The dose of insulin needed based on carbohydrates eaten varies from one patient to another, and can be determined with the help of a healthcare provider (show table 1).
Post-meal blood glucose management — Blood glucose levels can rise sharply after meals. Increasing the amount of soluble fiber in the meal may slow and/or lessen this rise, and may decrease the dose of insulin needed. Soluble fiber is found in fruits, vegetables, and beans. A high-fiber diet can also lower levels of low-density lipoprotein (LDL) cholesterol (sometimes called "bad" cholesterol).
Eating foods with a low glycemic index is another approach for controlling post-meal blood glucose levels. A diet of low-glycemic index foods may also decrease LDL cholesterol levels. The glycemic index of some foods is shown in the Table (show table 2).
Increasing the dose or changing the timing of very rapid or rapid-acting insulin before meals can help control post-meal glucose levels. Very rapid-acting insulin (lispro [Humalog®], aspart [Novolog®], or glulisine [Apidra®]) should be given within 15 minutes of eating, while rapid acting insulin (Regular or R) should be given 30 to 60 minutes before a meal (show table 3).
Other approaches that can help to reduce the rise in blood glucose levels after meals include the use of alpha-glucosidase inhibitors (like acarbose or miglitol) which can be taken as a pill with the first bite of a meal. These drugs slow down the rate at which starch is broken down into glucose and so delay the absorption of glucose into the blood after a meal. These drugs are effective in some people although they can cause flatulence and diarrhea as a side effect.
Two new injectable therapies (pramlintide [Symlin®], and exenatide [Byetta®]) can also decrease the rise in blood glucose after a meal. They can also increase satiety and decrease hunger which can lead to weight loss in some patients. However, both of these drugs can cause significant nausea in some patients. In addition, patients who are taking insulin will need to reduce their insulin dose if pramlintide or exenatide are added.
Dietary guidelines — The ratio of carbohydrates, protein, and fat is important to long-term health. Current recommendations are as follows: Carbohydrates: 45 to 65 percent of total calories Protein: 5 to 20 percent Fat: 25 to 30 percent (mostly monounsaturated or polyunsaturated, not saturated fat)
Clinicians may recommend different nutrient ratios for persons with other health conditions, pregnant women, and growing children.
A low carbohydrate diet has shown favorable results in short-term studies for persons trying to improve blood glucose control, cholesterol, and lose weight. Persons with type 2 diabetes may consider a low carbohydrate diet, but should work with their healthcare provider to individualize a plan.
A moderate-salt or low-salt diet is often recommended; a low-salt diet is especially useful for lowering high blood pressure.
Timing of food intake — Consistent timing of food intake is not necessary for all people with diabetes. However, people using intensive insulin treatment may find it easier to control their blood sugar levels when they eat approximately the same amount of carbohydrates at the same time each day.
Establishing healthy dietary habits — To get started with healthy eating habits, a patient may be asked to keep a food diary, discuss current eating patterns, attend a dietary class for people with diabetes, or meet with a dietitian. Eating habits should be changed slowly, making it easier to adopt new habits.
ALCOHOL USE — The recommendations for alcohol use in persons who are diabetic are similar to those for non-diabetics. On a daily basis, no more than two alcoholic beverages for men or one alcoholic beverage for women are recommended. One alcoholic beverage is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits (all of which contain 15 grams of alcohol).
Alcohol can cause either low or high blood glucose, depending upon the amount of alcohol consumed, if food was eaten at the same time, and the history of prior alcohol use or abuse. Persons with diabetes who choose to drink alcohol should drink moderately.
A moderate intake of alcohol may lower blood pressure and decrease the risk of coronary artery disease and stroke. However, excessive use of alcohol can increase the risk of neurologic and liver disease and high blood pressure.
QUITTING SMOKING — Over 25 percent of people newly diagnosed with diabetes are smokers. Quitting smoking is one of the most important things a patient can do to improve their health.
Smokers with diabetes have an increased risk of the following: Death, especially from heart attacks and strokes High "bad" cholesterol levels Worsened blood glucose controlled, compared to non-smokers Neurologic complications from diabetes Kidney disease leading to dialysis Foot ulcer and amputation of toes, feet or legs caused by peripheral vascular disease
Diabetics who quit smoking can decrease their risks. Most people who smoke find it difficult to quit; assistance is available from a number of sources. Healthcare providers have access to self-help materials, and can help select a quit date, provide contact information for local support groups, and prescribe nicotine replacement treatment, if needed.
EXERCISE — Exercise is beneficial for all individuals, with or without diabetes. Even persons with longstanding diabetes or diabetic complications can benefit from exercise.
For diabetics, exercise promotes cardiovascular fitness and weight loss, lowers high blood pressure, improves lipid profiles, improves blood glucose control in some cases, and leads to an overall sense of well-being. It may even help prevent type 2 diabetes in some people.
General exercise precautions — It is important to balance enthusiasm and common sense when beginning an exercise program. These precautions encourage patients to stay safe and ensure that exercise is productive. Wear well-fitting, protective footwear (See "Patient information: Foot care in diabetes"). Drink adequate liquids before, during, and after exercise to prevent dehydration, which can upset blood glucose levels.
Diabetics who use insulin should also: Measure blood glucose before, during, and after exercise to determine their body's typical response to exercise. If the pre-exercise blood glucose reading is 250 mg/dL or higher, exercise should be postponed until the level is under control. Consider a decrease in insulin dose by about 30 percent during exercise. Choose an insulin injection site away from exercising muscles (for example, avoid the legs if running) Keeping rapidly absorbed carbohydrates on hand (glucose tablets, hard candies, or juice). Eat a snack 15 to 30 minutes before exercise, and again every 30 minutes during exercise. Eat a source of slowly absorbed carbohydrates (dried fruit, fruit jerky, granola bars, or trail mix) immediately after exercise. This will counter a post-exercise drop in blood glucose levels.
The pre-exercise examination — People with diabetes who want to start an exercise program should consult with their healthcare provider first. A pre-exercise examination, including a supervised exercise stress test, may be needed for persons over the age of 35 and those who have had diabetes for more than 10 years.
Type of exercise — Gentle aerobic exercises, which increase the heart rate for a sustained period of time, are often the best choice for diabetics. Examples of aerobic exercise include walking, cycling, swimming, or rowing. Diabetics with well-controlled blood glucose levels and no complications can usually participate in most any type of exercise.
Choose exercise that is enjoyable and can be performed comfortably, making it easier to stay motivated and stick with a program over time. People who are accustomed to a sedentary lifestyle may find it particularly challenging to start and continue with an exercise program. Talk with a healthcare provider about any barriers that stand in the way of exercise; he or she may be able to suggest solutions.
People with diabetic eye complications (proliferative retinopathy) may be advised to avoid high-impact activities and strenuous weight-lifting, which can increase blood pressure and cause bleeding in the eye. People with neurologic complications (peripheral neuropathy) are usually advised to avoid traumatic weight-bearing exercises such as running, which can lead to foot ulcers and stress fractures although this depends on the severity of the nerve damage.
Intensity — Exercise does not have to be intense to be beneficial. Persons who want to increase the intensity of exercise should do so gradually, and should stop if he or she experience worrisome symptoms, such as chest discomfort or nausea.
Duration — A reasonable exercise session consists of 10 minutes of stretching and warm-up, followed by 20 minutes of gentle aerobic exercise. Eventually, you may wish to exercise for more than 30 minutes at a time. You should increase the duration of exercise gradually.
Timing — People who take insulin should try to exercise at the same time of the day. This practice can help to maintain predictable blood glucose levels.
Frequency — Most of the benefits of exercise for people with diabetes require a regular, long-term exercise program. Patients should commit to exercising 30 minutes a day most days of the week.
MEDICATIONS AND BLOOD GLUCOSE MONITORING — The day-to-day management of blood glucose levels can be complicated. Management may require a schedule of oral medications and/or insulin, frequent blood glucose monitoring, and carefully planned meals and snacks.
However, successful management of diabetes does not have to take the enjoyment out of life. It can be difficult to establish a routine that incorporates all aspects of diabetes care, though many people find that the routine becomes second nature once established. Written schedules may help patients to remember the details of a routine until they are committed to memory. It is also important to carefully manage situations that can complicate blood glucose control, such as sick days and vacations.
People with diabetes may need to take several medications throughout the day. Medications to lower high blood pressure, lower cholesterol levels, and low-dose aspirin may be used to manage and prevent complications. Each prescription should be taken exactly as directed on a daily basis. If the medication schedule is complex, a pill organizer or written outline may be helpful in remembering to take specific medications at specific times.
ROUTINE MEDICAL CARE — Making lifestyle changes is an excellent step towards diabetes management. However, routine medical care is important for people with diabetes; this may include frequent medical appointments and screening tests. Your healthcare team will periodically reevaluate the diabetes management plan, and can work to detect health problems that do not cause symptoms in the early stages.
Finally, it is important to listen to your body and seek care if questions or problems arise. This may require calling and seeing a clinician between scheduled appointments. Even persons who have had diabetes for many years have difficulty some times, and clinicians are skilled in helping to solve problems.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institue of Diabetes and Digestive and Kidney Diseases
(www.niddk.nih.gov/)
American Diabetes Association (ADA)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
The Hormone Foundation
(www.hormone.org/public/diabetes.cfm, available in English and Spanish)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Close, EJ, Wiles, PG, Lockton, JA, et al. The degree of day-to-day variation in food intake in diabetic patients. Diabet Med 1993; 10:514.
2. Pan, XR, Li, GW, Hu, YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT study. Diabetes Care 1997; 20:537.
3. American Diabetes Association. Nutritional Recommendations and Principles for People with Diabetes Mellitus. Diabetes Care 1994; 17:519.
4. Torjesen, PA, Birkeland, KI, Anderssen, SA, et al. Lifestyle changes may reverse development of the insulin resistance syndrome. The Oslo diet and exercise study: A randomized trial. Diabetes Care 1997; 20:26.
Lifestyle modifications can be a very effective way to keep diabetes in control. Improved blood glucose control can slow the progression of long-term complications. Multiple small changes can lead to improvements in diabetes control, including a decreased need for medication.
Diabetes requires a lifelong management plan, and persons with diabetes have a central role in this plan. Lifestyle modifications are an opportunity for diabetics to take charge of their health. Therefore, it is important to learn as much as possible about diabetes and to take an active role in making decisions about health care and treatment.
DIETARY CHANGES — Healthcare providers may recommend specific dietary changes for people with diabetes, depending upon the patient's therapy goals. Dietary changes can help with weight loss, improve blood glucose control, and lower blood cholesterol levels and blood pressure.
Calories — Lifestyle changes that promote weight loss are the primary lifestyle treatment for people with type 2 diabetes who are overweight. Improving caloric balance (eating fewer calories than are used by the body) should be consider the primary goal of lifestyle modification.
Weight loss can improve blood glucose control by decreasing insulin resistance and partially restoring the normal insulin-producing function of the pancreas. Weight loss can also lower blood pressure; high blood pressure and obesity are both risk factors in the development of cardiovascular disease. Weight gain can be a problem in patients who take insulin stimulators (like sulfonylureas, or meglitinides), thiazolidinediones (like pioglitazone and rosiglitazone) or who take insulin.
A sensible and sustainable diet, which may include reducing the number of calories eaten each day, allows for gradual weight loss over time. A healthcare provider or nutritionist can discuss an ideal weight goal with help to plan a safe and effective overall weight-loss program. While reducing calories and increasing activity are beneficial to anyone who is overweight, a focus on carbohydrate counting may also be useful for patient using insulin stimulators (like sulfonylureas and meglitinides) and insulin.
Carbohydrate counting — It is possible to adjust an insulin dose based upon the amount of carbohydrates eaten. The number of carbohydrates can be determined using nutrition labels or carbohydrate calculators (show figure 1). The dose of insulin needed based on carbohydrates eaten varies from one patient to another, and can be determined with the help of a healthcare provider (show table 1).
Post-meal blood glucose management — Blood glucose levels can rise sharply after meals. Increasing the amount of soluble fiber in the meal may slow and/or lessen this rise, and may decrease the dose of insulin needed. Soluble fiber is found in fruits, vegetables, and beans. A high-fiber diet can also lower levels of low-density lipoprotein (LDL) cholesterol (sometimes called "bad" cholesterol).
Eating foods with a low glycemic index is another approach for controlling post-meal blood glucose levels. A diet of low-glycemic index foods may also decrease LDL cholesterol levels. The glycemic index of some foods is shown in the Table (show table 2).
Increasing the dose or changing the timing of very rapid or rapid-acting insulin before meals can help control post-meal glucose levels. Very rapid-acting insulin (lispro [Humalog®], aspart [Novolog®], or glulisine [Apidra®]) should be given within 15 minutes of eating, while rapid acting insulin (Regular or R) should be given 30 to 60 minutes before a meal (show table 3).
Other approaches that can help to reduce the rise in blood glucose levels after meals include the use of alpha-glucosidase inhibitors (like acarbose or miglitol) which can be taken as a pill with the first bite of a meal. These drugs slow down the rate at which starch is broken down into glucose and so delay the absorption of glucose into the blood after a meal. These drugs are effective in some people although they can cause flatulence and diarrhea as a side effect.
Two new injectable therapies (pramlintide [Symlin®], and exenatide [Byetta®]) can also decrease the rise in blood glucose after a meal. They can also increase satiety and decrease hunger which can lead to weight loss in some patients. However, both of these drugs can cause significant nausea in some patients. In addition, patients who are taking insulin will need to reduce their insulin dose if pramlintide or exenatide are added.
Dietary guidelines — The ratio of carbohydrates, protein, and fat is important to long-term health. Current recommendations are as follows: Carbohydrates: 45 to 65 percent of total calories Protein: 5 to 20 percent Fat: 25 to 30 percent (mostly monounsaturated or polyunsaturated, not saturated fat)
Clinicians may recommend different nutrient ratios for persons with other health conditions, pregnant women, and growing children.
A low carbohydrate diet has shown favorable results in short-term studies for persons trying to improve blood glucose control, cholesterol, and lose weight. Persons with type 2 diabetes may consider a low carbohydrate diet, but should work with their healthcare provider to individualize a plan.
A moderate-salt or low-salt diet is often recommended; a low-salt diet is especially useful for lowering high blood pressure.
Timing of food intake — Consistent timing of food intake is not necessary for all people with diabetes. However, people using intensive insulin treatment may find it easier to control their blood sugar levels when they eat approximately the same amount of carbohydrates at the same time each day.
Establishing healthy dietary habits — To get started with healthy eating habits, a patient may be asked to keep a food diary, discuss current eating patterns, attend a dietary class for people with diabetes, or meet with a dietitian. Eating habits should be changed slowly, making it easier to adopt new habits.
ALCOHOL USE — The recommendations for alcohol use in persons who are diabetic are similar to those for non-diabetics. On a daily basis, no more than two alcoholic beverages for men or one alcoholic beverage for women are recommended. One alcoholic beverage is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits (all of which contain 15 grams of alcohol).
Alcohol can cause either low or high blood glucose, depending upon the amount of alcohol consumed, if food was eaten at the same time, and the history of prior alcohol use or abuse. Persons with diabetes who choose to drink alcohol should drink moderately.
A moderate intake of alcohol may lower blood pressure and decrease the risk of coronary artery disease and stroke. However, excessive use of alcohol can increase the risk of neurologic and liver disease and high blood pressure.
QUITTING SMOKING — Over 25 percent of people newly diagnosed with diabetes are smokers. Quitting smoking is one of the most important things a patient can do to improve their health.
Smokers with diabetes have an increased risk of the following: Death, especially from heart attacks and strokes High "bad" cholesterol levels Worsened blood glucose controlled, compared to non-smokers Neurologic complications from diabetes Kidney disease leading to dialysis Foot ulcer and amputation of toes, feet or legs caused by peripheral vascular disease
Diabetics who quit smoking can decrease their risks. Most people who smoke find it difficult to quit; assistance is available from a number of sources. Healthcare providers have access to self-help materials, and can help select a quit date, provide contact information for local support groups, and prescribe nicotine replacement treatment, if needed.
EXERCISE — Exercise is beneficial for all individuals, with or without diabetes. Even persons with longstanding diabetes or diabetic complications can benefit from exercise.
For diabetics, exercise promotes cardiovascular fitness and weight loss, lowers high blood pressure, improves lipid profiles, improves blood glucose control in some cases, and leads to an overall sense of well-being. It may even help prevent type 2 diabetes in some people.
General exercise precautions — It is important to balance enthusiasm and common sense when beginning an exercise program. These precautions encourage patients to stay safe and ensure that exercise is productive. Wear well-fitting, protective footwear (See "Patient information: Foot care in diabetes"). Drink adequate liquids before, during, and after exercise to prevent dehydration, which can upset blood glucose levels.
Diabetics who use insulin should also: Measure blood glucose before, during, and after exercise to determine their body's typical response to exercise. If the pre-exercise blood glucose reading is 250 mg/dL or higher, exercise should be postponed until the level is under control. Consider a decrease in insulin dose by about 30 percent during exercise. Choose an insulin injection site away from exercising muscles (for example, avoid the legs if running) Keeping rapidly absorbed carbohydrates on hand (glucose tablets, hard candies, or juice). Eat a snack 15 to 30 minutes before exercise, and again every 30 minutes during exercise. Eat a source of slowly absorbed carbohydrates (dried fruit, fruit jerky, granola bars, or trail mix) immediately after exercise. This will counter a post-exercise drop in blood glucose levels.
The pre-exercise examination — People with diabetes who want to start an exercise program should consult with their healthcare provider first. A pre-exercise examination, including a supervised exercise stress test, may be needed for persons over the age of 35 and those who have had diabetes for more than 10 years.
Type of exercise — Gentle aerobic exercises, which increase the heart rate for a sustained period of time, are often the best choice for diabetics. Examples of aerobic exercise include walking, cycling, swimming, or rowing. Diabetics with well-controlled blood glucose levels and no complications can usually participate in most any type of exercise.
Choose exercise that is enjoyable and can be performed comfortably, making it easier to stay motivated and stick with a program over time. People who are accustomed to a sedentary lifestyle may find it particularly challenging to start and continue with an exercise program. Talk with a healthcare provider about any barriers that stand in the way of exercise; he or she may be able to suggest solutions.
People with diabetic eye complications (proliferative retinopathy) may be advised to avoid high-impact activities and strenuous weight-lifting, which can increase blood pressure and cause bleeding in the eye. People with neurologic complications (peripheral neuropathy) are usually advised to avoid traumatic weight-bearing exercises such as running, which can lead to foot ulcers and stress fractures although this depends on the severity of the nerve damage.
Intensity — Exercise does not have to be intense to be beneficial. Persons who want to increase the intensity of exercise should do so gradually, and should stop if he or she experience worrisome symptoms, such as chest discomfort or nausea.
Duration — A reasonable exercise session consists of 10 minutes of stretching and warm-up, followed by 20 minutes of gentle aerobic exercise. Eventually, you may wish to exercise for more than 30 minutes at a time. You should increase the duration of exercise gradually.
Timing — People who take insulin should try to exercise at the same time of the day. This practice can help to maintain predictable blood glucose levels.
Frequency — Most of the benefits of exercise for people with diabetes require a regular, long-term exercise program. Patients should commit to exercising 30 minutes a day most days of the week.
MEDICATIONS AND BLOOD GLUCOSE MONITORING — The day-to-day management of blood glucose levels can be complicated. Management may require a schedule of oral medications and/or insulin, frequent blood glucose monitoring, and carefully planned meals and snacks.
However, successful management of diabetes does not have to take the enjoyment out of life. It can be difficult to establish a routine that incorporates all aspects of diabetes care, though many people find that the routine becomes second nature once established. Written schedules may help patients to remember the details of a routine until they are committed to memory. It is also important to carefully manage situations that can complicate blood glucose control, such as sick days and vacations.
People with diabetes may need to take several medications throughout the day. Medications to lower high blood pressure, lower cholesterol levels, and low-dose aspirin may be used to manage and prevent complications. Each prescription should be taken exactly as directed on a daily basis. If the medication schedule is complex, a pill organizer or written outline may be helpful in remembering to take specific medications at specific times.
ROUTINE MEDICAL CARE — Making lifestyle changes is an excellent step towards diabetes management. However, routine medical care is important for people with diabetes; this may include frequent medical appointments and screening tests. Your healthcare team will periodically reevaluate the diabetes management plan, and can work to detect health problems that do not cause symptoms in the early stages.
Finally, it is important to listen to your body and seek care if questions or problems arise. This may require calling and seeing a clinician between scheduled appointments. Even persons who have had diabetes for many years have difficulty some times, and clinicians are skilled in helping to solve problems.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institue of Diabetes and Digestive and Kidney Diseases
(www.niddk.nih.gov/)
American Diabetes Association (ADA)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
The Hormone Foundation
(www.hormone.org/public/diabetes.cfm, available in English and Spanish)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Close, EJ, Wiles, PG, Lockton, JA, et al. The degree of day-to-day variation in food intake in diabetic patients. Diabet Med 1993; 10:514.
2. Pan, XR, Li, GW, Hu, YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT study. Diabetes Care 1997; 20:537.
3. American Diabetes Association. Nutritional Recommendations and Principles for People with Diabetes Mellitus. Diabetes Care 1994; 17:519.
4. Torjesen, PA, Birkeland, KI, Anderssen, SA, et al. Lifestyle changes may reverse development of the insulin resistance syndrome. The Oslo diet and exercise study: A randomized trial. Diabetes Care 1997; 20:26.
Hypoglycemia (low blood glucose) in diabetes
INTRODUCTION — Hypoglycemia, also known as low blood sugar, occurs when levels of glucose (sugar) in the blood are too low. Hypoglycemia is common in people with diabetes who take insulin or oral medications that cause insulin secretion. People with type 2 diabetes often use diet control or oral medications that do not cause insulin secretion; hypoglycemia does not occur in these patients.
Hypoglycemia happens when a person with diabetes does one or more of the following: Takes too much insulin (or drugs that cause insulin secretion) Does not eat enough food Exercises vigorously without eating a snack or decreasing the dose of insulin beforehand Waits too long between meals Drinks excessive alcohol, although even moderate alcohol use can increase the risk of hypoglycemia in patients with type 1 diabetes
SYMPTOMS — The symptoms of hypoglycemia vary from person to person, and can change over time. Patients who drink excessive amounts of alcohol, are tired, or who take beta-blocking medications may not notice their symptoms, or may not recognize that the symptoms are due to hypoglycemia.
During the early stages of a hypoglycemic episode, symptoms may include: Sweating Tremor Hunger Anxiety
If untreated, symptoms can become more severe, and can include: Lack of coordination Weakness Lethargy Blurred vision Bizarre behavior or personality change Confusion Unconsciousness or seizure
When possible, hypoglycemia should be confirmed by measuring the blood glucose level. (See "Patient information: Self-blood glucose monitoring"). A blood glucose below 60 mg/dL, in the presence of symptoms, indicates hypoglycemia for most patients.
Some patients with diabetes can experience hypoglycemia at slightly higher blood glucose levels. Patients whose blood glucose levels are high for long periods of time may have symptoms of low blood glucose and feel poorly when levels approach 100 mg/dL. These patients should intensify their diabetic regimen to get blood glucose levels into a range that is closer to normal. This will lower the blood glucose level at which a patient feels symptoms.
Hypoglycemia unawareness — Hypoglycemia unawareness occurs when a person does not have the early symptoms of low blood glucose. As a result, the person cannot respond in the early stages, and severe signs of hypoglycemia, such as loss of consciousness or seizures, are more likely. It is a common occurrence, especially in patients who have had type 1 diabetes for greater than five to 10 years.
Hypoglycemia and hypoglycemia unawareness occur more frequently in patients who tightly control their blood glucose levels with insulin (called intensive therapy, show figure 1). Frequent low blood glucose levels reduce the production of the hormones which produce symptoms of low blood glucose.
Hypoglycemia unawareness can also occur in patients who take medications that stimulate insulin secretion (for example Micronase® [glyburide]), especially if they are elderly or have impaired kidney or heart function who take an oral medication that stimulates insulin secretion (show figure 2).
Nocturnal hypoglycemia — Low blood glucose that occurs when a person is sleeping (nocturnal hypoglycemia) can disrupt sleep and often goes unrecognized. Nocturnal hypoglycemia is a form of hypoglycemia unawareness. Thus, a person with nocturnal hypoglycemia is less likely to have symptoms that alert them to the need for treatment. Nocturnal hypoglycemia can be difficult to diagnose, and can increase the risk of hypoglycemia unawareness in the 48 to 72 hours that follow.
PREVENTION — The best way to prevent hypoglycemia is to monitor blood glucose levels frequently and be prepared at all times to treat it promptly. The patient as well as a close friend or relative need to learn the symptoms, and patients at risk for hypoglycemia (those treated with insulin and some oral medications, show figure 2) should always carry glucose tablets, hard candy, or other sources of fast-acting carbohydrate. Glucose tablets are recommended since they have a pleasant taste, but are not likely to be eaten for reasons other than hypoglycemia. Candy can be tempting to eat, even when blood glucose levels are normal, especially for children with diabetes.
Hypoglycemia can be frightening and unpleasant, and it is common for patients who have experienced an episode of severe hypoglycemia to be fearful of future episodes. Patients who experience this fear may keep their blood glucose excessively high, which can lead to long term complications.
It may be helpful to discuss fears of hypoglycemia with a healthcare provider. In addition, patients should ask about blood glucose awareness education and training in the use of glucagon, an injectable drug that raises blood sugar levels quickly. Blood glucose awareness training can improve a patient's ability to recognize low blood glucose earlier, which may help to prevent episodes of severe hypoglycemia.
TREATMENT — While the blood glucose level should be tested as soon as possible, treatment should not be delayed if monitoring equipment (blood glucose meter, test strips, lancet) is not readily available. Treatment of hypoglycemia should be quick, especially if blood glucose levels are less than 40 mg/dL.
As soon as symptoms are noted, a patient should eat 10 to 15 grams of fast-acting carbohydrate. Examples include: Three to four glucose tablets Six to eight hard candies 1/2 cup fruit juice
This amount of food is usually enough to raise the blood glucose into a safe range without causing high blood glucose levels (called hyperglycemia). Foods that contain fat (like candy bars) or protein (cheese) should initially be avoided, since they slow down the body's ability to absorb glucose.
After 15 minutes, the blood glucose level should be measured again. It is important to wait since it takes time for the body to absorb glucose and for symptoms to resolve. If the blood glucose level is below 60 mg/dL, or if symptoms persist, another 10 to 15 grams of fast-acting carbohydrate should be eaten.
Once symptoms and blood glucose levels are under control, a snack may be needed to control blood glucose levels until the next meal. If the next meal is more than one hour away or the patient has just completed vigorous exercise, a snack including 15 grams of carbohydrate and 1 ounce of protein should be eaten. Examples of this include crackers with cheese or one-half of a sandwich with peanut butter. It is important not to eat too much, as this can raise blood glucose levels above the target level.
Glucagon — If hypoglycemia is severe, the patient may become unconscious or unable to eat. A close friend or relative should be trained to recognize severe hypoglycemia and treat it quickly. Dealing with a loved one who is pale, sweaty, acting in a bizarre way, or unconscious and convulsing can be scary. An injection of glucagon stops these symptoms quickly.
Glucagon is a hormone that raises blood glucose levels. Glucagon is available in emergency kits, which can be bought with a prescription in a pharmacy (show picture 1). Directions are included in each kit; a roommate, spouse, or parent should familiarize themselves with the injection procedure before an emergency occurs.
It is important that the glucagon kit is easy to locate, is not expired, and that the friend or relative is able to stay calm. It is important that the kit is refilled when the expiration date approaches, though administering an expired kit is unlikely to cause harm.
Procedure — Glucagon is injected subcutaneously (under the skin) of the thigh or abdomen. The injection sites and technique are similar to an insulin injection. Remove the needle protector and inject the entire content of the syringe (a clear solution) into the glucagon powder. Do not remove the plastic clip on the syringe. Remove syringe from the bottle. Swirl the mixture gently until the powder is dissolved. The solution should be clear. Do not use the solution if it is discolored. Hold the bottle upside down and withdraw the contents into the syringe (1 mg mark on syringe for adults and children over 44 pounds [20 kilograms]). Children under 44 pounds need one-half the dose, and only 1/2 the solution should be withdrawn (0.5 mg mark on syringe). Cleanse the injection site (abdomen or thigh) with an alcohol swab (show figure 3) Insert the needle into the skin (show picture 2). Press the plunger to inject the glucagon. Withdraw the needle, and replace the syringe in the storage case (do not attempt to re-cap the needle). Press lightly at the injection site. Turn the patient to his or her side. This prevents choking if the patient vomits.
Symptoms should resolve within 10 to 15 minutes, although nausea and vomiting may follow 60 to 90 minutes later. As soon as the patient is awake and able to swallow, a fast-acting carbohydrate such as glucose tablets or juice should be offered. After the patient begins to feel better, he or she should eat a snack with protein, such as crackers and cheese or a peanut butter sandwich.
If the patient is not conscious within 10 minutes, another glucagon injection should be given, if a second kit is available. Emergency help should be called immediately.
WHEN TO SEEK HELP — A family member or friend should take a patient to the hospital or call for emergency assistance (911 in many US communities) immediately if the patient: Remains confused or in an altered mental state after being treated with glucagon Is unconscious (or nearly unconscious) and glucagon is not available Continues to have low blood glucose despite eating adequate amounts of a fast-acting carbohydrate or receiving glucagon
Once in a hospital or ambulance, intravenous glucose is given to raise levels immediately.
FOLLOW UP CARE — After the blood glucose level is normal and symptoms are gone, a patient can usually resume his or her normal activities. A patient who required glucagon should speak with his or her healthcare provider. This can help to identify the cause of a severely low blood glucose level, and adjustments can be made to prevent future reactions. Patients who require emergency care may be observed for a few hours before being released. A friend or relative should drive the patient home.
Patients should be especially careful in the first 48 to 72 hours after a hypoglycemic episode, because his or her ability to recognize the symptoms of low blood glucose may be impaired. In addition, the body's ability to counteract low blood glucose levels is decreased.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Diabetes & Digestive & Kidney Diseases
(www.niddk.nih.gov)
American Diabetes Association (ADA)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
The Endocrine Society
(www.endo-society.org)
The Hormone Foundation
(www.hormone.org/public/diabetes.cfm, available in English and Spanish)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Cox, DJ, Gonder-Frederick, L, Julian, DM, Clarke, W. Long-term follow-up evaluation of blood glucose awareness training. Diabetes Care 1994; 17:1.
2. Fanelli, CG, Paramore, DS, Hershey, T, et al. Impact of nocturnal hypoglycemia on hypoglycemic cognitive dysfunction in type 1 diabetes. Diabetes 1998; 47:1920.
3. Irvine, AA, Cox, D. Gonder-Frederick, L. Fear of hypoglycemia: Relationship to physical symptoms in patients with insulin-dependent diabetes. Health Psych 1992; 11:135.
4. Weinger, K, Kinsley, BT, Levy, CJ, et al. The perception of safe driving ability during hypoglycemia in patients with type 1 diabetes mellitus. Am J Med 1999; 107:246.
Hypoglycemia happens when a person with diabetes does one or more of the following: Takes too much insulin (or drugs that cause insulin secretion) Does not eat enough food Exercises vigorously without eating a snack or decreasing the dose of insulin beforehand Waits too long between meals Drinks excessive alcohol, although even moderate alcohol use can increase the risk of hypoglycemia in patients with type 1 diabetes
SYMPTOMS — The symptoms of hypoglycemia vary from person to person, and can change over time. Patients who drink excessive amounts of alcohol, are tired, or who take beta-blocking medications may not notice their symptoms, or may not recognize that the symptoms are due to hypoglycemia.
During the early stages of a hypoglycemic episode, symptoms may include: Sweating Tremor Hunger Anxiety
If untreated, symptoms can become more severe, and can include: Lack of coordination Weakness Lethargy Blurred vision Bizarre behavior or personality change Confusion Unconsciousness or seizure
When possible, hypoglycemia should be confirmed by measuring the blood glucose level. (See "Patient information: Self-blood glucose monitoring"). A blood glucose below 60 mg/dL, in the presence of symptoms, indicates hypoglycemia for most patients.
Some patients with diabetes can experience hypoglycemia at slightly higher blood glucose levels. Patients whose blood glucose levels are high for long periods of time may have symptoms of low blood glucose and feel poorly when levels approach 100 mg/dL. These patients should intensify their diabetic regimen to get blood glucose levels into a range that is closer to normal. This will lower the blood glucose level at which a patient feels symptoms.
Hypoglycemia unawareness — Hypoglycemia unawareness occurs when a person does not have the early symptoms of low blood glucose. As a result, the person cannot respond in the early stages, and severe signs of hypoglycemia, such as loss of consciousness or seizures, are more likely. It is a common occurrence, especially in patients who have had type 1 diabetes for greater than five to 10 years.
Hypoglycemia and hypoglycemia unawareness occur more frequently in patients who tightly control their blood glucose levels with insulin (called intensive therapy, show figure 1). Frequent low blood glucose levels reduce the production of the hormones which produce symptoms of low blood glucose.
Hypoglycemia unawareness can also occur in patients who take medications that stimulate insulin secretion (for example Micronase® [glyburide]), especially if they are elderly or have impaired kidney or heart function who take an oral medication that stimulates insulin secretion (show figure 2).
Nocturnal hypoglycemia — Low blood glucose that occurs when a person is sleeping (nocturnal hypoglycemia) can disrupt sleep and often goes unrecognized. Nocturnal hypoglycemia is a form of hypoglycemia unawareness. Thus, a person with nocturnal hypoglycemia is less likely to have symptoms that alert them to the need for treatment. Nocturnal hypoglycemia can be difficult to diagnose, and can increase the risk of hypoglycemia unawareness in the 48 to 72 hours that follow.
PREVENTION — The best way to prevent hypoglycemia is to monitor blood glucose levels frequently and be prepared at all times to treat it promptly. The patient as well as a close friend or relative need to learn the symptoms, and patients at risk for hypoglycemia (those treated with insulin and some oral medications, show figure 2) should always carry glucose tablets, hard candy, or other sources of fast-acting carbohydrate. Glucose tablets are recommended since they have a pleasant taste, but are not likely to be eaten for reasons other than hypoglycemia. Candy can be tempting to eat, even when blood glucose levels are normal, especially for children with diabetes.
Hypoglycemia can be frightening and unpleasant, and it is common for patients who have experienced an episode of severe hypoglycemia to be fearful of future episodes. Patients who experience this fear may keep their blood glucose excessively high, which can lead to long term complications.
It may be helpful to discuss fears of hypoglycemia with a healthcare provider. In addition, patients should ask about blood glucose awareness education and training in the use of glucagon, an injectable drug that raises blood sugar levels quickly. Blood glucose awareness training can improve a patient's ability to recognize low blood glucose earlier, which may help to prevent episodes of severe hypoglycemia.
TREATMENT — While the blood glucose level should be tested as soon as possible, treatment should not be delayed if monitoring equipment (blood glucose meter, test strips, lancet) is not readily available. Treatment of hypoglycemia should be quick, especially if blood glucose levels are less than 40 mg/dL.
As soon as symptoms are noted, a patient should eat 10 to 15 grams of fast-acting carbohydrate. Examples include: Three to four glucose tablets Six to eight hard candies 1/2 cup fruit juice
This amount of food is usually enough to raise the blood glucose into a safe range without causing high blood glucose levels (called hyperglycemia). Foods that contain fat (like candy bars) or protein (cheese) should initially be avoided, since they slow down the body's ability to absorb glucose.
After 15 minutes, the blood glucose level should be measured again. It is important to wait since it takes time for the body to absorb glucose and for symptoms to resolve. If the blood glucose level is below 60 mg/dL, or if symptoms persist, another 10 to 15 grams of fast-acting carbohydrate should be eaten.
Once symptoms and blood glucose levels are under control, a snack may be needed to control blood glucose levels until the next meal. If the next meal is more than one hour away or the patient has just completed vigorous exercise, a snack including 15 grams of carbohydrate and 1 ounce of protein should be eaten. Examples of this include crackers with cheese or one-half of a sandwich with peanut butter. It is important not to eat too much, as this can raise blood glucose levels above the target level.
Glucagon — If hypoglycemia is severe, the patient may become unconscious or unable to eat. A close friend or relative should be trained to recognize severe hypoglycemia and treat it quickly. Dealing with a loved one who is pale, sweaty, acting in a bizarre way, or unconscious and convulsing can be scary. An injection of glucagon stops these symptoms quickly.
Glucagon is a hormone that raises blood glucose levels. Glucagon is available in emergency kits, which can be bought with a prescription in a pharmacy (show picture 1). Directions are included in each kit; a roommate, spouse, or parent should familiarize themselves with the injection procedure before an emergency occurs.
It is important that the glucagon kit is easy to locate, is not expired, and that the friend or relative is able to stay calm. It is important that the kit is refilled when the expiration date approaches, though administering an expired kit is unlikely to cause harm.
Procedure — Glucagon is injected subcutaneously (under the skin) of the thigh or abdomen. The injection sites and technique are similar to an insulin injection. Remove the needle protector and inject the entire content of the syringe (a clear solution) into the glucagon powder. Do not remove the plastic clip on the syringe. Remove syringe from the bottle. Swirl the mixture gently until the powder is dissolved. The solution should be clear. Do not use the solution if it is discolored. Hold the bottle upside down and withdraw the contents into the syringe (1 mg mark on syringe for adults and children over 44 pounds [20 kilograms]). Children under 44 pounds need one-half the dose, and only 1/2 the solution should be withdrawn (0.5 mg mark on syringe). Cleanse the injection site (abdomen or thigh) with an alcohol swab (show figure 3) Insert the needle into the skin (show picture 2). Press the plunger to inject the glucagon. Withdraw the needle, and replace the syringe in the storage case (do not attempt to re-cap the needle). Press lightly at the injection site. Turn the patient to his or her side. This prevents choking if the patient vomits.
Symptoms should resolve within 10 to 15 minutes, although nausea and vomiting may follow 60 to 90 minutes later. As soon as the patient is awake and able to swallow, a fast-acting carbohydrate such as glucose tablets or juice should be offered. After the patient begins to feel better, he or she should eat a snack with protein, such as crackers and cheese or a peanut butter sandwich.
If the patient is not conscious within 10 minutes, another glucagon injection should be given, if a second kit is available. Emergency help should be called immediately.
WHEN TO SEEK HELP — A family member or friend should take a patient to the hospital or call for emergency assistance (911 in many US communities) immediately if the patient: Remains confused or in an altered mental state after being treated with glucagon Is unconscious (or nearly unconscious) and glucagon is not available Continues to have low blood glucose despite eating adequate amounts of a fast-acting carbohydrate or receiving glucagon
Once in a hospital or ambulance, intravenous glucose is given to raise levels immediately.
FOLLOW UP CARE — After the blood glucose level is normal and symptoms are gone, a patient can usually resume his or her normal activities. A patient who required glucagon should speak with his or her healthcare provider. This can help to identify the cause of a severely low blood glucose level, and adjustments can be made to prevent future reactions. Patients who require emergency care may be observed for a few hours before being released. A friend or relative should drive the patient home.
Patients should be especially careful in the first 48 to 72 hours after a hypoglycemic episode, because his or her ability to recognize the symptoms of low blood glucose may be impaired. In addition, the body's ability to counteract low blood glucose levels is decreased.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Diabetes & Digestive & Kidney Diseases
(www.niddk.nih.gov)
American Diabetes Association (ADA)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
The Endocrine Society
(www.endo-society.org)
The Hormone Foundation
(www.hormone.org/public/diabetes.cfm, available in English and Spanish)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Cox, DJ, Gonder-Frederick, L, Julian, DM, Clarke, W. Long-term follow-up evaluation of blood glucose awareness training. Diabetes Care 1994; 17:1.
2. Fanelli, CG, Paramore, DS, Hershey, T, et al. Impact of nocturnal hypoglycemia on hypoglycemic cognitive dysfunction in type 1 diabetes. Diabetes 1998; 47:1920.
3. Irvine, AA, Cox, D. Gonder-Frederick, L. Fear of hypoglycemia: Relationship to physical symptoms in patients with insulin-dependent diabetes. Health Psych 1992; 11:135.
4. Weinger, K, Kinsley, BT, Levy, CJ, et al. The perception of safe driving ability during hypoglycemia in patients with type 1 diabetes mellitus. Am J Med 1999; 107:246.
Hypoglycemia (low blood glucose) in diabetes
INTRODUCTION — Hypoglycemia, also known as low blood sugar, occurs when levels of glucose (sugar) in the blood are too low. Hypoglycemia is common in people with diabetes who take insulin or oral medications that cause insulin secretion. People with type 2 diabetes often use diet control or oral medications that do not cause insulin secretion; hypoglycemia does not occur in these patients.
Hypoglycemia happens when a person with diabetes does one or more of the following: Takes too much insulin (or drugs that cause insulin secretion) Does not eat enough food Exercises vigorously without eating a snack or decreasing the dose of insulin beforehand Waits too long between meals Drinks excessive alcohol, although even moderate alcohol use can increase the risk of hypoglycemia in patients with type 1 diabetes
SYMPTOMS — The symptoms of hypoglycemia vary from person to person, and can change over time. Patients who drink excessive amounts of alcohol, are tired, or who take beta-blocking medications may not notice their symptoms, or may not recognize that the symptoms are due to hypoglycemia.
During the early stages of a hypoglycemic episode, symptoms may include: Sweating Tremor Hunger Anxiety
If untreated, symptoms can become more severe, and can include: Lack of coordination Weakness Lethargy Blurred vision Bizarre behavior or personality change Confusion Unconsciousness or seizure
When possible, hypoglycemia should be confirmed by measuring the blood glucose level. (See "Patient information: Self-blood glucose monitoring"). A blood glucose below 60 mg/dL, in the presence of symptoms, indicates hypoglycemia for most patients.
Some patients with diabetes can experience hypoglycemia at slightly higher blood glucose levels. Patients whose blood glucose levels are high for long periods of time may have symptoms of low blood glucose and feel poorly when levels approach 100 mg/dL. These patients should intensify their diabetic regimen to get blood glucose levels into a range that is closer to normal. This will lower the blood glucose level at which a patient feels symptoms.
Hypoglycemia unawareness — Hypoglycemia unawareness occurs when a person does not have the early symptoms of low blood glucose. As a result, the person cannot respond in the early stages, and severe signs of hypoglycemia, such as loss of consciousness or seizures, are more likely. It is a common occurrence, especially in patients who have had type 1 diabetes for greater than five to 10 years.
Hypoglycemia and hypoglycemia unawareness occur more frequently in patients who tightly control their blood glucose levels with insulin (called intensive therapy, show figure 1). Frequent low blood glucose levels reduce the production of the hormones which produce symptoms of low blood glucose.
Hypoglycemia unawareness can also occur in patients who take medications that stimulate insulin secretion (for example Micronase® [glyburide]), especially if they are elderly or have impaired kidney or heart function who take an oral medication that stimulates insulin secretion (show figure 2).
Nocturnal hypoglycemia — Low blood glucose that occurs when a person is sleeping (nocturnal hypoglycemia) can disrupt sleep and often goes unrecognized. Nocturnal hypoglycemia is a form of hypoglycemia unawareness. Thus, a person with nocturnal hypoglycemia is less likely to have symptoms that alert them to the need for treatment. Nocturnal hypoglycemia can be difficult to diagnose, and can increase the risk of hypoglycemia unawareness in the 48 to 72 hours that follow.
PREVENTION — The best way to prevent hypoglycemia is to monitor blood glucose levels frequently and be prepared at all times to treat it promptly. The patient as well as a close friend or relative need to learn the symptoms, and patients at risk for hypoglycemia (those treated with insulin and some oral medications, show figure 2) should always carry glucose tablets, hard candy, or other sources of fast-acting carbohydrate. Glucose tablets are recommended since they have a pleasant taste, but are not likely to be eaten for reasons other than hypoglycemia. Candy can be tempting to eat, even when blood glucose levels are normal, especially for children with diabetes.
Hypoglycemia can be frightening and unpleasant, and it is common for patients who have experienced an episode of severe hypoglycemia to be fearful of future episodes. Patients who experience this fear may keep their blood glucose excessively high, which can lead to long term complications.
It may be helpful to discuss fears of hypoglycemia with a healthcare provider. In addition, patients should ask about blood glucose awareness education and training in the use of glucagon, an injectable drug that raises blood sugar levels quickly. Blood glucose awareness training can improve a patient's ability to recognize low blood glucose earlier, which may help to prevent episodes of severe hypoglycemia.
TREATMENT — While the blood glucose level should be tested as soon as possible, treatment should not be delayed if monitoring equipment (blood glucose meter, test strips, lancet) is not readily available. Treatment of hypoglycemia should be quick, especially if blood glucose levels are less than 40 mg/dL.
As soon as symptoms are noted, a patient should eat 10 to 15 grams of fast-acting carbohydrate. Examples include: Three to four glucose tablets Six to eight hard candies 1/2 cup fruit juice
This amount of food is usually enough to raise the blood glucose into a safe range without causing high blood glucose levels (called hyperglycemia). Foods that contain fat (like candy bars) or protein (cheese) should initially be avoided, since they slow down the body's ability to absorb glucose.
After 15 minutes, the blood glucose level should be measured again. It is important to wait since it takes time for the body to absorb glucose and for symptoms to resolve. If the blood glucose level is below 60 mg/dL, or if symptoms persist, another 10 to 15 grams of fast-acting carbohydrate should be eaten.
Once symptoms and blood glucose levels are under control, a snack may be needed to control blood glucose levels until the next meal. If the next meal is more than one hour away or the patient has just completed vigorous exercise, a snack including 15 grams of carbohydrate and 1 ounce of protein should be eaten. Examples of this include crackers with cheese or one-half of a sandwich with peanut butter. It is important not to eat too much, as this can raise blood glucose levels above the target level.
Glucagon — If hypoglycemia is severe, the patient may become unconscious or unable to eat. A close friend or relative should be trained to recognize severe hypoglycemia and treat it quickly. Dealing with a loved one who is pale, sweaty, acting in a bizarre way, or unconscious and convulsing can be scary. An injection of glucagon stops these symptoms quickly.
Glucagon is a hormone that raises blood glucose levels. Glucagon is available in emergency kits, which can be bought with a prescription in a pharmacy (show picture 1). Directions are included in each kit; a roommate, spouse, or parent should familiarize themselves with the injection procedure before an emergency occurs.
It is important that the glucagon kit is easy to locate, is not expired, and that the friend or relative is able to stay calm. It is important that the kit is refilled when the expiration date approaches, though administering an expired kit is unlikely to cause harm.
Procedure — Glucagon is injected subcutaneously (under the skin) of the thigh or abdomen. The injection sites and technique are similar to an insulin injection. Remove the needle protector and inject the entire content of the syringe (a clear solution) into the glucagon powder. Do not remove the plastic clip on the syringe. Remove syringe from the bottle. Swirl the mixture gently until the powder is dissolved. The solution should be clear. Do not use the solution if it is discolored. Hold the bottle upside down and withdraw the contents into the syringe (1 mg mark on syringe for adults and children over 44 pounds [20 kilograms]). Children under 44 pounds need one-half the dose, and only 1/2 the solution should be withdrawn (0.5 mg mark on syringe). Cleanse the injection site (abdomen or thigh) with an alcohol swab (show figure 3) Insert the needle into the skin (show picture 2). Press the plunger to inject the glucagon. Withdraw the needle, and replace the syringe in the storage case (do not attempt to re-cap the needle). Press lightly at the injection site. Turn the patient to his or her side. This prevents choking if the patient vomits.
Symptoms should resolve within 10 to 15 minutes, although nausea and vomiting may follow 60 to 90 minutes later. As soon as the patient is awake and able to swallow, a fast-acting carbohydrate such as glucose tablets or juice should be offered. After the patient begins to feel better, he or she should eat a snack with protein, such as crackers and cheese or a peanut butter sandwich.
If the patient is not conscious within 10 minutes, another glucagon injection should be given, if a second kit is available. Emergency help should be called immediately.
WHEN TO SEEK HELP — A family member or friend should take a patient to the hospital or call for emergency assistance (911 in many US communities) immediately if the patient: Remains confused or in an altered mental state after being treated with glucagon Is unconscious (or nearly unconscious) and glucagon is not available Continues to have low blood glucose despite eating adequate amounts of a fast-acting carbohydrate or receiving glucagon
Once in a hospital or ambulance, intravenous glucose is given to raise levels immediately.
FOLLOW UP CARE — After the blood glucose level is normal and symptoms are gone, a patient can usually resume his or her normal activities. A patient who required glucagon should speak with his or her healthcare provider. This can help to identify the cause of a severely low blood glucose level, and adjustments can be made to prevent future reactions. Patients who require emergency care may be observed for a few hours before being released. A friend or relative should drive the patient home.
Patients should be especially careful in the first 48 to 72 hours after a hypoglycemic episode, because his or her ability to recognize the symptoms of low blood glucose may be impaired. In addition, the body's ability to counteract low blood glucose levels is decreased.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Diabetes & Digestive & Kidney Diseases
(www.niddk.nih.gov)
American Diabetes Association (ADA)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
The Endocrine Society
(www.endo-society.org)
The Hormone Foundation
(www.hormone.org/public/diabetes.cfm, available in English and Spanish)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Cox, DJ, Gonder-Frederick, L, Julian, DM, Clarke, W. Long-term follow-up evaluation of blood glucose awareness training. Diabetes Care 1994; 17:1.
2. Fanelli, CG, Paramore, DS, Hershey, T, et al. Impact of nocturnal hypoglycemia on hypoglycemic cognitive dysfunction in type 1 diabetes. Diabetes 1998; 47:1920.
3. Irvine, AA, Cox, D. Gonder-Frederick, L. Fear of hypoglycemia: Relationship to physical symptoms in patients with insulin-dependent diabetes. Health Psych 1992; 11:135.
4. Weinger, K, Kinsley, BT, Levy, CJ, et al. The perception of safe driving ability during hypoglycemia in patients with type 1 diabetes mellitus. Am J Med 1999; 107:246.
Hypoglycemia happens when a person with diabetes does one or more of the following: Takes too much insulin (or drugs that cause insulin secretion) Does not eat enough food Exercises vigorously without eating a snack or decreasing the dose of insulin beforehand Waits too long between meals Drinks excessive alcohol, although even moderate alcohol use can increase the risk of hypoglycemia in patients with type 1 diabetes
SYMPTOMS — The symptoms of hypoglycemia vary from person to person, and can change over time. Patients who drink excessive amounts of alcohol, are tired, or who take beta-blocking medications may not notice their symptoms, or may not recognize that the symptoms are due to hypoglycemia.
During the early stages of a hypoglycemic episode, symptoms may include: Sweating Tremor Hunger Anxiety
If untreated, symptoms can become more severe, and can include: Lack of coordination Weakness Lethargy Blurred vision Bizarre behavior or personality change Confusion Unconsciousness or seizure
When possible, hypoglycemia should be confirmed by measuring the blood glucose level. (See "Patient information: Self-blood glucose monitoring"). A blood glucose below 60 mg/dL, in the presence of symptoms, indicates hypoglycemia for most patients.
Some patients with diabetes can experience hypoglycemia at slightly higher blood glucose levels. Patients whose blood glucose levels are high for long periods of time may have symptoms of low blood glucose and feel poorly when levels approach 100 mg/dL. These patients should intensify their diabetic regimen to get blood glucose levels into a range that is closer to normal. This will lower the blood glucose level at which a patient feels symptoms.
Hypoglycemia unawareness — Hypoglycemia unawareness occurs when a person does not have the early symptoms of low blood glucose. As a result, the person cannot respond in the early stages, and severe signs of hypoglycemia, such as loss of consciousness or seizures, are more likely. It is a common occurrence, especially in patients who have had type 1 diabetes for greater than five to 10 years.
Hypoglycemia and hypoglycemia unawareness occur more frequently in patients who tightly control their blood glucose levels with insulin (called intensive therapy, show figure 1). Frequent low blood glucose levels reduce the production of the hormones which produce symptoms of low blood glucose.
Hypoglycemia unawareness can also occur in patients who take medications that stimulate insulin secretion (for example Micronase® [glyburide]), especially if they are elderly or have impaired kidney or heart function who take an oral medication that stimulates insulin secretion (show figure 2).
Nocturnal hypoglycemia — Low blood glucose that occurs when a person is sleeping (nocturnal hypoglycemia) can disrupt sleep and often goes unrecognized. Nocturnal hypoglycemia is a form of hypoglycemia unawareness. Thus, a person with nocturnal hypoglycemia is less likely to have symptoms that alert them to the need for treatment. Nocturnal hypoglycemia can be difficult to diagnose, and can increase the risk of hypoglycemia unawareness in the 48 to 72 hours that follow.
PREVENTION — The best way to prevent hypoglycemia is to monitor blood glucose levels frequently and be prepared at all times to treat it promptly. The patient as well as a close friend or relative need to learn the symptoms, and patients at risk for hypoglycemia (those treated with insulin and some oral medications, show figure 2) should always carry glucose tablets, hard candy, or other sources of fast-acting carbohydrate. Glucose tablets are recommended since they have a pleasant taste, but are not likely to be eaten for reasons other than hypoglycemia. Candy can be tempting to eat, even when blood glucose levels are normal, especially for children with diabetes.
Hypoglycemia can be frightening and unpleasant, and it is common for patients who have experienced an episode of severe hypoglycemia to be fearful of future episodes. Patients who experience this fear may keep their blood glucose excessively high, which can lead to long term complications.
It may be helpful to discuss fears of hypoglycemia with a healthcare provider. In addition, patients should ask about blood glucose awareness education and training in the use of glucagon, an injectable drug that raises blood sugar levels quickly. Blood glucose awareness training can improve a patient's ability to recognize low blood glucose earlier, which may help to prevent episodes of severe hypoglycemia.
TREATMENT — While the blood glucose level should be tested as soon as possible, treatment should not be delayed if monitoring equipment (blood glucose meter, test strips, lancet) is not readily available. Treatment of hypoglycemia should be quick, especially if blood glucose levels are less than 40 mg/dL.
As soon as symptoms are noted, a patient should eat 10 to 15 grams of fast-acting carbohydrate. Examples include: Three to four glucose tablets Six to eight hard candies 1/2 cup fruit juice
This amount of food is usually enough to raise the blood glucose into a safe range without causing high blood glucose levels (called hyperglycemia). Foods that contain fat (like candy bars) or protein (cheese) should initially be avoided, since they slow down the body's ability to absorb glucose.
After 15 minutes, the blood glucose level should be measured again. It is important to wait since it takes time for the body to absorb glucose and for symptoms to resolve. If the blood glucose level is below 60 mg/dL, or if symptoms persist, another 10 to 15 grams of fast-acting carbohydrate should be eaten.
Once symptoms and blood glucose levels are under control, a snack may be needed to control blood glucose levels until the next meal. If the next meal is more than one hour away or the patient has just completed vigorous exercise, a snack including 15 grams of carbohydrate and 1 ounce of protein should be eaten. Examples of this include crackers with cheese or one-half of a sandwich with peanut butter. It is important not to eat too much, as this can raise blood glucose levels above the target level.
Glucagon — If hypoglycemia is severe, the patient may become unconscious or unable to eat. A close friend or relative should be trained to recognize severe hypoglycemia and treat it quickly. Dealing with a loved one who is pale, sweaty, acting in a bizarre way, or unconscious and convulsing can be scary. An injection of glucagon stops these symptoms quickly.
Glucagon is a hormone that raises blood glucose levels. Glucagon is available in emergency kits, which can be bought with a prescription in a pharmacy (show picture 1). Directions are included in each kit; a roommate, spouse, or parent should familiarize themselves with the injection procedure before an emergency occurs.
It is important that the glucagon kit is easy to locate, is not expired, and that the friend or relative is able to stay calm. It is important that the kit is refilled when the expiration date approaches, though administering an expired kit is unlikely to cause harm.
Procedure — Glucagon is injected subcutaneously (under the skin) of the thigh or abdomen. The injection sites and technique are similar to an insulin injection. Remove the needle protector and inject the entire content of the syringe (a clear solution) into the glucagon powder. Do not remove the plastic clip on the syringe. Remove syringe from the bottle. Swirl the mixture gently until the powder is dissolved. The solution should be clear. Do not use the solution if it is discolored. Hold the bottle upside down and withdraw the contents into the syringe (1 mg mark on syringe for adults and children over 44 pounds [20 kilograms]). Children under 44 pounds need one-half the dose, and only 1/2 the solution should be withdrawn (0.5 mg mark on syringe). Cleanse the injection site (abdomen or thigh) with an alcohol swab (show figure 3) Insert the needle into the skin (show picture 2). Press the plunger to inject the glucagon. Withdraw the needle, and replace the syringe in the storage case (do not attempt to re-cap the needle). Press lightly at the injection site. Turn the patient to his or her side. This prevents choking if the patient vomits.
Symptoms should resolve within 10 to 15 minutes, although nausea and vomiting may follow 60 to 90 minutes later. As soon as the patient is awake and able to swallow, a fast-acting carbohydrate such as glucose tablets or juice should be offered. After the patient begins to feel better, he or she should eat a snack with protein, such as crackers and cheese or a peanut butter sandwich.
If the patient is not conscious within 10 minutes, another glucagon injection should be given, if a second kit is available. Emergency help should be called immediately.
WHEN TO SEEK HELP — A family member or friend should take a patient to the hospital or call for emergency assistance (911 in many US communities) immediately if the patient: Remains confused or in an altered mental state after being treated with glucagon Is unconscious (or nearly unconscious) and glucagon is not available Continues to have low blood glucose despite eating adequate amounts of a fast-acting carbohydrate or receiving glucagon
Once in a hospital or ambulance, intravenous glucose is given to raise levels immediately.
FOLLOW UP CARE — After the blood glucose level is normal and symptoms are gone, a patient can usually resume his or her normal activities. A patient who required glucagon should speak with his or her healthcare provider. This can help to identify the cause of a severely low blood glucose level, and adjustments can be made to prevent future reactions. Patients who require emergency care may be observed for a few hours before being released. A friend or relative should drive the patient home.
Patients should be especially careful in the first 48 to 72 hours after a hypoglycemic episode, because his or her ability to recognize the symptoms of low blood glucose may be impaired. In addition, the body's ability to counteract low blood glucose levels is decreased.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Diabetes & Digestive & Kidney Diseases
(www.niddk.nih.gov)
American Diabetes Association (ADA)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
The Endocrine Society
(www.endo-society.org)
The Hormone Foundation
(www.hormone.org/public/diabetes.cfm, available in English and Spanish)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Cox, DJ, Gonder-Frederick, L, Julian, DM, Clarke, W. Long-term follow-up evaluation of blood glucose awareness training. Diabetes Care 1994; 17:1.
2. Fanelli, CG, Paramore, DS, Hershey, T, et al. Impact of nocturnal hypoglycemia on hypoglycemic cognitive dysfunction in type 1 diabetes. Diabetes 1998; 47:1920.
3. Irvine, AA, Cox, D. Gonder-Frederick, L. Fear of hypoglycemia: Relationship to physical symptoms in patients with insulin-dependent diabetes. Health Psych 1992; 11:135.
4. Weinger, K, Kinsley, BT, Levy, CJ, et al. The perception of safe driving ability during hypoglycemia in patients with type 1 diabetes mellitus. Am J Med 1999; 107:246.
Diabetes type 2: Treatment
INTRODUCTION — Type 2 diabetes mellitus occurs when the pancreas (an organ in the abdomen) produces insufficient amounts of the hormone insulin and/or the body's tissues become resistant to normal or even high levels of insulin. This causes high blood glucose (sugar) levels, which can lead to a number of complications if untreated.
People with type 2 diabetes require regular monitoring and ongoing treatment to maintain normal or near-normal blood glucose levels. Treatment includes lifestyle adjustments, self-care measures, and medications, which can minimize the risk of diabetes and cardiovascular (heart-related) complications.
This topic review will discuss the treatment of type 2 diabetes. Separate topic reviews about other aspects of type 2 diabetes are also available. (See "Patient information: Diabetes mellitus; type 2" and see "Patient information: Self-blood glucose monitoring" and see "Patient information: Hypoglycemia (low blood glucose) in diabetes" and see "Patient information: Lifestyle modifications in type 2 diabetes" and see "Patient information: Preventing complications in diabetes mellitus").
TREATMENT GOALS
Blood glucose control — The goal of treatment in type 2 diabetes is to keep blood glucose levels at normal or near-normal levels. Careful control of blood glucose levels can help prevent the long-term effects of poorly controlled blood glucose (diabetic complications of the eye, kidney, and cardiovascular system).
Blood glucose control can be measured by checking the blood glucose level before the first meal of the day (fasting). A normal fasting blood glucose level is less than 100 mg/dL (5.6 mmol/L), although some people will have a different goal. A healthcare provider can help to determine this goal with the patient. Some people will need to test their blood glucose level before and/or after other meals during the day, and the frequency of testing can change as diabetes progresses. (See "Patient information: Self-blood glucose monitoring").
Blood glucose control can also be measured with a blood test called A1C. The A1C blood test measures the average blood glucose level during the past two to three months. The test is done by giving a small sample of blood from a vein or fingertip in a clinician's office. The goal A1C for most people with type 2 diabetes is 7.0 percent or less, which corresponds to an average blood glucose of 150 mg/dL (8.3 mmol/L, show figure 1). A healthcare provider can determine the A1C goal for an individual patient.
The average blood glucose goal (150 mg/dl or 8.3 mmol/L) is higher than the fasting blood glucose goal (100 mg/dL or 5.6 mmol/L) for several reasons. Blood glucose levels increase after eating. The amount and speed of the increase depend upon the type and amount of food eaten at a particular meal. The increase also depends upon the type and dose of diabetes treatment(s) used and the person's activity level.
Cardiovascular risk control — The most common long-term complication of type 2 diabetes is cardiovascular (heart) disease, which can cause myocardial infarction (heart attack), angina (chest pain), stroke, and even death. The risk of heart disease is estimated to be at least twice that of persons without diabetes. (See "Patient information: Preventing complications in diabetes mellitus").
However, persons with type 2 diabetes can substantially lower the risk of cardiovascular disease by quitting smoking, taking a low-dose aspirin every day, and by managing high blood pressure and hyperlipidemia (high cholesterol) with diet, exercise, and medications. (See "Patient information: High cholesterol and lipids (hyperlipidemia)" and see "Patient information: High blood pressure treatment" and see "Patient information: Smoking cessation" and see "Patient information: Aspirin and heart disease").
Persons with type 2 diabetes are also at increased risk of developing eye, kidney, and nerve complications that can result in blindness, kidney failure, foot ulcers requiring amputation, and impotence in men. These complications can occur after many years of diabetes and are related to elevated levels of blood glucose over time. Complications can be prevented or delayed by keeping blood sugar levels as close to normal as possible and by carefully controlling blood pressure. Diabetes remains the greatest cause of blindness, kidney failure, and amputations in the United States and in much of the world.
DIET — Changes in diet can improve many aspects of type 2 diabetes, including obesity, high blood pressure, and the body's ability to produce and respond to insulin. Response to dietary changes depends upon the number of calories consumed, types of foods chosen, and the amount of weight lost.
For a person who is newly diagnosed with diabetes and who is overweight or obese, losing any amount of weight can reduce or eliminate the need for medications and improve blood glucose levels.
The American Diabetes Association recommends a low fat, low calorie, high complex carbohydrate diet. A dietitian can help to determine the optimal number of calories and fat for an individual patient. (See "Patient information: Weight loss treatments").
The following are general diet recommendations: Eat a lot of vegetables and fruits, at least five servings a day. Limit starchy vegetables (eg, potatoes) but eat as many non-starchy fruits or vegetables as desired. Choose foods with whole grains rather than processed grains. Consider whole wheat bread, brown rice, or whole wheat pasta instead of white bread, white rice, or regular pasta. High fiber foods can help a person to feel fuller sooner; 15 to 30 grams of fiber are recommended daily (show table 1A-1C). Eat a limited amount of red meat, and choose lean cuts of meat that end in loin (pork loin, tenderloin, sirloin). Remove skin from chicken and turkey before eating. Include fish two to three times per week. Choose low or fat-free dairy products, such as skim milk, non-fat yogurt, and low-fat cheese. Avoid high calorie snack foods, including regular soda, fruit punch, candy, chips, cookies, cakes, and full-fat ice cream. Use liquid oils (olive, canola) instead of solid fats (butter, margarine, shortening) for cooking. Fat should be limited to less than 30 percent of a person's total daily calories. For a 1500 calorie per day diet, this would mean about 45 g or less of fat per day, which can be counted using the nutrition information labels on most food packages (show figure 2).
For patients who are not able to lose weight with diet alone, a weight loss medication may be considered. Patients with type 2 diabetes who have a BMI greater than 35 kg/m2 can also consider a surgical weight loss procedure. (See "Patient information: Weight loss treatments", section on Weight loss medications and see "Patient information: Weight loss surgery").
EXERCISE — Regular exercise can benefit people with type 2 diabetes, even if weight is not lost. Exercise improves blood glucose control because it improves the body's response to insulin. (See "Patient information: Exercise").
Exercise does not need to be vigorous and it does not need to be continuous to produce health benefits; it can be broken up into three or four ten-minute sessions per day. The recommended goal is 30 minutes of moderate-intensity exercise at least five days per week. However, exercising only one or two days per week is better than not exercising at all.
PSYCHOLOGICAL TREATMENTS — Patients with type 2 diabetes often experience significant stress related to their disease and the increased responsibilities that come with it, including blood glucose testing, dietary considerations, exercise, healthcare provider visits, the need for medication, and the potential risks of complications. It is not uncommon to become depressed as a result of this stress, and this can make taking care of oneself more difficult.
Committing to new treatments and lifestyle changes can be difficult, and it is not uncommon to feel that the benefits of treatment are not worth the effort. Having an open and honest discussion with clinicians can help patients to understand their diagnosis and the need for treatment.
Involving family and friends can help people with diabetes to manage their disease by offering reminders to take medication, test blood glucose levels, and providing a ride to appointments. Family and friends can also give encouragement and support to eat a healthy diet and stick with an exercise plan.
Working with a psychotherapist or social worker can help patients with type 2 diabetes to cope with new responsibilities and worries. A number of studies have shown that patients who have psychotherapy in addition to traditional medical care have reduced stress and improved blood glucose control compared to patients who received only traditional care [1].
MEDICATION — A number of oral medications are available for the treatment of type 2 diabetes. A table of these medications is available in table 2 (show table 2).
Metformin — Most patients who are newly diagnosed with type 2 diabetes will immediately begin a medication called metformin (Glucophage®, Gumetza®, Riomet®, Fortamet®). Metformin improves the body's response to insulin to reduce elevated blood glucose levels.
Metformin is a pill that is usually started with a dose of 500 mg with the evening meal; a second dose may be added one to two weeks later (500 mg with breakfast). The dose may be increased every one to two weeks thereafter, up to a total of 850 mg twice per day.
Common side effects of metformin include nausea, diarrhea, and gas. These are usually not severe, especially if metformin is taken along with food and the dose is increased gradually. Patients with certain types of kidney, liver, and heart disease, and those who drink alcohol excessively should not take metformin. It should not be taken within 48 hours of any test that uses iodine-based contrast dye, and it should be stopped before surgical procedures. It is not recommended for patients older than 80 years unless kidney function testing shows that the kidneys are functioning well.
When to add a second medication — For patients who initially take metformin, a second medication may be added within the first two to three months if blood glucose control is not adequate. "Adequate" control is defined as an A1C level less than 7 percent for most people; insulin may be recommended if the A1C is elevated, especially if it is higher than 8.5 percent.
Sulfonylureas — Sulfonylureas have been used to treat type 2 diabetes for many years. They work by increasing insulin production, and can lower blood glucose levels by approximately 20 percent. However, they lose effectiveness over time. Sulfonylureas are generally used if metformin does not adequately control blood glucose levels when taken alone, but may be used first in people who have liver, kidney, or heart disease and in those who drink alcohol excessively. They should not be used by patients who are allergic to sulfa drugs.
A number of sulfonylureas are available (Diabinese®, Orinase®, Glucotrol®, Diabeta®, Micronase®, Glynase®, Amaryl®), and the choice between them depends mainly upon cost and availability; their efficacy is similar. The medication is in pill form and is taken once or twice daily.
Patients who take sulfonylureas are at risk of low blood glucose, known as hypoglycemia. This can cause sweating, shaking, hunger, and anxiety, and must be treated quickly by eating 10 to 15 grams of fast-acting carbohydrate (eg, fruit juice, hard candy, glucose tablets). Delaying treatment can cause the person to lose consciousness. A full discussion of hypoglycemia is available separately. (See "Patient information: Hypoglycemia (low blood glucose) in diabetes").
Insulin — In the past, insulin treatment was reserved for patients with type 2 diabetes who did not have adequate blood glucose control with oral medications and lifestyle changes. However, there is increasing evidence that using insulin at earlier stages may improve overall diabetes control and help to preserve the pancreas's ability to make insulin. Insulin injections may be used as a first-line treatment in some patients, or it can be added to or substituted for oral medications.
Insulin requires an injection by the patient or a family member/friend. Inhaled insulin is newly available, but its effectiveness in treating type 2 diabetes is still being evaluated.
Most patients with type 2 diabetes begin by taking one insulin injection per day, usually at 10 P.M. The dose can be slowly increased every few days, depending upon the person's first morning blood glucose level (which should be measured every morning before eating). Some patients will need additional injections throughout the day while others have a good response to only one injection per day.
Meglitinides — Meglitinides include repaglinide (Prandin®) and nateglinide (Starlix®). They work to lower blood glucose levels, similar to the sulfonylureas, and may be used in patients who are allergic to sulfa-based drugs. They are taken in pill form. These medications are not generally used as a first-line treatment because they are more expensive than sulfonylureas and are short-acting, so they must be taken with each meal.
Thiazolidinediones — This class of medications includes rosiglitazone (Avandia®) and pioglitazone (Actos®), which work to lower blood glucose levels by increasing the body's sensitivity to insulin. They are taken in pill form and usually used second-line, in combination with other medications such as metformin, a sulfonylurea, or insulin.
Common side effects of thiazolidinediones include weight gain and swelling of the feet and ankles. There is a small but serious risk of developing or worsening congestive heart failure in patients who use thiazolidinediones. Close monitoring of swelling is important to detect this condition.
Alpha-glucosidase inhibitors — These medications, which include acarbose (Precose®) and miglitol (Glyset®), work by interfering with the absorption of carbohydrates in the intestines. This results in lower blood glucose levels, though are not as effective as metformin or the sulfonylureas. They can be combined with other medications if the first medication does not lower blood glucose levels sufficiently.
The main side effects of alpha-glucosidase inhibitors are gas (flatulence), diarrhea, and abdominal pain; starting with a low dose may minimize these side effects. The medication is usually taken three times per day with the first bite of each meal.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Diabetes and Digestive and Kidney Diseases
(www.niddk.nih.gov/)
American Diabetes Association (ADA)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
Canadian Diabetes Associates
(www.diabetes.ca)
U.S. Center for Disease Control and Prevention
(www.cdc.gov/diabetes)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ismail, K, Winkley, K, Rabe-Hesketh, S. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet 2004; 363:1589.
2. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352:837.
3. Nathan, DM, Buse, JB, Davidson, MB, et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2006; 29:1963.
4. Norris, SL, Zhang, X, Avenell, A, et al. Long-term effectiveness of lifestyle and behavioral weight loss interventions in adults with type 2 diabetes: a meta-analysis. Am J Med 2004; 117:762.
People with type 2 diabetes require regular monitoring and ongoing treatment to maintain normal or near-normal blood glucose levels. Treatment includes lifestyle adjustments, self-care measures, and medications, which can minimize the risk of diabetes and cardiovascular (heart-related) complications.
This topic review will discuss the treatment of type 2 diabetes. Separate topic reviews about other aspects of type 2 diabetes are also available. (See "Patient information: Diabetes mellitus; type 2" and see "Patient information: Self-blood glucose monitoring" and see "Patient information: Hypoglycemia (low blood glucose) in diabetes" and see "Patient information: Lifestyle modifications in type 2 diabetes" and see "Patient information: Preventing complications in diabetes mellitus").
TREATMENT GOALS
Blood glucose control — The goal of treatment in type 2 diabetes is to keep blood glucose levels at normal or near-normal levels. Careful control of blood glucose levels can help prevent the long-term effects of poorly controlled blood glucose (diabetic complications of the eye, kidney, and cardiovascular system).
Blood glucose control can be measured by checking the blood glucose level before the first meal of the day (fasting). A normal fasting blood glucose level is less than 100 mg/dL (5.6 mmol/L), although some people will have a different goal. A healthcare provider can help to determine this goal with the patient. Some people will need to test their blood glucose level before and/or after other meals during the day, and the frequency of testing can change as diabetes progresses. (See "Patient information: Self-blood glucose monitoring").
Blood glucose control can also be measured with a blood test called A1C. The A1C blood test measures the average blood glucose level during the past two to three months. The test is done by giving a small sample of blood from a vein or fingertip in a clinician's office. The goal A1C for most people with type 2 diabetes is 7.0 percent or less, which corresponds to an average blood glucose of 150 mg/dL (8.3 mmol/L, show figure 1). A healthcare provider can determine the A1C goal for an individual patient.
The average blood glucose goal (150 mg/dl or 8.3 mmol/L) is higher than the fasting blood glucose goal (100 mg/dL or 5.6 mmol/L) for several reasons. Blood glucose levels increase after eating. The amount and speed of the increase depend upon the type and amount of food eaten at a particular meal. The increase also depends upon the type and dose of diabetes treatment(s) used and the person's activity level.
Cardiovascular risk control — The most common long-term complication of type 2 diabetes is cardiovascular (heart) disease, which can cause myocardial infarction (heart attack), angina (chest pain), stroke, and even death. The risk of heart disease is estimated to be at least twice that of persons without diabetes. (See "Patient information: Preventing complications in diabetes mellitus").
However, persons with type 2 diabetes can substantially lower the risk of cardiovascular disease by quitting smoking, taking a low-dose aspirin every day, and by managing high blood pressure and hyperlipidemia (high cholesterol) with diet, exercise, and medications. (See "Patient information: High cholesterol and lipids (hyperlipidemia)" and see "Patient information: High blood pressure treatment" and see "Patient information: Smoking cessation" and see "Patient information: Aspirin and heart disease").
Persons with type 2 diabetes are also at increased risk of developing eye, kidney, and nerve complications that can result in blindness, kidney failure, foot ulcers requiring amputation, and impotence in men. These complications can occur after many years of diabetes and are related to elevated levels of blood glucose over time. Complications can be prevented or delayed by keeping blood sugar levels as close to normal as possible and by carefully controlling blood pressure. Diabetes remains the greatest cause of blindness, kidney failure, and amputations in the United States and in much of the world.
DIET — Changes in diet can improve many aspects of type 2 diabetes, including obesity, high blood pressure, and the body's ability to produce and respond to insulin. Response to dietary changes depends upon the number of calories consumed, types of foods chosen, and the amount of weight lost.
For a person who is newly diagnosed with diabetes and who is overweight or obese, losing any amount of weight can reduce or eliminate the need for medications and improve blood glucose levels.
The American Diabetes Association recommends a low fat, low calorie, high complex carbohydrate diet. A dietitian can help to determine the optimal number of calories and fat for an individual patient. (See "Patient information: Weight loss treatments").
The following are general diet recommendations: Eat a lot of vegetables and fruits, at least five servings a day. Limit starchy vegetables (eg, potatoes) but eat as many non-starchy fruits or vegetables as desired. Choose foods with whole grains rather than processed grains. Consider whole wheat bread, brown rice, or whole wheat pasta instead of white bread, white rice, or regular pasta. High fiber foods can help a person to feel fuller sooner; 15 to 30 grams of fiber are recommended daily (show table 1A-1C). Eat a limited amount of red meat, and choose lean cuts of meat that end in loin (pork loin, tenderloin, sirloin). Remove skin from chicken and turkey before eating. Include fish two to three times per week. Choose low or fat-free dairy products, such as skim milk, non-fat yogurt, and low-fat cheese. Avoid high calorie snack foods, including regular soda, fruit punch, candy, chips, cookies, cakes, and full-fat ice cream. Use liquid oils (olive, canola) instead of solid fats (butter, margarine, shortening) for cooking. Fat should be limited to less than 30 percent of a person's total daily calories. For a 1500 calorie per day diet, this would mean about 45 g or less of fat per day, which can be counted using the nutrition information labels on most food packages (show figure 2).
For patients who are not able to lose weight with diet alone, a weight loss medication may be considered. Patients with type 2 diabetes who have a BMI greater than 35 kg/m2 can also consider a surgical weight loss procedure. (See "Patient information: Weight loss treatments", section on Weight loss medications and see "Patient information: Weight loss surgery").
EXERCISE — Regular exercise can benefit people with type 2 diabetes, even if weight is not lost. Exercise improves blood glucose control because it improves the body's response to insulin. (See "Patient information: Exercise").
Exercise does not need to be vigorous and it does not need to be continuous to produce health benefits; it can be broken up into three or four ten-minute sessions per day. The recommended goal is 30 minutes of moderate-intensity exercise at least five days per week. However, exercising only one or two days per week is better than not exercising at all.
PSYCHOLOGICAL TREATMENTS — Patients with type 2 diabetes often experience significant stress related to their disease and the increased responsibilities that come with it, including blood glucose testing, dietary considerations, exercise, healthcare provider visits, the need for medication, and the potential risks of complications. It is not uncommon to become depressed as a result of this stress, and this can make taking care of oneself more difficult.
Committing to new treatments and lifestyle changes can be difficult, and it is not uncommon to feel that the benefits of treatment are not worth the effort. Having an open and honest discussion with clinicians can help patients to understand their diagnosis and the need for treatment.
Involving family and friends can help people with diabetes to manage their disease by offering reminders to take medication, test blood glucose levels, and providing a ride to appointments. Family and friends can also give encouragement and support to eat a healthy diet and stick with an exercise plan.
Working with a psychotherapist or social worker can help patients with type 2 diabetes to cope with new responsibilities and worries. A number of studies have shown that patients who have psychotherapy in addition to traditional medical care have reduced stress and improved blood glucose control compared to patients who received only traditional care [1].
MEDICATION — A number of oral medications are available for the treatment of type 2 diabetes. A table of these medications is available in table 2 (show table 2).
Metformin — Most patients who are newly diagnosed with type 2 diabetes will immediately begin a medication called metformin (Glucophage®, Gumetza®, Riomet®, Fortamet®). Metformin improves the body's response to insulin to reduce elevated blood glucose levels.
Metformin is a pill that is usually started with a dose of 500 mg with the evening meal; a second dose may be added one to two weeks later (500 mg with breakfast). The dose may be increased every one to two weeks thereafter, up to a total of 850 mg twice per day.
Common side effects of metformin include nausea, diarrhea, and gas. These are usually not severe, especially if metformin is taken along with food and the dose is increased gradually. Patients with certain types of kidney, liver, and heart disease, and those who drink alcohol excessively should not take metformin. It should not be taken within 48 hours of any test that uses iodine-based contrast dye, and it should be stopped before surgical procedures. It is not recommended for patients older than 80 years unless kidney function testing shows that the kidneys are functioning well.
When to add a second medication — For patients who initially take metformin, a second medication may be added within the first two to three months if blood glucose control is not adequate. "Adequate" control is defined as an A1C level less than 7 percent for most people; insulin may be recommended if the A1C is elevated, especially if it is higher than 8.5 percent.
Sulfonylureas — Sulfonylureas have been used to treat type 2 diabetes for many years. They work by increasing insulin production, and can lower blood glucose levels by approximately 20 percent. However, they lose effectiveness over time. Sulfonylureas are generally used if metformin does not adequately control blood glucose levels when taken alone, but may be used first in people who have liver, kidney, or heart disease and in those who drink alcohol excessively. They should not be used by patients who are allergic to sulfa drugs.
A number of sulfonylureas are available (Diabinese®, Orinase®, Glucotrol®, Diabeta®, Micronase®, Glynase®, Amaryl®), and the choice between them depends mainly upon cost and availability; their efficacy is similar. The medication is in pill form and is taken once or twice daily.
Patients who take sulfonylureas are at risk of low blood glucose, known as hypoglycemia. This can cause sweating, shaking, hunger, and anxiety, and must be treated quickly by eating 10 to 15 grams of fast-acting carbohydrate (eg, fruit juice, hard candy, glucose tablets). Delaying treatment can cause the person to lose consciousness. A full discussion of hypoglycemia is available separately. (See "Patient information: Hypoglycemia (low blood glucose) in diabetes").
Insulin — In the past, insulin treatment was reserved for patients with type 2 diabetes who did not have adequate blood glucose control with oral medications and lifestyle changes. However, there is increasing evidence that using insulin at earlier stages may improve overall diabetes control and help to preserve the pancreas's ability to make insulin. Insulin injections may be used as a first-line treatment in some patients, or it can be added to or substituted for oral medications.
Insulin requires an injection by the patient or a family member/friend. Inhaled insulin is newly available, but its effectiveness in treating type 2 diabetes is still being evaluated.
Most patients with type 2 diabetes begin by taking one insulin injection per day, usually at 10 P.M. The dose can be slowly increased every few days, depending upon the person's first morning blood glucose level (which should be measured every morning before eating). Some patients will need additional injections throughout the day while others have a good response to only one injection per day.
Meglitinides — Meglitinides include repaglinide (Prandin®) and nateglinide (Starlix®). They work to lower blood glucose levels, similar to the sulfonylureas, and may be used in patients who are allergic to sulfa-based drugs. They are taken in pill form. These medications are not generally used as a first-line treatment because they are more expensive than sulfonylureas and are short-acting, so they must be taken with each meal.
Thiazolidinediones — This class of medications includes rosiglitazone (Avandia®) and pioglitazone (Actos®), which work to lower blood glucose levels by increasing the body's sensitivity to insulin. They are taken in pill form and usually used second-line, in combination with other medications such as metformin, a sulfonylurea, or insulin.
Common side effects of thiazolidinediones include weight gain and swelling of the feet and ankles. There is a small but serious risk of developing or worsening congestive heart failure in patients who use thiazolidinediones. Close monitoring of swelling is important to detect this condition.
Alpha-glucosidase inhibitors — These medications, which include acarbose (Precose®) and miglitol (Glyset®), work by interfering with the absorption of carbohydrates in the intestines. This results in lower blood glucose levels, though are not as effective as metformin or the sulfonylureas. They can be combined with other medications if the first medication does not lower blood glucose levels sufficiently.
The main side effects of alpha-glucosidase inhibitors are gas (flatulence), diarrhea, and abdominal pain; starting with a low dose may minimize these side effects. The medication is usually taken three times per day with the first bite of each meal.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Diabetes and Digestive and Kidney Diseases
(www.niddk.nih.gov/)
American Diabetes Association (ADA)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
Canadian Diabetes Associates
(www.diabetes.ca)
U.S. Center for Disease Control and Prevention
(www.cdc.gov/diabetes)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ismail, K, Winkley, K, Rabe-Hesketh, S. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet 2004; 363:1589.
2. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352:837.
3. Nathan, DM, Buse, JB, Davidson, MB, et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2006; 29:1963.
4. Norris, SL, Zhang, X, Avenell, A, et al. Long-term effectiveness of lifestyle and behavioral weight loss interventions in adults with type 2 diabetes: a meta-analysis. Am J Med 2004; 117:762.
Diabetes type 2: Treatment
INTRODUCTION — Type 2 diabetes mellitus occurs when the pancreas (an organ in the abdomen) produces insufficient amounts of the hormone insulin and/or the body's tissues become resistant to normal or even high levels of insulin. This causes high blood glucose (sugar) levels, which can lead to a number of complications if untreated.
People with type 2 diabetes require regular monitoring and ongoing treatment to maintain normal or near-normal blood glucose levels. Treatment includes lifestyle adjustments, self-care measures, and medications, which can minimize the risk of diabetes and cardiovascular (heart-related) complications.
This topic review will discuss the treatment of type 2 diabetes. Separate topic reviews about other aspects of type 2 diabetes are also available. (See "Patient information: Diabetes mellitus; type 2" and see "Patient information: Self-blood glucose monitoring" and see "Patient information: Hypoglycemia (low blood glucose) in diabetes" and see "Patient information: Lifestyle modifications in type 2 diabetes" and see "Patient information: Preventing complications in diabetes mellitus").
TREATMENT GOALS
Blood glucose control — The goal of treatment in type 2 diabetes is to keep blood glucose levels at normal or near-normal levels. Careful control of blood glucose levels can help prevent the long-term effects of poorly controlled blood glucose (diabetic complications of the eye, kidney, and cardiovascular system).
Blood glucose control can be measured by checking the blood glucose level before the first meal of the day (fasting). A normal fasting blood glucose level is less than 100 mg/dL (5.6 mmol/L), although some people will have a different goal. A healthcare provider can help to determine this goal with the patient. Some people will need to test their blood glucose level before and/or after other meals during the day, and the frequency of testing can change as diabetes progresses. (See "Patient information: Self-blood glucose monitoring").
Blood glucose control can also be measured with a blood test called A1C. The A1C blood test measures the average blood glucose level during the past two to three months. The test is done by giving a small sample of blood from a vein or fingertip in a clinician's office. The goal A1C for most people with type 2 diabetes is 7.0 percent or less, which corresponds to an average blood glucose of 150 mg/dL (8.3 mmol/L, show figure 1). A healthcare provider can determine the A1C goal for an individual patient.
The average blood glucose goal (150 mg/dl or 8.3 mmol/L) is higher than the fasting blood glucose goal (100 mg/dL or 5.6 mmol/L) for several reasons. Blood glucose levels increase after eating. The amount and speed of the increase depend upon the type and amount of food eaten at a particular meal. The increase also depends upon the type and dose of diabetes treatment(s) used and the person's activity level.
Cardiovascular risk control — The most common long-term complication of type 2 diabetes is cardiovascular (heart) disease, which can cause myocardial infarction (heart attack), angina (chest pain), stroke, and even death. The risk of heart disease is estimated to be at least twice that of persons without diabetes. (See "Patient information: Preventing complications in diabetes mellitus").
However, persons with type 2 diabetes can substantially lower the risk of cardiovascular disease by quitting smoking, taking a low-dose aspirin every day, and by managing high blood pressure and hyperlipidemia (high cholesterol) with diet, exercise, and medications. (See "Patient information: High cholesterol and lipids (hyperlipidemia)" and see "Patient information: High blood pressure treatment" and see "Patient information: Smoking cessation" and see "Patient information: Aspirin and heart disease").
Persons with type 2 diabetes are also at increased risk of developing eye, kidney, and nerve complications that can result in blindness, kidney failure, foot ulcers requiring amputation, and impotence in men. These complications can occur after many years of diabetes and are related to elevated levels of blood glucose over time. Complications can be prevented or delayed by keeping blood sugar levels as close to normal as possible and by carefully controlling blood pressure. Diabetes remains the greatest cause of blindness, kidney failure, and amputations in the United States and in much of the world.
DIET — Changes in diet can improve many aspects of type 2 diabetes, including obesity, high blood pressure, and the body's ability to produce and respond to insulin. Response to dietary changes depends upon the number of calories consumed, types of foods chosen, and the amount of weight lost.
For a person who is newly diagnosed with diabetes and who is overweight or obese, losing any amount of weight can reduce or eliminate the need for medications and improve blood glucose levels.
The American Diabetes Association recommends a low fat, low calorie, high complex carbohydrate diet. A dietitian can help to determine the optimal number of calories and fat for an individual patient. (See "Patient information: Weight loss treatments").
The following are general diet recommendations: Eat a lot of vegetables and fruits, at least five servings a day. Limit starchy vegetables (eg, potatoes) but eat as many non-starchy fruits or vegetables as desired. Choose foods with whole grains rather than processed grains. Consider whole wheat bread, brown rice, or whole wheat pasta instead of white bread, white rice, or regular pasta. High fiber foods can help a person to feel fuller sooner; 15 to 30 grams of fiber are recommended daily (show table 1A-1C). Eat a limited amount of red meat, and choose lean cuts of meat that end in loin (pork loin, tenderloin, sirloin). Remove skin from chicken and turkey before eating. Include fish two to three times per week. Choose low or fat-free dairy products, such as skim milk, non-fat yogurt, and low-fat cheese. Avoid high calorie snack foods, including regular soda, fruit punch, candy, chips, cookies, cakes, and full-fat ice cream. Use liquid oils (olive, canola) instead of solid fats (butter, margarine, shortening) for cooking. Fat should be limited to less than 30 percent of a person's total daily calories. For a 1500 calorie per day diet, this would mean about 45 g or less of fat per day, which can be counted using the nutrition information labels on most food packages (show figure 2).
For patients who are not able to lose weight with diet alone, a weight loss medication may be considered. Patients with type 2 diabetes who have a BMI greater than 35 kg/m2 can also consider a surgical weight loss procedure. (See "Patient information: Weight loss treatments", section on Weight loss medications and see "Patient information: Weight loss surgery").
EXERCISE — Regular exercise can benefit people with type 2 diabetes, even if weight is not lost. Exercise improves blood glucose control because it improves the body's response to insulin. (See "Patient information: Exercise").
Exercise does not need to be vigorous and it does not need to be continuous to produce health benefits; it can be broken up into three or four ten-minute sessions per day. The recommended goal is 30 minutes of moderate-intensity exercise at least five days per week. However, exercising only one or two days per week is better than not exercising at all.
PSYCHOLOGICAL TREATMENTS — Patients with type 2 diabetes often experience significant stress related to their disease and the increased responsibilities that come with it, including blood glucose testing, dietary considerations, exercise, healthcare provider visits, the need for medication, and the potential risks of complications. It is not uncommon to become depressed as a result of this stress, and this can make taking care of oneself more difficult.
Committing to new treatments and lifestyle changes can be difficult, and it is not uncommon to feel that the benefits of treatment are not worth the effort. Having an open and honest discussion with clinicians can help patients to understand their diagnosis and the need for treatment.
Involving family and friends can help people with diabetes to manage their disease by offering reminders to take medication, test blood glucose levels, and providing a ride to appointments. Family and friends can also give encouragement and support to eat a healthy diet and stick with an exercise plan.
Working with a psychotherapist or social worker can help patients with type 2 diabetes to cope with new responsibilities and worries. A number of studies have shown that patients who have psychotherapy in addition to traditional medical care have reduced stress and improved blood glucose control compared to patients who received only traditional care [1].
MEDICATION — A number of oral medications are available for the treatment of type 2 diabetes. A table of these medications is available in table 2 (show table 2).
Metformin — Most patients who are newly diagnosed with type 2 diabetes will immediately begin a medication called metformin (Glucophage®, Gumetza®, Riomet®, Fortamet®). Metformin improves the body's response to insulin to reduce elevated blood glucose levels.
Metformin is a pill that is usually started with a dose of 500 mg with the evening meal; a second dose may be added one to two weeks later (500 mg with breakfast). The dose may be increased every one to two weeks thereafter, up to a total of 850 mg twice per day.
Common side effects of metformin include nausea, diarrhea, and gas. These are usually not severe, especially if metformin is taken along with food and the dose is increased gradually. Patients with certain types of kidney, liver, and heart disease, and those who drink alcohol excessively should not take metformin. It should not be taken within 48 hours of any test that uses iodine-based contrast dye, and it should be stopped before surgical procedures. It is not recommended for patients older than 80 years unless kidney function testing shows that the kidneys are functioning well.
When to add a second medication — For patients who initially take metformin, a second medication may be added within the first two to three months if blood glucose control is not adequate. "Adequate" control is defined as an A1C level less than 7 percent for most people; insulin may be recommended if the A1C is elevated, especially if it is higher than 8.5 percent.
Sulfonylureas — Sulfonylureas have been used to treat type 2 diabetes for many years. They work by increasing insulin production, and can lower blood glucose levels by approximately 20 percent. However, they lose effectiveness over time. Sulfonylureas are generally used if metformin does not adequately control blood glucose levels when taken alone, but may be used first in people who have liver, kidney, or heart disease and in those who drink alcohol excessively. They should not be used by patients who are allergic to sulfa drugs.
A number of sulfonylureas are available (Diabinese®, Orinase®, Glucotrol®, Diabeta®, Micronase®, Glynase®, Amaryl®), and the choice between them depends mainly upon cost and availability; their efficacy is similar. The medication is in pill form and is taken once or twice daily.
Patients who take sulfonylureas are at risk of low blood glucose, known as hypoglycemia. This can cause sweating, shaking, hunger, and anxiety, and must be treated quickly by eating 10 to 15 grams of fast-acting carbohydrate (eg, fruit juice, hard candy, glucose tablets). Delaying treatment can cause the person to lose consciousness. A full discussion of hypoglycemia is available separately. (See "Patient information: Hypoglycemia (low blood glucose) in diabetes").
Insulin — In the past, insulin treatment was reserved for patients with type 2 diabetes who did not have adequate blood glucose control with oral medications and lifestyle changes. However, there is increasing evidence that using insulin at earlier stages may improve overall diabetes control and help to preserve the pancreas's ability to make insulin. Insulin injections may be used as a first-line treatment in some patients, or it can be added to or substituted for oral medications.
Insulin requires an injection by the patient or a family member/friend. Inhaled insulin is newly available, but its effectiveness in treating type 2 diabetes is still being evaluated.
Most patients with type 2 diabetes begin by taking one insulin injection per day, usually at 10 P.M. The dose can be slowly increased every few days, depending upon the person's first morning blood glucose level (which should be measured every morning before eating). Some patients will need additional injections throughout the day while others have a good response to only one injection per day.
Meglitinides — Meglitinides include repaglinide (Prandin®) and nateglinide (Starlix®). They work to lower blood glucose levels, similar to the sulfonylureas, and may be used in patients who are allergic to sulfa-based drugs. They are taken in pill form. These medications are not generally used as a first-line treatment because they are more expensive than sulfonylureas and are short-acting, so they must be taken with each meal.
Thiazolidinediones — This class of medications includes rosiglitazone (Avandia®) and pioglitazone (Actos®), which work to lower blood glucose levels by increasing the body's sensitivity to insulin. They are taken in pill form and usually used second-line, in combination with other medications such as metformin, a sulfonylurea, or insulin.
Common side effects of thiazolidinediones include weight gain and swelling of the feet and ankles. There is a small but serious risk of developing or worsening congestive heart failure in patients who use thiazolidinediones. Close monitoring of swelling is important to detect this condition.
Alpha-glucosidase inhibitors — These medications, which include acarbose (Precose®) and miglitol (Glyset®), work by interfering with the absorption of carbohydrates in the intestines. This results in lower blood glucose levels, though are not as effective as metformin or the sulfonylureas. They can be combined with other medications if the first medication does not lower blood glucose levels sufficiently.
The main side effects of alpha-glucosidase inhibitors are gas (flatulence), diarrhea, and abdominal pain; starting with a low dose may minimize these side effects. The medication is usually taken three times per day with the first bite of each meal.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Diabetes and Digestive and Kidney Diseases
(www.niddk.nih.gov/)
American Diabetes Association (ADA)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
Canadian Diabetes Associates
(www.diabetes.ca)
U.S. Center for Disease Control and Prevention
(www.cdc.gov/diabetes)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ismail, K, Winkley, K, Rabe-Hesketh, S. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet 2004; 363:1589.
2. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352:837.
3. Nathan, DM, Buse, JB, Davidson, MB, et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2006; 29:1963.
4. Norris, SL, Zhang, X, Avenell, A, et al. Long-term effectiveness of lifestyle and behavioral weight loss interventions in adults with type 2 diabetes: a meta-analysis. Am J Med 2004; 117:762.
People with type 2 diabetes require regular monitoring and ongoing treatment to maintain normal or near-normal blood glucose levels. Treatment includes lifestyle adjustments, self-care measures, and medications, which can minimize the risk of diabetes and cardiovascular (heart-related) complications.
This topic review will discuss the treatment of type 2 diabetes. Separate topic reviews about other aspects of type 2 diabetes are also available. (See "Patient information: Diabetes mellitus; type 2" and see "Patient information: Self-blood glucose monitoring" and see "Patient information: Hypoglycemia (low blood glucose) in diabetes" and see "Patient information: Lifestyle modifications in type 2 diabetes" and see "Patient information: Preventing complications in diabetes mellitus").
TREATMENT GOALS
Blood glucose control — The goal of treatment in type 2 diabetes is to keep blood glucose levels at normal or near-normal levels. Careful control of blood glucose levels can help prevent the long-term effects of poorly controlled blood glucose (diabetic complications of the eye, kidney, and cardiovascular system).
Blood glucose control can be measured by checking the blood glucose level before the first meal of the day (fasting). A normal fasting blood glucose level is less than 100 mg/dL (5.6 mmol/L), although some people will have a different goal. A healthcare provider can help to determine this goal with the patient. Some people will need to test their blood glucose level before and/or after other meals during the day, and the frequency of testing can change as diabetes progresses. (See "Patient information: Self-blood glucose monitoring").
Blood glucose control can also be measured with a blood test called A1C. The A1C blood test measures the average blood glucose level during the past two to three months. The test is done by giving a small sample of blood from a vein or fingertip in a clinician's office. The goal A1C for most people with type 2 diabetes is 7.0 percent or less, which corresponds to an average blood glucose of 150 mg/dL (8.3 mmol/L, show figure 1). A healthcare provider can determine the A1C goal for an individual patient.
The average blood glucose goal (150 mg/dl or 8.3 mmol/L) is higher than the fasting blood glucose goal (100 mg/dL or 5.6 mmol/L) for several reasons. Blood glucose levels increase after eating. The amount and speed of the increase depend upon the type and amount of food eaten at a particular meal. The increase also depends upon the type and dose of diabetes treatment(s) used and the person's activity level.
Cardiovascular risk control — The most common long-term complication of type 2 diabetes is cardiovascular (heart) disease, which can cause myocardial infarction (heart attack), angina (chest pain), stroke, and even death. The risk of heart disease is estimated to be at least twice that of persons without diabetes. (See "Patient information: Preventing complications in diabetes mellitus").
However, persons with type 2 diabetes can substantially lower the risk of cardiovascular disease by quitting smoking, taking a low-dose aspirin every day, and by managing high blood pressure and hyperlipidemia (high cholesterol) with diet, exercise, and medications. (See "Patient information: High cholesterol and lipids (hyperlipidemia)" and see "Patient information: High blood pressure treatment" and see "Patient information: Smoking cessation" and see "Patient information: Aspirin and heart disease").
Persons with type 2 diabetes are also at increased risk of developing eye, kidney, and nerve complications that can result in blindness, kidney failure, foot ulcers requiring amputation, and impotence in men. These complications can occur after many years of diabetes and are related to elevated levels of blood glucose over time. Complications can be prevented or delayed by keeping blood sugar levels as close to normal as possible and by carefully controlling blood pressure. Diabetes remains the greatest cause of blindness, kidney failure, and amputations in the United States and in much of the world.
DIET — Changes in diet can improve many aspects of type 2 diabetes, including obesity, high blood pressure, and the body's ability to produce and respond to insulin. Response to dietary changes depends upon the number of calories consumed, types of foods chosen, and the amount of weight lost.
For a person who is newly diagnosed with diabetes and who is overweight or obese, losing any amount of weight can reduce or eliminate the need for medications and improve blood glucose levels.
The American Diabetes Association recommends a low fat, low calorie, high complex carbohydrate diet. A dietitian can help to determine the optimal number of calories and fat for an individual patient. (See "Patient information: Weight loss treatments").
The following are general diet recommendations: Eat a lot of vegetables and fruits, at least five servings a day. Limit starchy vegetables (eg, potatoes) but eat as many non-starchy fruits or vegetables as desired. Choose foods with whole grains rather than processed grains. Consider whole wheat bread, brown rice, or whole wheat pasta instead of white bread, white rice, or regular pasta. High fiber foods can help a person to feel fuller sooner; 15 to 30 grams of fiber are recommended daily (show table 1A-1C). Eat a limited amount of red meat, and choose lean cuts of meat that end in loin (pork loin, tenderloin, sirloin). Remove skin from chicken and turkey before eating. Include fish two to three times per week. Choose low or fat-free dairy products, such as skim milk, non-fat yogurt, and low-fat cheese. Avoid high calorie snack foods, including regular soda, fruit punch, candy, chips, cookies, cakes, and full-fat ice cream. Use liquid oils (olive, canola) instead of solid fats (butter, margarine, shortening) for cooking. Fat should be limited to less than 30 percent of a person's total daily calories. For a 1500 calorie per day diet, this would mean about 45 g or less of fat per day, which can be counted using the nutrition information labels on most food packages (show figure 2).
For patients who are not able to lose weight with diet alone, a weight loss medication may be considered. Patients with type 2 diabetes who have a BMI greater than 35 kg/m2 can also consider a surgical weight loss procedure. (See "Patient information: Weight loss treatments", section on Weight loss medications and see "Patient information: Weight loss surgery").
EXERCISE — Regular exercise can benefit people with type 2 diabetes, even if weight is not lost. Exercise improves blood glucose control because it improves the body's response to insulin. (See "Patient information: Exercise").
Exercise does not need to be vigorous and it does not need to be continuous to produce health benefits; it can be broken up into three or four ten-minute sessions per day. The recommended goal is 30 minutes of moderate-intensity exercise at least five days per week. However, exercising only one or two days per week is better than not exercising at all.
PSYCHOLOGICAL TREATMENTS — Patients with type 2 diabetes often experience significant stress related to their disease and the increased responsibilities that come with it, including blood glucose testing, dietary considerations, exercise, healthcare provider visits, the need for medication, and the potential risks of complications. It is not uncommon to become depressed as a result of this stress, and this can make taking care of oneself more difficult.
Committing to new treatments and lifestyle changes can be difficult, and it is not uncommon to feel that the benefits of treatment are not worth the effort. Having an open and honest discussion with clinicians can help patients to understand their diagnosis and the need for treatment.
Involving family and friends can help people with diabetes to manage their disease by offering reminders to take medication, test blood glucose levels, and providing a ride to appointments. Family and friends can also give encouragement and support to eat a healthy diet and stick with an exercise plan.
Working with a psychotherapist or social worker can help patients with type 2 diabetes to cope with new responsibilities and worries. A number of studies have shown that patients who have psychotherapy in addition to traditional medical care have reduced stress and improved blood glucose control compared to patients who received only traditional care [1].
MEDICATION — A number of oral medications are available for the treatment of type 2 diabetes. A table of these medications is available in table 2 (show table 2).
Metformin — Most patients who are newly diagnosed with type 2 diabetes will immediately begin a medication called metformin (Glucophage®, Gumetza®, Riomet®, Fortamet®). Metformin improves the body's response to insulin to reduce elevated blood glucose levels.
Metformin is a pill that is usually started with a dose of 500 mg with the evening meal; a second dose may be added one to two weeks later (500 mg with breakfast). The dose may be increased every one to two weeks thereafter, up to a total of 850 mg twice per day.
Common side effects of metformin include nausea, diarrhea, and gas. These are usually not severe, especially if metformin is taken along with food and the dose is increased gradually. Patients with certain types of kidney, liver, and heart disease, and those who drink alcohol excessively should not take metformin. It should not be taken within 48 hours of any test that uses iodine-based contrast dye, and it should be stopped before surgical procedures. It is not recommended for patients older than 80 years unless kidney function testing shows that the kidneys are functioning well.
When to add a second medication — For patients who initially take metformin, a second medication may be added within the first two to three months if blood glucose control is not adequate. "Adequate" control is defined as an A1C level less than 7 percent for most people; insulin may be recommended if the A1C is elevated, especially if it is higher than 8.5 percent.
Sulfonylureas — Sulfonylureas have been used to treat type 2 diabetes for many years. They work by increasing insulin production, and can lower blood glucose levels by approximately 20 percent. However, they lose effectiveness over time. Sulfonylureas are generally used if metformin does not adequately control blood glucose levels when taken alone, but may be used first in people who have liver, kidney, or heart disease and in those who drink alcohol excessively. They should not be used by patients who are allergic to sulfa drugs.
A number of sulfonylureas are available (Diabinese®, Orinase®, Glucotrol®, Diabeta®, Micronase®, Glynase®, Amaryl®), and the choice between them depends mainly upon cost and availability; their efficacy is similar. The medication is in pill form and is taken once or twice daily.
Patients who take sulfonylureas are at risk of low blood glucose, known as hypoglycemia. This can cause sweating, shaking, hunger, and anxiety, and must be treated quickly by eating 10 to 15 grams of fast-acting carbohydrate (eg, fruit juice, hard candy, glucose tablets). Delaying treatment can cause the person to lose consciousness. A full discussion of hypoglycemia is available separately. (See "Patient information: Hypoglycemia (low blood glucose) in diabetes").
Insulin — In the past, insulin treatment was reserved for patients with type 2 diabetes who did not have adequate blood glucose control with oral medications and lifestyle changes. However, there is increasing evidence that using insulin at earlier stages may improve overall diabetes control and help to preserve the pancreas's ability to make insulin. Insulin injections may be used as a first-line treatment in some patients, or it can be added to or substituted for oral medications.
Insulin requires an injection by the patient or a family member/friend. Inhaled insulin is newly available, but its effectiveness in treating type 2 diabetes is still being evaluated.
Most patients with type 2 diabetes begin by taking one insulin injection per day, usually at 10 P.M. The dose can be slowly increased every few days, depending upon the person's first morning blood glucose level (which should be measured every morning before eating). Some patients will need additional injections throughout the day while others have a good response to only one injection per day.
Meglitinides — Meglitinides include repaglinide (Prandin®) and nateglinide (Starlix®). They work to lower blood glucose levels, similar to the sulfonylureas, and may be used in patients who are allergic to sulfa-based drugs. They are taken in pill form. These medications are not generally used as a first-line treatment because they are more expensive than sulfonylureas and are short-acting, so they must be taken with each meal.
Thiazolidinediones — This class of medications includes rosiglitazone (Avandia®) and pioglitazone (Actos®), which work to lower blood glucose levels by increasing the body's sensitivity to insulin. They are taken in pill form and usually used second-line, in combination with other medications such as metformin, a sulfonylurea, or insulin.
Common side effects of thiazolidinediones include weight gain and swelling of the feet and ankles. There is a small but serious risk of developing or worsening congestive heart failure in patients who use thiazolidinediones. Close monitoring of swelling is important to detect this condition.
Alpha-glucosidase inhibitors — These medications, which include acarbose (Precose®) and miglitol (Glyset®), work by interfering with the absorption of carbohydrates in the intestines. This results in lower blood glucose levels, though are not as effective as metformin or the sulfonylureas. They can be combined with other medications if the first medication does not lower blood glucose levels sufficiently.
The main side effects of alpha-glucosidase inhibitors are gas (flatulence), diarrhea, and abdominal pain; starting with a low dose may minimize these side effects. The medication is usually taken three times per day with the first bite of each meal.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Diabetes and Digestive and Kidney Diseases
(www.niddk.nih.gov/)
American Diabetes Association (ADA)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
Canadian Diabetes Associates
(www.diabetes.ca)
U.S. Center for Disease Control and Prevention
(www.cdc.gov/diabetes)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ismail, K, Winkley, K, Rabe-Hesketh, S. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet 2004; 363:1589.
2. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352:837.
3. Nathan, DM, Buse, JB, Davidson, MB, et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2006; 29:1963.
4. Norris, SL, Zhang, X, Avenell, A, et al. Long-term effectiveness of lifestyle and behavioral weight loss interventions in adults with type 2 diabetes: a meta-analysis. Am J Med 2004; 117:762.
Diabetes type 2: Insulin treatment
INTRODUCTION — Type 2 diabetes mellitus occurs when the pancreas (an organ in the abdomen) produces insufficient amounts of the hormone insulin and/or the body's tissues become resistant to normal or even high levels of insulin. This causes high blood glucose (sugar) levels, which can lead to a number of complications if untreated.
People with type 2 diabetes require regular monitoring and ongoing treatment to maintain normal or near-normal blood glucose levels. Treatment includes lifestyle adjustments, self-care measures, and medications, which can minimize the risk of diabetes-related and cardiovascular complications (eg, heart attacks and strokes). Learning to manage diabetes is a process that continues over a lifetime. The diagnosis of diabetes can be overwhelming at the beginning; however, most people are able to lead normal lives and many patients become experts in their own care.
This topic review discusses the role of insulin in blood glucose control for patients with type 2 diabetes. Separate topic reviews about other aspects of type 2 diabetes are also available. (See "Patient information: Diabetes mellitus; type 2" and see "Patient information: Self-blood glucose monitoring" and see "Patient information: Hypoglycemia (low blood glucose) in diabetes" and see "Patient information: Lifestyle modifications in type 2 diabetes" and see "Patient information: Preventing complications in diabetes mellitus").
IMPORTANCE OF BLOOD GLUCOSE CONTROL — Keeping blood glucose levels in control is one way to decrease the risk of complications related to type 2 diabetes. The most common complication of type 2 diabetes is heart disease, also known as macrovascular disease. Macro- means large, and vascular means vessels. Untreated heart disease increases the risk of heart attack.
Individuals with type 2 diabetes are also at increased risk of developing microvascular (small vessel) disease of the eyes, kidneys, and nerves, which can result in blindness, kidney failure, foot ulcers requiring amputation, and impotence in men. Microvascular and macrovascular complications usually occur after many years of diabetes and are related to elevated levels of blood glucose over time. However, these complications may be present when type 2 diabetes is first diagnosed due to a delay in seeking medical care.
One of the largest studies to examine the benefit of tight blood glucose control was the United Kingdom Prospective Diabetes Study (UKPDS). It demonstrated that strict glycemic control in patients with type 2 diabetes reduces the risk of microvascular disease. It is not clear if blood glucose control affects the risk of macrovascular complications [1]. However, other therapies are available to decrease these risks. (See "Patient information: Preventing complications in diabetes mellitus").
Monitoring — Most people with type 2 diabetes need to monitor their blood glucose levels at home. This is especially true if the person uses a medication for diabetes that can cause low blood glucose levels (eg, insulin).
Blood glucose control is often measured by checking the blood glucose level before the first meal of the day (fasting). A normal fasting blood glucose level is less than 100 mg/dL (5.6 mmol/L), although some people will have a different goal. A healthcare provider can help to determine this goal with the patient. Some people will need to test their blood glucose level before and/or after other meals during the day. The frequency of testing and blood glucose goals can change over time, so periodic visits to discuss these issues are important. (See "Patient information: Self-blood glucose monitoring").
Blood glucose control can also be measured with a blood test called A1C. The A1C blood test measures the average blood glucose level during the past two to three months. The test is done by giving a small sample of blood from a vein or fingertip in a clinician's office. The goal A1C for most people with type 2 diabetes is less than 7 percent, which corresponds to an average blood glucose of 150 mg/dL (8.3 mmol/L, show table 1). A healthcare provider can determine a person's individual A1C goal.
The average blood glucose goal (150 mg/dl or 8.3 mmol/L) is higher than the fasting blood glucose goal (100 mg/dL or 5.6 mmol/L) for several reasons. Blood glucose levels increase after eating. The amount and speed of the increase depend upon the type and amount of food eaten at a particular meal. The increase also depends upon the type and dose of diabetes treatment(s) used and the person's activity level.
How often to see your clinician — Most patients with type 2 diabetes meet with their healthcare provider every three to four months; blood glucose levels and medications, including insulin dosing, are reviewed at these visits, helping patients to fine-tune their diabetes control.
TREATMENT OPTIONS — Most people who are newly diagnosed with type 2 diabetes are usually treated with a combination of diet, exercise, and an oral medication (eg, pills). Some oral medications (eg, metformin) improve the body's response to insulin. Other medications cause the body to produce more insulin. (See "Patient information: Diabetes type 2: Treatment").
A second medication may be added within the first two to three months if blood glucose control is not adequate. "Adequate" control is defined as an A1C level less than 7 percent for most people; insulin may be recommended early if the A1C remains elevated despite lifestyle changes and diabetes pills, especially if the A1C is higher than 8.5 percent.
The need for a second medication is not uncommon [2]. Type 2 diabetes typically progresses with age, causing the body to produce less insulin and resist the action of insulin that is produced. In addition, it can be difficult for some people to follow the recommended diet, exercise, or treatment plan. Being diagnosed with a new medical problem or requiring a new medication can also change the body's needs for insulin, sometimes requiring a change in diabetes treatment. For example, when a person with type 2 diabetes takes corticosteroids (eg, prednisone) for an asthma attack, the blood glucose levels increase. This usually requires a higher dose of diabetes medication.
Oral medication plus insulin — Some people with type 2 diabetes require only oral medications for treatment. Other people will need to add insulin because their blood glucose levels are not controlled. Using a combination of treatments (oral medication plus insulin) generally means that the patient can take a lower dose of insulin, compared to if insulin treatment is used alone. There may also be a reduced risk of weight gain if combination therapy is used.
Insulin is usually given once per day, either in the morning or at bedtime. Small insulin doses are generally recommended when treatment first begins; the dose is adjusted over days, weeks, and months, once the body's response to insulin treatment is known.
To determine how and when to adjust the dose, the blood glucose level should be measured every morning before eating. If the value is consistently higher than 130 mg/dL (7.2 mmol/L), the clinician may recommend increasing the insulin dose. (See "Patient information: Self-blood glucose monitoring").
Insulin alone — Current recommendations are for most people with type 2 diabetes to be treated with metformin plus another medication such as insulin, as necessary. However, for a variety of reasons, some people are treated only with insulin. People taking insulin alone often require two injections of intermediate-acting insulin or one injection of long-acting insulin per day (see "Types of insulin" below). (See "Patient information: Hypoglycemia (low blood glucose) in diabetes").
If a long-acting insulin or a twice daily injection of intermediate-acting insulin is not adequate to control blood glucose levels, a more intensive insulin treatment regimen may be recommended. Intensive insulin treatment requires at least two injections of insulin per day, usually including a rapid-acting and long-acting insulin, or the use of an insulin pump. It also requires that the person monitor their blood glucose levels several times per day. This is discussed in greater detail in a separate topic review. (See "Patient information: Diabetes type 1: Insulin treatment", section on intensive insulin treatment).
TYPES OF INSULIN — There are several types of insulin. These types are classified according to how quickly the insulin begins to work and how long it remains active (show table 2):
Injectable insulin Rapid-acting (eg, insulin lispro [Humalog®], insulin aspart [Novolog®], and insulin glulisine [Apidra®]) Short-acting (eg, insulin regular) Intermediate-acting (eg, insulin NPH) Long-acting (eg, insulin glargine [Lantus®], insulin detemir [Levemir®])
The various types of insulin can be used in combination to achieve around-the-clock blood glucose control.
Inhaled insulin — An inhaled form of rapid-acting insulin is available, although it is not yet in common use. Inhaled insulin may be used in combination with long-acting insulin injections. The main issue with this new treatment is that it is difficult to make adjustments in the dose. Patients interested in using this type of insulin should talk with their health care provider.
INSULIN ADMINISTRATION — Insulin cannot be taken in pill form. It is usually injected into the layer of fat under the skin (called subcutaneous injection).
The following figure demonstrates the sites where insulin may be injected (show figure 1). Patients as well as parents or partners should learn to draw up and inject insulin. The site also determines how quickly the insulin is absorbed. (See "Site of injection" below).
Drawing up insulin — There are many different types of syringes and needles, so it's best to get specific instructions for drawing up insulin from a healthcare provider. Basic information is provided in the table (show table 2). Persons using an insulin pen should follow the instructions provided by the pen manufacturer and their clinician (see "Insulin pen injectors" below).
Before drawing up insulin, it is important to know the dose and type of insulin needed; persons using more than one type of insulin should calculate the total dose needed before drawing up their insulin. Some persons, including children and those with difficulty seeing, may need assistance. Magnification and other assistive devices are available. People who have difficulty drawing up their insulin should discuss this with their clinician.
Injection angle — Insulin is usually injected under the skin using a needle and syringe (show figure 2). It is important to use the correct injection angle since injecting too deeply could deliver insulin to the muscle, where it is absorbed too quickly. On the other hand, injections that are too shallow are more painful and not absorbed well.
The best angle for insulin injection depends upon a patient's body type, injection site, and length of the needle used. A healthcare professional can help determine the right angle of injection.
Injection technique — The following is a description of subcutaneous insulin injection. Choose the site to inject (show figure 1). It is not necessary to clean the skin with alcohol unless the skin is dirty. Pinch up a fold of skin and quickly insert the needle at a 90º angle (or other angle, as described above, show figure 2). Keep the skin pinched to avoid injecting insulin into the muscle. Push the plunger down completely to inject the insulin. Hold the syringe and needle in place for five seconds. Release the skin fold. Remove the needle from the skin.
If blood or clear fluid (insulin) is seen at the injection site, the patient should apply pressure to the area for five to eight seconds. The area should not be rubbed because this can cause the insulin to be absorbed too quickly.
Needles and syringes should be used once and then thrown away; needles become dull quickly, potentially increasing the pain of injection. Used needles and syringes should not be included with regular household trash, but should instead be placed in a puncture-proof container (also known as a sharps container), available from most pharmacies or hospital supply stores.
Some patients wonder about the safety of injecting insulin through their clothing. One small study examined the risks and benefits of this technique, and found that blood glucose control did not differ between the group that injected insulin through a single layer of clothing and those that injected directly into the skin [3]. There were no reports of infections in either group, although a few patients who injected through clothing reported blood stains on their clothing or bruises on the skin. People who are interested in using this technique should speak with their healthcare provider before trying it.
Insulin pen injectors — Insulin pen injectors are available and may be more convenient to carry and use when away from home. Most are approximately the size of a large writing pen and contain a disposable insulin cartridge and needle. Some types of insulin and some insulin mixtures are not available in cartridges, meaning pens may not be an option in some situations.
Pens are especially useful for accurately injecting very small doses of insulin, and may be helpful for persons with impaired vision. Pens are generally more expensive than traditional syringes and needles. A number of insulin pens are available, and the specific instructions for use of each type should be obtained from the manufacturer or a healthcare provider.
OTHER FACTORS AFFECTING INSULIN ACTION — Several factors can affect how injected insulin works.
Dose of insulin injected — The dose of insulin injected affects the rate at which the body absorbs it. Larger doses of insulin may be absorbed more slowly than smaller doses.
Site of injection — Clinicians usually recommend rotating injection sites to minimize tissue irritation. When changing sites, it is important to keep in mind that insulin is absorbed at different rates in different areas of the body.
Insulin is absorbed fastest from the abdominal area, slowest from the leg and buttock, and at an intermediate rate from the arm. This may vary with the amount of fat present; areas with more fat under the skin absorb insulin more slowly (show figure 1).
It is reasonable to use the same general area for injections given at the same time of the day. Sometimes abdominal injections, which are absorbed more quickly, are preferred before meals. Injection into the thigh or buttock may be best for the evening dose because the insulin will be absorbed more slowly during the night.
Smoking and physical activity — Any factors that alter the rate of blood flow through the skin and fat will change insulin absorption. Smoking decreases blood flow. In contrast, factors that increase blood flow (such as exercise, saunas, hot baths, and massage of the injection site) increase insulin absorption. To avoid low blood sugar, insulin injections should be given after a bath or sauna. It is best to inject insulin into the arm or abdomen and wait 30 minutes before running. A lower dose of insulin may be recommended before or after exercise; this should be discussed with a healthcare provider.
Time since opening the bottle — Most insulin remains potent and effective for up to a month after the bottle has been opened (if kept in the refrigerator between injections). However, the potency of intermediate and long acting insulin begins to decrease after 30 days. This can be a problem for people who require very small doses of insulin, for whom a bottle might last two months or more. It is advisable to start a new bottle at least every 30 days.
For very rapid acting insulin used in pen injectors, it is acceptable to keep the pen injector at room temperature (in a purse or jacket pocket) for up to 14 days, provided that the pen is not exposed to temperature extremes. However, after 14 days, a new insulin cartridge or pen should be used, even if there is insulin left in the old cartridge.
Individual differences — The same dose of the same type of insulin may have different effects in different people with diabetes. Some trial and error is usually necessary to find the ideal type(s) and dose of insulin and schedule for each person.
Insulin needs often change over a person's lifetime. Changes in weight, diet, health conditions (including pregnancy), activity level, and occupation can have an impact on the amount of insulin needed to control blood glucose levels. Patients are often able to adjust their own insulin dose, but may require assistance in some situations. (See "Patient information: Care during pregnancy for women with type 1 or 2 diabetes").
SPECIAL SITUATIONS — Several special situations can complicate insulin treatment for a person with diabetes. With advance planning and careful calculation, these situations are less likely to cause serious difficulties. A healthcare provider can assist patients in handling these situations.
Eating out — Eating out can be challenging since ingredients used, calorie and fat content, and portion sizes are usually different from meals prepared at home. Patients can estimate their insulin needs in several ways, including nutrition information from restaurants or a hand-held reference book.
Hypo- and hyperglycemia can occur more easily in situations where new or different foods are eaten; thus patients should keep a fast-acting source of carbohydrates and blood glucose monitor on hand at all times. (See "Patient information: Hypoglycemia (low blood glucose) in diabetes").
Surgery — Patients who undergo surgery may be instructed not to eat for eight to 12 hours before their procedure. A healthcare provider can help to determine the dose and timing of insulin before and after the procedure, especially if a patient will be unable to eat a normal diet afterwards.
Infections — Mild infections, such as a cold, sore throat, or urinary tract infection, can cause blood glucose levels to rise. In this situation, frequent telephone contact with a healthcare provider, careful blood glucose monitoring, and increasing the insulin dose are often recommended. It is important to drink an adequate amount of fluids while ill to avoid dehydration. Patients with nausea or vomiting may require medication to control their symptoms and avoid dehydration.
Travel — Managing blood glucose levels and insulin treatment while traveling can be difficult, especially when traveling across multiple time zones. In addition, activity levels and diet are often different while traveling, making careful blood glucose monitoring essential. Patients should speak with their healthcare provider before traveling to develop a treatment plan. (See "Patient information: General travel advice", section on Traveling with medical conditions).
STAYING MOTIVATED — Living with diabetes can be very demanding and some patients lose motivation over time. Healthcare providers can provide tips and encouragement to help patients stay on track. Helpful information and support is also available from the American Diabetes Association (ADA), at (800)-DIABETES (800-342-2383) and at www.diabetes.org.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Diabetes and Digestive and Kidney Diseases
(www.niddk.nih.gov/)
American Diabetes Association (ADA)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
Canadian Diabetes Associates
(www.diabetes.ca)
Juvenile Diabetes Research Foundation
(www.jdrf.org)
U.S. Center for Disease Control and Prevention
(www.cdc.gov/diabetes)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352:837.
2. Turner, RC, Cull, CA, Frighi, V, Holman, RR for the UK Prospective Diabetes Study (UKPDS) Group. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes. Progressive requirement for multiple therapies (UKPDS 49). JAMA 1999; 281:2005.
3. Fleming, DR, Jacober, SJ, Vandenberg, MA, et al. The safety of injecting insulin through clothing. Diabetes Care 1997; 20:244.
4. Yki-Järvinen, H, Dressler, A, Ziemen, M. Less nocturnal hypoglycemia and better post-dinner glucose control with bedtime insulin glargine compared with bedtime NPH insulin during insulin combination therapy in type 2 diabetes. Diabetes Care 2000; 23:1130.
5. Taylor, R, Davies, R, Fox, C, et al. Appropriate insulin regimes for type 2 diabetes: a multicenter randomized crossover study. Diabetes Care 2000; 23:1612.
People with type 2 diabetes require regular monitoring and ongoing treatment to maintain normal or near-normal blood glucose levels. Treatment includes lifestyle adjustments, self-care measures, and medications, which can minimize the risk of diabetes-related and cardiovascular complications (eg, heart attacks and strokes). Learning to manage diabetes is a process that continues over a lifetime. The diagnosis of diabetes can be overwhelming at the beginning; however, most people are able to lead normal lives and many patients become experts in their own care.
This topic review discusses the role of insulin in blood glucose control for patients with type 2 diabetes. Separate topic reviews about other aspects of type 2 diabetes are also available. (See "Patient information: Diabetes mellitus; type 2" and see "Patient information: Self-blood glucose monitoring" and see "Patient information: Hypoglycemia (low blood glucose) in diabetes" and see "Patient information: Lifestyle modifications in type 2 diabetes" and see "Patient information: Preventing complications in diabetes mellitus").
IMPORTANCE OF BLOOD GLUCOSE CONTROL — Keeping blood glucose levels in control is one way to decrease the risk of complications related to type 2 diabetes. The most common complication of type 2 diabetes is heart disease, also known as macrovascular disease. Macro- means large, and vascular means vessels. Untreated heart disease increases the risk of heart attack.
Individuals with type 2 diabetes are also at increased risk of developing microvascular (small vessel) disease of the eyes, kidneys, and nerves, which can result in blindness, kidney failure, foot ulcers requiring amputation, and impotence in men. Microvascular and macrovascular complications usually occur after many years of diabetes and are related to elevated levels of blood glucose over time. However, these complications may be present when type 2 diabetes is first diagnosed due to a delay in seeking medical care.
One of the largest studies to examine the benefit of tight blood glucose control was the United Kingdom Prospective Diabetes Study (UKPDS). It demonstrated that strict glycemic control in patients with type 2 diabetes reduces the risk of microvascular disease. It is not clear if blood glucose control affects the risk of macrovascular complications [1]. However, other therapies are available to decrease these risks. (See "Patient information: Preventing complications in diabetes mellitus").
Monitoring — Most people with type 2 diabetes need to monitor their blood glucose levels at home. This is especially true if the person uses a medication for diabetes that can cause low blood glucose levels (eg, insulin).
Blood glucose control is often measured by checking the blood glucose level before the first meal of the day (fasting). A normal fasting blood glucose level is less than 100 mg/dL (5.6 mmol/L), although some people will have a different goal. A healthcare provider can help to determine this goal with the patient. Some people will need to test their blood glucose level before and/or after other meals during the day. The frequency of testing and blood glucose goals can change over time, so periodic visits to discuss these issues are important. (See "Patient information: Self-blood glucose monitoring").
Blood glucose control can also be measured with a blood test called A1C. The A1C blood test measures the average blood glucose level during the past two to three months. The test is done by giving a small sample of blood from a vein or fingertip in a clinician's office. The goal A1C for most people with type 2 diabetes is less than 7 percent, which corresponds to an average blood glucose of 150 mg/dL (8.3 mmol/L, show table 1). A healthcare provider can determine a person's individual A1C goal.
The average blood glucose goal (150 mg/dl or 8.3 mmol/L) is higher than the fasting blood glucose goal (100 mg/dL or 5.6 mmol/L) for several reasons. Blood glucose levels increase after eating. The amount and speed of the increase depend upon the type and amount of food eaten at a particular meal. The increase also depends upon the type and dose of diabetes treatment(s) used and the person's activity level.
How often to see your clinician — Most patients with type 2 diabetes meet with their healthcare provider every three to four months; blood glucose levels and medications, including insulin dosing, are reviewed at these visits, helping patients to fine-tune their diabetes control.
TREATMENT OPTIONS — Most people who are newly diagnosed with type 2 diabetes are usually treated with a combination of diet, exercise, and an oral medication (eg, pills). Some oral medications (eg, metformin) improve the body's response to insulin. Other medications cause the body to produce more insulin. (See "Patient information: Diabetes type 2: Treatment").
A second medication may be added within the first two to three months if blood glucose control is not adequate. "Adequate" control is defined as an A1C level less than 7 percent for most people; insulin may be recommended early if the A1C remains elevated despite lifestyle changes and diabetes pills, especially if the A1C is higher than 8.5 percent.
The need for a second medication is not uncommon [2]. Type 2 diabetes typically progresses with age, causing the body to produce less insulin and resist the action of insulin that is produced. In addition, it can be difficult for some people to follow the recommended diet, exercise, or treatment plan. Being diagnosed with a new medical problem or requiring a new medication can also change the body's needs for insulin, sometimes requiring a change in diabetes treatment. For example, when a person with type 2 diabetes takes corticosteroids (eg, prednisone) for an asthma attack, the blood glucose levels increase. This usually requires a higher dose of diabetes medication.
Oral medication plus insulin — Some people with type 2 diabetes require only oral medications for treatment. Other people will need to add insulin because their blood glucose levels are not controlled. Using a combination of treatments (oral medication plus insulin) generally means that the patient can take a lower dose of insulin, compared to if insulin treatment is used alone. There may also be a reduced risk of weight gain if combination therapy is used.
Insulin is usually given once per day, either in the morning or at bedtime. Small insulin doses are generally recommended when treatment first begins; the dose is adjusted over days, weeks, and months, once the body's response to insulin treatment is known.
To determine how and when to adjust the dose, the blood glucose level should be measured every morning before eating. If the value is consistently higher than 130 mg/dL (7.2 mmol/L), the clinician may recommend increasing the insulin dose. (See "Patient information: Self-blood glucose monitoring").
Insulin alone — Current recommendations are for most people with type 2 diabetes to be treated with metformin plus another medication such as insulin, as necessary. However, for a variety of reasons, some people are treated only with insulin. People taking insulin alone often require two injections of intermediate-acting insulin or one injection of long-acting insulin per day (see "Types of insulin" below). (See "Patient information: Hypoglycemia (low blood glucose) in diabetes").
If a long-acting insulin or a twice daily injection of intermediate-acting insulin is not adequate to control blood glucose levels, a more intensive insulin treatment regimen may be recommended. Intensive insulin treatment requires at least two injections of insulin per day, usually including a rapid-acting and long-acting insulin, or the use of an insulin pump. It also requires that the person monitor their blood glucose levels several times per day. This is discussed in greater detail in a separate topic review. (See "Patient information: Diabetes type 1: Insulin treatment", section on intensive insulin treatment).
TYPES OF INSULIN — There are several types of insulin. These types are classified according to how quickly the insulin begins to work and how long it remains active (show table 2):
Injectable insulin Rapid-acting (eg, insulin lispro [Humalog®], insulin aspart [Novolog®], and insulin glulisine [Apidra®]) Short-acting (eg, insulin regular) Intermediate-acting (eg, insulin NPH) Long-acting (eg, insulin glargine [Lantus®], insulin detemir [Levemir®])
The various types of insulin can be used in combination to achieve around-the-clock blood glucose control.
Inhaled insulin — An inhaled form of rapid-acting insulin is available, although it is not yet in common use. Inhaled insulin may be used in combination with long-acting insulin injections. The main issue with this new treatment is that it is difficult to make adjustments in the dose. Patients interested in using this type of insulin should talk with their health care provider.
INSULIN ADMINISTRATION — Insulin cannot be taken in pill form. It is usually injected into the layer of fat under the skin (called subcutaneous injection).
The following figure demonstrates the sites where insulin may be injected (show figure 1). Patients as well as parents or partners should learn to draw up and inject insulin. The site also determines how quickly the insulin is absorbed. (See "Site of injection" below).
Drawing up insulin — There are many different types of syringes and needles, so it's best to get specific instructions for drawing up insulin from a healthcare provider. Basic information is provided in the table (show table 2). Persons using an insulin pen should follow the instructions provided by the pen manufacturer and their clinician (see "Insulin pen injectors" below).
Before drawing up insulin, it is important to know the dose and type of insulin needed; persons using more than one type of insulin should calculate the total dose needed before drawing up their insulin. Some persons, including children and those with difficulty seeing, may need assistance. Magnification and other assistive devices are available. People who have difficulty drawing up their insulin should discuss this with their clinician.
Injection angle — Insulin is usually injected under the skin using a needle and syringe (show figure 2). It is important to use the correct injection angle since injecting too deeply could deliver insulin to the muscle, where it is absorbed too quickly. On the other hand, injections that are too shallow are more painful and not absorbed well.
The best angle for insulin injection depends upon a patient's body type, injection site, and length of the needle used. A healthcare professional can help determine the right angle of injection.
Injection technique — The following is a description of subcutaneous insulin injection. Choose the site to inject (show figure 1). It is not necessary to clean the skin with alcohol unless the skin is dirty. Pinch up a fold of skin and quickly insert the needle at a 90º angle (or other angle, as described above, show figure 2). Keep the skin pinched to avoid injecting insulin into the muscle. Push the plunger down completely to inject the insulin. Hold the syringe and needle in place for five seconds. Release the skin fold. Remove the needle from the skin.
If blood or clear fluid (insulin) is seen at the injection site, the patient should apply pressure to the area for five to eight seconds. The area should not be rubbed because this can cause the insulin to be absorbed too quickly.
Needles and syringes should be used once and then thrown away; needles become dull quickly, potentially increasing the pain of injection. Used needles and syringes should not be included with regular household trash, but should instead be placed in a puncture-proof container (also known as a sharps container), available from most pharmacies or hospital supply stores.
Some patients wonder about the safety of injecting insulin through their clothing. One small study examined the risks and benefits of this technique, and found that blood glucose control did not differ between the group that injected insulin through a single layer of clothing and those that injected directly into the skin [3]. There were no reports of infections in either group, although a few patients who injected through clothing reported blood stains on their clothing or bruises on the skin. People who are interested in using this technique should speak with their healthcare provider before trying it.
Insulin pen injectors — Insulin pen injectors are available and may be more convenient to carry and use when away from home. Most are approximately the size of a large writing pen and contain a disposable insulin cartridge and needle. Some types of insulin and some insulin mixtures are not available in cartridges, meaning pens may not be an option in some situations.
Pens are especially useful for accurately injecting very small doses of insulin, and may be helpful for persons with impaired vision. Pens are generally more expensive than traditional syringes and needles. A number of insulin pens are available, and the specific instructions for use of each type should be obtained from the manufacturer or a healthcare provider.
OTHER FACTORS AFFECTING INSULIN ACTION — Several factors can affect how injected insulin works.
Dose of insulin injected — The dose of insulin injected affects the rate at which the body absorbs it. Larger doses of insulin may be absorbed more slowly than smaller doses.
Site of injection — Clinicians usually recommend rotating injection sites to minimize tissue irritation. When changing sites, it is important to keep in mind that insulin is absorbed at different rates in different areas of the body.
Insulin is absorbed fastest from the abdominal area, slowest from the leg and buttock, and at an intermediate rate from the arm. This may vary with the amount of fat present; areas with more fat under the skin absorb insulin more slowly (show figure 1).
It is reasonable to use the same general area for injections given at the same time of the day. Sometimes abdominal injections, which are absorbed more quickly, are preferred before meals. Injection into the thigh or buttock may be best for the evening dose because the insulin will be absorbed more slowly during the night.
Smoking and physical activity — Any factors that alter the rate of blood flow through the skin and fat will change insulin absorption. Smoking decreases blood flow. In contrast, factors that increase blood flow (such as exercise, saunas, hot baths, and massage of the injection site) increase insulin absorption. To avoid low blood sugar, insulin injections should be given after a bath or sauna. It is best to inject insulin into the arm or abdomen and wait 30 minutes before running. A lower dose of insulin may be recommended before or after exercise; this should be discussed with a healthcare provider.
Time since opening the bottle — Most insulin remains potent and effective for up to a month after the bottle has been opened (if kept in the refrigerator between injections). However, the potency of intermediate and long acting insulin begins to decrease after 30 days. This can be a problem for people who require very small doses of insulin, for whom a bottle might last two months or more. It is advisable to start a new bottle at least every 30 days.
For very rapid acting insulin used in pen injectors, it is acceptable to keep the pen injector at room temperature (in a purse or jacket pocket) for up to 14 days, provided that the pen is not exposed to temperature extremes. However, after 14 days, a new insulin cartridge or pen should be used, even if there is insulin left in the old cartridge.
Individual differences — The same dose of the same type of insulin may have different effects in different people with diabetes. Some trial and error is usually necessary to find the ideal type(s) and dose of insulin and schedule for each person.
Insulin needs often change over a person's lifetime. Changes in weight, diet, health conditions (including pregnancy), activity level, and occupation can have an impact on the amount of insulin needed to control blood glucose levels. Patients are often able to adjust their own insulin dose, but may require assistance in some situations. (See "Patient information: Care during pregnancy for women with type 1 or 2 diabetes").
SPECIAL SITUATIONS — Several special situations can complicate insulin treatment for a person with diabetes. With advance planning and careful calculation, these situations are less likely to cause serious difficulties. A healthcare provider can assist patients in handling these situations.
Eating out — Eating out can be challenging since ingredients used, calorie and fat content, and portion sizes are usually different from meals prepared at home. Patients can estimate their insulin needs in several ways, including nutrition information from restaurants or a hand-held reference book.
Hypo- and hyperglycemia can occur more easily in situations where new or different foods are eaten; thus patients should keep a fast-acting source of carbohydrates and blood glucose monitor on hand at all times. (See "Patient information: Hypoglycemia (low blood glucose) in diabetes").
Surgery — Patients who undergo surgery may be instructed not to eat for eight to 12 hours before their procedure. A healthcare provider can help to determine the dose and timing of insulin before and after the procedure, especially if a patient will be unable to eat a normal diet afterwards.
Infections — Mild infections, such as a cold, sore throat, or urinary tract infection, can cause blood glucose levels to rise. In this situation, frequent telephone contact with a healthcare provider, careful blood glucose monitoring, and increasing the insulin dose are often recommended. It is important to drink an adequate amount of fluids while ill to avoid dehydration. Patients with nausea or vomiting may require medication to control their symptoms and avoid dehydration.
Travel — Managing blood glucose levels and insulin treatment while traveling can be difficult, especially when traveling across multiple time zones. In addition, activity levels and diet are often different while traveling, making careful blood glucose monitoring essential. Patients should speak with their healthcare provider before traveling to develop a treatment plan. (See "Patient information: General travel advice", section on Traveling with medical conditions).
STAYING MOTIVATED — Living with diabetes can be very demanding and some patients lose motivation over time. Healthcare providers can provide tips and encouragement to help patients stay on track. Helpful information and support is also available from the American Diabetes Association (ADA), at (800)-DIABETES (800-342-2383) and at www.diabetes.org.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Diabetes and Digestive and Kidney Diseases
(www.niddk.nih.gov/)
American Diabetes Association (ADA)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
Canadian Diabetes Associates
(www.diabetes.ca)
Juvenile Diabetes Research Foundation
(www.jdrf.org)
U.S. Center for Disease Control and Prevention
(www.cdc.gov/diabetes)
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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352:837.
2. Turner, RC, Cull, CA, Frighi, V, Holman, RR for the UK Prospective Diabetes Study (UKPDS) Group. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes. Progressive requirement for multiple therapies (UKPDS 49). JAMA 1999; 281:2005.
3. Fleming, DR, Jacober, SJ, Vandenberg, MA, et al. The safety of injecting insulin through clothing. Diabetes Care 1997; 20:244.
4. Yki-Järvinen, H, Dressler, A, Ziemen, M. Less nocturnal hypoglycemia and better post-dinner glucose control with bedtime insulin glargine compared with bedtime NPH insulin during insulin combination therapy in type 2 diabetes. Diabetes Care 2000; 23:1130.
5. Taylor, R, Davies, R, Fox, C, et al. Appropriate insulin regimes for type 2 diabetes: a multicenter randomized crossover study. Diabetes Care 2000; 23:1612.
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