Preventing & Treating Diabetes

Introduction

Experts estimate that more than 26 million Americans are living with diabetes. That exceeds 8 percent of the population, or just about one out of every 12 people. Of those, 7 million are undiagnosed—they don’t know they have it. Perhaps even more alarming, roughly 80 million Americans may have “prediabetes.”

10 Key Steps for Keeping Diabetes in Check

1. Monitor & control blood sugar
2. Exercise (with friends when possible)
3. Eat a low-carb diet
4. Maintain a healthy body weight
5. Enlist your support network
6. Manage stress
7. Feel free to indulge in coffee if you have prediabetes
8. Consider adding cinnamon to your diet
9. Get adequate vitamin D
10. If needed, talk to your doctor about medications

The treatment for type 1 diabetes is fairly complicated, and requires a doctor’s vigilant supervision. So we’ll be focusing mostly on type 2 diabetes in this guide. Many of these suggestions can be helpful for type 1 diabetes, not to mention those of us who don’t have diabetes

To say that we’re experiencing a diabetes epidemic hardly begins to describe the problem. Chances are that just about everyone knows someone with diabetes. And in fact, some experts believe that it will soon affect nearly half our population.

Maybe you’re asking yourself: just how serious is diabetes? If 7 million people are walking around with it undiagnosed, is it really such big a deal? Unfortunately, it’s a very, very big deal. According to National Diabetes Statistics, diabetes is the seventh leading cause of death in the U.S. It’s also the leading cause of kidney failure, lowerlimb amputations not caused by trauma, and new cases of blindness among adults. It can also cause other deadly or devastating health complications, like heart attacks; strokes; severe neuropathy (nerve damage); musculoskeletal changes; and sexual dysfunction for both men and women.

That said, these outcomes absolutely are not inevitable. And while diabetes is a serious condition that requires careful monitoring, coordination with healthcare providers, and real effort to manage, it can be managed—in rare cases, even reversed.

For a diabetic to stay healthy, feel well, and avoid complications, the trick is to keep blood sugar levels within normal limits carefully and consistently. Managing blood sugar can cut a diabetic’s risk of having a heart attack or stroke in half (N. Engl. J. Med. 2005).

Of course, controlling blood sugar is easier said than done. But for those motivated to make a few significant lifestyle changes—changes that would benefit all of us, not just people with elevated bloodsugar levels—the effects can be dramatic. Even life-saving.

But what exactly is diabetes? And what causes it?

When a person has diabetes, his blood is flooded with sugar (glucose), and yet his cells can’t get the energy they need from it. That’s because a diabetic’s insulin, the hormone that processes glucose, either isn’t working properly or there isn’t enough of it.

There are two kinds of diabetes. In type 1, the immune system attacks the pancreas and destroys the beta cells there that produce insulin. Because insulin is crucial for the proper functioning of our cells, type 1 diabetics have to get it by injection.

Type 1 diabetes is sometimes referred to as “juvenile diabetes”—though that’s misleading, both because it can come on in adulthood, and because type 2 diabetes is increasingly common in kids and teens. In fact, the Centers for Disease Control predicts that one in three kids under age 5 will develop type 2 in the course of their lives. If they’re Latino, those numbers shoot to one out of two. This is especially alarming since obesity-linked type 2 diabetes advances more quickly in kids and is harder to control than in adults.

With type 2 diabetes, which is far more common, the problem isn’t a lack of insulin. In fact, sometimes there’s an overabundance. But the body’s cells don’t respond well to it; that’s what’s meant by “insulin resistance.”

As for type 2’s causes, there’s a general consensus that obesity and inactivity are important factors. But some experts believe there could be other triggers, too, like high-fructose corn syrup—found in everything from soda to cereal to salad dressing—which can affect insulin resistance in animals. We suggest avoiding it whenever possible.

Some experts believe that the endocrine disrupter bisphenol A (BPA) also may lead to insulin resistance. It’s a compound found in many plastics, cans and cash register receipts. Apart from avoiding sodas and plastics—and, needless to say, all sodas in plastics—what else can someone with type 2 diabetes or prediabetes do to get and stay healthy? The good news is: a lot.

Tracking Blood Sugar Over Time

Fasting Blood Sugar

As we noted above, monitoring blood sugar is crucial for determining if you are have diabetes or prediabetes. The usual thresholds for diagnosis require a blood test taken when you are fasting (have had nothing to eat for at least eight hours). Under those conditions, a result of 99 mg/dL or lower indicates no diabetes. A test result of 126 mg/dL or higher is the signal that you have diabetes. Then there is the gray zone. With fasting blood sugar results between 100 and 125 mg/dL, doctors classify people as having pre-diabetes. Following through on the suggestions in this Guide may help you drive your blood sugar down so that you no longer fall in the prediabetic range. Using a continuous glucose monitor (CGM) can help you see in real time how what you eat affects your blood sugar.

HbA1c

When your healthcare provider wants to get a sense of your blood sugar over time, they will probably use a test of glycosylated hemoglobin, or HbA1c (sometimes abbreviated A1c). This measures how much sugar has attached itself to the hemoglobin protein in your red blood cells. This gives a sense of what your blood sugar has been doing over the past six to eight weeks.

People with normal blood sugar generally have an A1c level below 5.7%. At 6.5% or higher, the A1c clearly indicates diabetes. As with blood sugar, intermediate results for the A1c test (between 5.7 and 6.4%) suggest prediabetes. Getting the A1c down below 5.7% is desirable.

If your primary care provider is concerned that you might have diabetes, but you haven’t fasted, you might get a “random blood sugar test.” If the blood sugar is 200 mg/dL, your provider will probably swing into action. You may be asked to undergo a glucose tolerance test and you will almost certainly be required to do a fasting blood sugar test. Those will give a more definitive assessment of diabetes. If you do have diabetes, you will learn how to test your own blood sugar. This may feel daunting or scary at first. But as you will read further on, this can be a very powerful tool for learning how your body reacts to the things you eat.

Diabetes & Diet

Metabolic Syndrome & Preventing Diabetes

When people at risk for diabetes are also overweight; have high blood pressure; high triglycerides; and low HDL (“good”) cholesterol; they’re said to have metabolic syndrome.

It’s very worthwhile for these folks to make lifestyle changes that will help keep their metabolic syndrome from turning into full-blown diabetes. Cutting carbs from their diets is one helpful place to start.

Dr. Bernstein’s Best Bet Veggies

Besides lean protein (eggs, fish, meat, poultry and seafood), Dr. Richard Bernstein recommends these foods for blood sugar control:

• Artichokes
• Asparagus
• Bell peppers
• Bok choy
• Broccoli
• Brussels sprouts
• Cabbage
• Cauliflower
• Celery
• Eggplant
• Escarole
• Green beans
• Greens (beet, collard)
• Mushrooms
• Sauerkraut
• Scallions
• Snow peas
• Soy
• Spaghetti squash
• Spinach
• Tofu
• Zucchini

A Day on Dr. Bernstein’s Diabetes Diet

If you’re wondering what a day on the Bernstein diet might actually look like, here is one possibility.

Breakfast: eggs or omelet

Lunch: salad (2 cups) with a lean protein, e.g. tuna or turkey

Dinner: another serving of lean protein, like chicken or lean beef, an additional cup of salad, and another 2/3 cup vegetables from the “do eat” list on p. 2

When it comes to controlling blood sugar, diet is the first line of defense. That sounds obvious. But according to diabetes expert Dr. Richard Bernstein, one of our heroes (and himself a type 1 diabetic, not to mention an engineer, physician, inventor of blood sugar self-monitoring, and author of The Diabetes Diet), the diet advocated by the American Diabetes Association contains too many high-carbohydrate foods that cause dramatic spikes in blood sugar, requiring high doses of medication.

Instead, Dr. Bernstein recommends a very low carbohydrate diet, avoiding beans, bread and crackers, breakfast cereal and other grains, candy and sweeteners (including sugar-free candies and honey), pasta, potatoes and rice. He also eschews fruit, carrots, corn, onions, tomatoes and low-fat yogurt. Following this regimen not only stabilizes blood sugars and keeps them in the normal range, but can also lead to modest weight loss—one of the very best ways to reduce the risk of serious health complications. Shedding even 5 percent of your initial body weight can help bring down blood pressure and triglycerides and reduce insulin resistance.

Cutting carbs seems like a big commitment, but it can have a dramatic impact on everything from blood sugar to cholesterol to body weight that we strongly encourage everyone—not just diabetics—to give it a try. Many believe that cutting carbs can actually reduce carb cravings, which would surely be a great boon.

If forswearing chips, donuts, and beer for life feels like too much to take on, why not try it for just a month, and see how you feel? Record your blood sugars, monitor your energy level, and see what happens. We can all do just about anything for a month. Many who significantly cut carbs from their diets experience such an improvement in how they feel that the changes create their own momentum.

Low-Cal vs. Low-Carb

One reason that some people feel resistant to going low-carb is that they’re afraid they’ll have to go hungry. But in fact, a study in the journal Nutrition (Oct., 2012) showed just the opposite: restrictive calorie diets are actually less effective at helping to keep the weight of type 2 diabetics in check than a very low-carb diet. Starving yourself doesn’t pay. Cutting sugars and starches does.

The study, which was conducted over a period of roughly 6 months, looked at 363 overweight and obese participants, 102 of whom had type 2 diabetes. Participants were then assigned to either a low-calorie or a low-carb “ketogenic” diet.

Both groups saw improvements in nearly every category measured: weight, body mass index, waist circumference, blood glucose, glycosylated hemoglobin, total cholesterol, LDL and HDL cholesterol and triglycerides. But the group on the low-carb diet did significantly better than those on a low-cal diet.

In short, there’s no need to suffer on wilty celery sticks and miso soup. Your blood glucose levels could actually go down even more on a diet incorporating delicious grilled meats (not processed ones); seafood; seasonal non-starchy vegetables; full-fat yogurt and cheese.

Diets that take a low-carb approach include Atkins, Dukan, Paleo, South Beach, Zone, and countless others, especially Dr. Bernstein’s The Diabetes Diet. These approaches are fairly similar, so we suggest you pick the one that appeals to you most. The diet you like is the one you’re most likely to stick with.

For vegetarians and other bean-lovers who just can’t abide Dr. Bernstein’s advice to forgo legumes, some research suggests that eating a cup of beans or lentils a day may have a modest, positive effect on blood sugar, blood pressure, and cholesterol levels in type 2 diabetes, and may even help reduce the risk of heart attacks (Archives of Internal Medicine, Oct. 2012). An earlier study found that a vegetarian diet offered better results for body weight and insulin resistance than a conventional diabetes diet matched for calories (Diabetic Medicine, May 2011). Both of these studies were rather small, and neither compared the vegetarian bean-based diet to a lowcarb version. But if you just can’t say no to frijoles, they certainly beat rice, bread, and potatoes as dietary staples.

To select the best diet and exercise regimen, we strongly recommend consulting a diabetes educator who can coach you.

Non-Drug Approaches

Cinnamon Coffee

• 2 TB ground coffee
• 1/4 tsp ground cinnamon
• Stevia and creamer (or soy milk, or other substitute) to taste

Our favorite way to enjoy coffee is in a “pour over”: i.e., place a paper filter in a ceramic or glass filter, add your coffee and cinnamon grounds, then slowly pour 8 to 10 ounces of boiling water over the grounds to brew up a single cup, flavoring with stevia and your preferred creamer to taste. (We prefer ceramic and glass filters because we worry about BPA leaching into coffee with plastic filters.)

There’s an added bonus to consuming your cinnamon this way: if you put the cinnamon in with your coffee grounds (instead of directly into your cup of coffee afterwards), the toxic coumarin compounds in the cinnamon ought to be filtered out: they’re not water soluble.

If you don’t like the taste of cinnamon, you can also consume it in capsule form. Look for it as a dietary supplement online or in health food stores.

We recommend that you check with your doctor whenever you take dietary supplements. If she recommends it, have your liver enzymes checked.

Rx for Dark Chocolate?

Surprising as it may sound, dark chocolate (with as little sugar as possible) may actually improve insulin sensitivity, as well as decrease cholesterol and heart disease risk (Diabetes Care, Feb. 2012). But it obviously won’t help in the battle of the bulge, so caloric adjustments should be made to the rest of the diet. And the “dose,” alas, is very small- -just 27g per day, or about an ounce. And of course if you find that in your case, chocolate actually happens to raise your blood sugar numbers, you’ll have to kick cocoa to the curb.

Flavoring Coffee for Favorable Numbers

Folks who enjoy java appear to be at considerably lower risk for developing diabetes, whether they drink caf or decaf.

You can help bring down your risk even more if you use stevia instead of sugar or skip the sweetener all together. And if you add to your grounds a pinch of cassia cinnamon (the normal spice-rack kind), your risk drops further. Even better, cinnamon can help keep down blood sugar numbers for those who’ve already developed diabetes. You can overdose on cinnamon, so be careful: too much coumarin, in cinnamon, is toxic to the liver. Ask your doctor to check your liver enzymes.

On top of making dietary changes and adding exercise to your routine, there are a number of other non-drug approaches that can help keep your blood-sugar numbers in a safe and consistent range.

Cinnamon & Vinegar & Coffee, Oh My!

Not all of the dietary changes we suggest are about removing things from the diet. Adding certain tasty elements may have a positive effect on blood sugars and insulin resistance.

Some might surprise you. For instance, research suggests that the flavonoids in cocoa can slightly improve insulin sensitivity and blood pressure (Journal of Nutrition, Nov. 2011), so a bit of dark chocolate every now and then at the end of a low-carb meal may be just what the doctor ordered. Sadly, the “dose” is small (see sidebar).

Not so for your morning cup of joe. Coffee lovers who have not yet developed diabetes significantly decrease their risk of getting it by indulging in a cup (or 2 or 3) of java (Am. J Clin. Nutr., April 2010). Especially true if you sweeten it with stevia instead of sugar, and if you sprinkle 1/4 to 1/2 tsp cinnamon in with your grounds.

Vinegar (Ann. Nutr. Metab. 2010) and perhaps also mustard, or more specifically its active ingredient curcumin (Diabetes Care, July 2012), are other unexpected blood sugar busters, at least when consumed with a high-carb meal (European Journal of Nutrition, July 2010). Very tasty when consumed together in dijon salad dressing.

Researchers have also found that black tea (BMJ, November 2012), oolong tea (Diabetes Care, June 2003), and perhaps to a lesser extent green tea (J Nutr Health Aging, 2012) can help prevent diabetes, too, and control blood glucose for those who are already diabetic. Just remember to be cautious about sweetening your tea, and we suggest taking it dairy-free; milk seems to counteract some of its positive effects.

Supplements

There are also several dietary supplements that may be especially important for diabetics: vitamin D, selenium, and chromium. Diabetics are at an increased risk of coronary artery disease, and being vitamin-D deficient can increase that risk (Diabetes Care, Jan. 2012).

Many people worldwide are deficient in vitamin D because we all spend so much time indoors these days. (The body metabolizes vitamin D from the sun.) You may want to talk to your doctor about taking a vitamin-D supplement, or perhaps even go straight to the source and get 15-20 minutes of direct sunlight per day. (Any more and you’ll need sunblock.)

As for selenium, researchers at Harvard found that people who got enough of it were less likely to develop diabetes (Diabetes Care, May 2012). Foods like nuts, especially brazil nuts; meat; whole grains; and fish are rich in selenium. It can be taken as a supplement, but as with most supplements, there’s a sweet spot. Too much can be quite toxic, so consult your doctor.

Talk to your doctor, too, about chromium supplementation. Minute amounts of chromium may help with insulin sensitivity and blood sugars. But it’s very easy—and dangerous—to overdo it.

Herbs for Diabetes

Several herbs have been used for many, many years to control blood glucose and prevent diabetes. As with all other changes to your routine, be sure to talk to your doctor before adding herbs to your regimen, and monitor your blood sugars carefully for changes.

Bitter Melon

Bitter melon is in the squash family. It isn’t safe for kids or pregnant women, but it may help others bring down blood sugars (BMC Complement Altern Med. 2010). It’s very astringent, so you may want to de-seed and parboil the melon before preparing it.

Fenugreek

Fenugreek is a seed used in Indian cooking. It can occasionally cause digestive side effects and it may interact with anticoagulants. But it appears to lower blood sugar experimentally (J. Biosci. Jun. 2010). The normal dose is 1 or 2 grams of seeds three times a day.

Nopal Cactus

Scientific data on controlling blood sugars with nopal cactus (prickly pear) are limited to animals (J. Ethnopharmacol. Jan. 2012). But several readers report that consuming it as a juice or tea can help get their numbers down into a safe range.

Monitoring Blood Sugar

Diabetes Resources

Some diabetes experts whose opinions we trust include: Dr. Richard K. Bernstein, whose website is askdrbernstein.net; Dr. William Polonsky, CEO of the Behavioral Diabetes Institute (behavioraldiabetes. org); and Dr. Mark Hyman, founder and medical director of the UltraWellness Center (drmarkhyman.com and bloodsugarsolutions.com).

You can find interviews we’ve done with all three at peoplespharmacy.com.

Some websites that may be helpful include diabetesdaily.com and diabetesmine.com

It’s absolutely crucial for diabetics (and all of us) to keep blood-sugar levels in a safe and healthy range. As we mentioned earlier, keeping these numbers in check can cut a diabetic’s heart attack or stroke risk by a whopping fifty percent.

One of the best ways to ensure that your blood sugars are consistently staying within normal limits is to measure them often, and to record your findings.

Diabetes expert Dr. Richard Bernstein recommends that those who have recently been diagnosed as diabetic or prediabetic should plan to spend two weeks measuring and writing down blood sugars at all of the following times throughout the day:

• Right after waking up
• Just after breakfast
• Two hours after all meals and snacks
• At bedtime

Before and after you exercise After an initial two-week testing period, which will give you a good baseline understanding of your blood sugars, you can drop back to taking just a few readings per day.

Healthy Numbers

Of course, keeping your numbers in a healthy range requires knowing what “healthy” means.

The cut-off for a diagnosis of diabetes is a fasting blood-glucose reading of 126 milligrams per deciliter. “High normal” is 110 mg/dl—although there are experts who think that anyone with a reading of 100 mg/ dl should be diagnosed as prediabetic.

“Normal” is a little bit different for different people, but Dr. Bernstein has told us that healthy adults tend to cluster around 83. In fact, he was astounded to discover in a diabetes journal that a chart plotting blood sugars vs. mortality in large population studies showed that those with a fasting blood-glucose level of 83 had the lowest rates of mortality.

That’s not to say, however, that 83 is a magic number. For instance, a normal healthy range for children is in the 70s. Carefully charting your own blood sugars will help you determine the levels at which you feel your best.

Keeping careful track of your bloodglucose levels will also help you see very clearly how the different foods you eat and the activities you undertake can affect your blood sugars. Adjusting diet, exercise, sleep, and stress levels accordingly is one of the most powerful ways you can take control of your health.

Paired Testing

Once you become a testing expert, you can start doing “paired testing” to see how certain dietary and lifestyle choices affect your blood glucose. Paired testing means taking readings before and after eating or drinking or doing something specific for several days in a row. It can give you all sorts of information: about the effects of exercise; why you feel tired after lunch; how much dark chocolate is your ideal “dose,” etc. This allows you to turn blood sugar monitoring into a form of experimentation.

There are scores of devices to measure blood sugar on the market, and more are introduced all the time. For that, we have Dr. Bernstein to thank: he invented self-monitoring decades ago, back when doctors never dreamed diabetics might be able or willing to measure their own levels. Blood glucose monitors have become very affordable and convenient. Talk to your doctor or other diabetics about the most accurate device available. (When we asked Dr. Bernstein if he felt vindicated now that his ideas are taken for granted, he said no. Official dietary guidelines haven’t changed much, and as a result, neither have mortality rates.)

There are lots of ways to record these numbers, and nowadays, there are dozens of smartphone and computer apps designed specifically for helping diabetics chart their blood-sugar and other numbers. For instance, iTunes sells bant; dLife; DiabetesTracker; and Glucose Buddy, just to name a few. But if you feel most comfortable writing your numbers down with a pen and paper, by all means, do whatever is easiest and most comfortable for you. Just make sure to keep track of them in such a way that they’ll be decipherable to other people, as you should definitely plan to share your blood-glucose numbers with your doctor.

Exercise: “Harnessing the Power of Convenience”

10 Tips to Making Exercise A Fixture

1. Make it easy

Pick an activity that doesn’t require lots of extra time or expensive gear. If you join a gym, choose one on your route. Go first thing in the morning. Do little things, like parking farther from the office or grocery store, to make exercise inevitable.

2. Make it fun

Do something with friends: pick-up basketball, tennis, a walking group or dance class. Or do something that gives you precious time to yourself.

3. Set a routine

Do the same activities at the same times every week.

4. Set a goal

Pick something in the future you’d like to achieve: a 5k; a dance rehearsal; a weight-lifting benchmark.

5. Build up over time

Give yourself time to improve. Add just a few extra minutes of jogging or pounds of weight to lift each week. In 6 months, your progress will amaze you.

6. Quit smoking

Easier said than done. But it’ll make a huge difference in your fitness (and overall health).

7. Be competitive

Work on weight-loss or exercise goals with friends and family.

8. Create accountability

Report set-backs & progress to a person you trust to encourage and support you.

9. Keep a record

Log your activities and results. It’ll be proof positive that what you’re doing is working.

10. Be nice to yourself

Be patient with yourself. Acknowledge that what you’re doing is hard. If you miss a day, don’t be too hard on yourself. Just keep showing up. Give yourself hope.

Adding regular exercise to our routines is another lifestyle change that can make a huge, positive impact.

The exercise doesn’t have to be brutal— no blood, tears, or even buckets of sweat required. Losing just a little bit of weight can have a real beneficial effect on blood sugars and insulin sensitivity. For some people, a 10- or 12-pound weight loss is even enough to help them get off of some or all of their medications.

In fact, in a study published in the Annals of Internal Medicine (2005), weight loss of just 7 percent of initial body weight coupled with 30 minutes of moderate exercise 5 times a week was more effective at controlling diabetes than taking the prescription drug metformin was. Exercise also does good things for cholesterol and blood pressure, not to mention mood, sleep, and energy. All of which influence your overall health.

But the trick to exercise-induced weight loss isn’t running at the treadmill’s highest setting or heaving the heaviest set of weights. The only real trick to exercise is doing it. And the only real way to trick yourself into this trick is by picking something you like and sticking with it.

Dr. Bill Polonsky, CEO of the Behavioral Diabetes Institute and Associate Clinical Professor in Psychiatry at the University of California, San Diego, favors an approach he described to us as “harnessing the power of convenience.”

In order to do it, you first have to identify the primary obstacles between you and regular exercise. Each one is truly surmountable, if you are dedicated to prioritizing your health for your own sake and the sake of your family.

For instance, if you find it hard to set aside 30 minutes each day for a workout, try slicing it into 5-minute mini-workouts instead. Parking as far away from the entrance as humanly possible at work, the grocery store, and when doing errands might add up to most of a day’s exercise. Add one quick mid-morning and mid-afternoon break to walk a few loops around the office listening to your favorite podcast or song, and you could be done for the day.

For those who prefer to exercise at a gym, one way to harness the power of convenience is to pick a gym that’s right on your daily travel route, and then to go first thing in the morning. Excuses build up as the day wears on.

But the most important thing to remember about exercise is that we only make it an indispensible part of our lives when it becomes something we truly enjoy. For those who don’t currently exercise, the idea that it could ever be truly enjoyable might sound hard to believe. But the truth is that athletes aren’t fundamentally different from the rest of us. They do exercise because it makes them feel good. And it can do the same thing for you.

But making exercise fun means a little something different for each of us, and it’s worth figuring out how best to make it entertaining for you. For example, if you feel your life is too harried and frenetic for socializing, and you miss having interactions with friends, then creating a walking club where you can catch up while you work out might be just the way to go. Taking a regular zumba or yoga class at the Y might be a similarly fitting antidote to feeling stressed-out or isolated.

On the other hand, if you’re a busy parent or caretaker and feel you never have time to yourself, then exercise can be a perfect excuse to give you time to be alone with your thoughts: commuting to the office by bike or going for a quiet jog might well become the most cherished time of your day.

Then again, if you know you’re competitive in other areas of life, why not use that to your advantage when it comes to exercise? You could try setting benchmarks with other friends who are trying to lose weight; consider making yourself and each other accountable by sharing set-backs and accomplishments; join a gym class with people who are a little fitter than you; or pick a goal for something you’d like to achieve: a 5K race you want to complete; an amount of weight you’d one day like to be able to bench press; a dance routine you want to be able to do, etc.

But don’t try to do it all in one week. Build up what you do incrementally, over time. Have patience with yourself. And if you ever fall off the wagon, be nice to yourself. You can always get back on.

Diabetes Drugs

Sitagliptin (Januvia)

Sitagliptin and other drugs in its class are a relatively recent type of pill for type 2 diabetes. Like the sulfonylureas, they increase the output of insulin from the pancreas.

Januvia is dangerous for anyone experiencing ketoacidosis. (Remember, this can be the result of a very low-carb diet as well as an undesirable complication of diabetes.) The drug also increases the risk of pancreatitis, a very serious side effect. Another severe side effect is an allergic reaction that may start as hives or a rash and proceed to swelling of the face, tongue or throat that can interfere with breathing. This is a medical emergency.

Januvia may also cause low blood sugar, another potentially dangerous complication. More common side effects include runny nose; sore throat; headache; cold symptoms; digestive distress; leg or hand edema.

The benefits of Januvia and other “gliptins” are that they do not cause weight gain, control blood sugar, help lower blood pressure and may reduce cardiovascular risk, although this has not yet been firmly established (Nat Rev Cardiol., online Jan. 8, 2013).

Liraglutide (Victoza)

Liraglutide and the related drug exanatide (Byetta) are injectable medications for type 2 diabetes. Although Victoza can be used in conjunction with insulin if necessary, it should never be added to the same syringe. Victoza does not lead to weight gain, and may even help some people lose weight. It also does not usually cause severely low blood sugar. Serious side effects include: a severe allergic reaction; blurred vision or slurred speech; difficult urination; abdominal pain; fever and sore throat; and shortness of breath. More common side effects include digestive distress; dizziness; or headache.

There are concerns, based on animal studies, that the drug may raise the risk of thyroid cancer. Pancreatitis is also a serious concern.

Every drug has potential side effects, and some diabetes medicines have been linked to serious ones. We can understand concern about taking them. But while getting off medication with lifestyle changes is an admirable goal, many type 2 diabetics are unable to keep blood glucose in a safe range without one or more pills.

There’s a huge array of diabetes drugs available. Everyone is different, so you and your doctor will need to work out the best medication regimen for you. It’s worth keeping in mind that new research indicates that so-called “tight control” achieved with medication may not offer the best results for preventing deaths from complications (N Engl J Med., May 3, 2011). This unexpected result underscores the importance of individualized goals and care plans. Preliminary research suggests that soon after diagnosis, stepping up a regimen gradually isn’t as effective as “hitting the disease early and hard” with short-term insulin treatment (WSJ, July 9, 2012).

Metformin (Glucophage)

Metformin is often the first-line medication prescribed. It can be quite effective on its own at controlling blood sugars, as a large meta-analysis by the Cochrane Collaboration showed in 2005. An added benefit is that metformin doesn’t cause people to pack on pounds, as many oral medicines can; in fact, it helps some to lose weight.

But it’s not safe for people with kidney disease or congestive heart failure, and anyone taking it needs to get the kidneys checked at least once a year. If the kidneys can’t clear the drug effectively, metformin levels build up in the body and put a strain on the mitochondria in the liver (Metabolism, Feb. 2016).

Such high levels of metformin result in lactic acidosis, a rare but potentially fatal side effect. Anyone who experiences muscle pain; shortness of breath; stomachache, nausea, or vomiting; fatigue; low blood pressure or irregular heartbeats while taking metformin needs to see the doctor right away.

Lactic acidosis can be especially tricky to identify because digestive distress (diarrhea, nausea, flatulence, stomachache) is a common side effect of metformin. This often goes away a few weeks after starting the medicine. Still, you’re always better safe than sorry, so check with your doctor if you’re experiencing discomfort.

Keep in mind that metformin can also lead to vitamin B12 deficiency over time. This in turn may result in anemia or neuropathy. Other side effects include skin rash, hair loss, headache, palpitations, dizziness, or a flu-like syndrome (Clinical Diabetes, Jan. 2022).

Pioglitazone (Actos)

Pioglitazone (Actos) improves insulin sensitivity and decreases insulin resistance. Its biological action leads to lower blood sugar levels and helps bring HbA1c into a more normal range. As a bonus, Actos lowers triglycerides and raises good HDL cholesterol.

There are some clouds over this drug, however. Actos is related to another diabetes drug called rosiglitazone (Avandia) that has virtually disappeared from the market. That’s because people taking Avandia have an increased risk of heart attacks as well as other serious side effects.

Actos has its own problems. Investigators in Europe have discovered that this diabetes drug is linked to an increased risk of bladder cancer. For this reason it was banned in France and Germany. In addition, Actos can cause fluid retention and trigger congestive heart failure. Anyone with heart failure must avoid Actos! Other complications may include: an increased risk of bone fractures; headaches; toothaches; sinusitis; sore throats; bronchitis; colds; muscle pain; flatulence; anemia; macular edema and liver toxicity.

Sulfonylureas

The oldest class of oral diabetes medicines have a tongue-twister name: sulfonylureas [Sulfo-Neel-U-Ree-ah]. In the early 1940s researchers discovered by accident that such medications lowered blood sugar levels in animals. They have been prescribed since the 1950s to control type 2 diabetes. Today, the most frequently prescribed drugs in this category include glimepiride, glipizide and glyburide.

Despite decades of use, these medications remain controversial. They don’t always control blood glucose levels well. Some people eventually become resistant to treatment. These drugs can also lead to weight gain, not a desirable situation for someone with diabetes. This class of drugs may actually increase the risk of cardiovascular death–the opposite of what anyone wants! They can also lower blood sugar too much (hypoglycemia) which is not good for the brain or the body. Other side effects include: digestive distress; nausea; headache; blurred vision; dizziness; drowsiness; rash; liver damage; and blood disorders.

GLP-1 Agonists Against Type 2 Diabetes

We started paying attention to something called glucagon-like peptide 1 (GLP-1) many years ago. That’s because back in 2005 the FDA approved exenatide (Byetta). Liraglutide (Victoza) got the FDA’s green light in 2010. Both drugs work through GLP-1 receptors to help people normalize blood sugar levels. The drugs are called GLP-1 agonists.

Ok…I can sense you are starting to yawn. We are deep in the pharmacological weeds, but please hang in there a moment more. The pharmaceutical industry, sensing it might be on to something interesting, kept working on compounds that could activate GLP-1 receptors. These drugs have become very hot commodities in recent years because of their ability to lower blood sugar and help people lose weight.

GLP-1 is a natural substance produced in the small intestines. It gloms on to special GLP-1 receptors in pancreatic beta cells and stimulates the release of insulin. In addition, GLP-1 slows the release of food from the stomach into the small intestines. That effect is called delayed gastric empyting. The dual actions of these drugs (and several other complex physiological effects) help lower blood glucose and reduce appetite and food intake. That translates into weight loss! And that is why GLP-1 agonists have become so popular in recent years. Drugs that help control type 2 diabetes and manage obesity are popular with physicians and patients.

Here Are Some Other Examples of GLP-1 Agonists:

• Dulaglutide (Trulicity)
• Exenatide extended releas (Bydureon)
• Liraglutide (Victoza, Saxenda)
• Lixisenatide (Adlyxin)
• Semaglutide (Ozempic, Rybelsus, Wegovy)
• Tirzepatide (Mounjaro): this drug activates both GLP-1 and GIP receptors

Some of these formulations are intended as once-weekly self injections. Others are injected daily. Rybelsus is an oral form of semaglutide that is taken once daily to help control glood sugar.

GLP-1 Agonists and Weight Loss:

People who did not have diabetes weren’t particularly interested in drugs like Trulicity, Ozempic or Rybelsus. That all changed when social media began spreading the word that drugs in this category could help people lose weight. But we are getting ahead of ourselves.

Semaglutide was approved by the FDA in 2017 as the self-injectable diabetes drug Ozempic. It was considered a longer-acting GLP-1 agonist compared with liraglutide. An oral version of semaglutide, Rybelsus, got the FDA’s green light for type 2 diabetes in 2019. The same drug, semaglutide, got the FDA’s coveted approval rating for weight loss in 2021. The new name was Wegovy!

In studies, it seems more effective than other weight loss medications (Diabetes, Obesity & Metabolism, Feb. 2021). Over 16 months, people taking Wegovy lost an average of 15% of their body weight (around 35 pounds). Those on placebo lost 2.5%, on average. All of the participants in the trial exercised regularly and followed a healthful diet.

In addition, Wegovy may have another advantage. An earlier trial demonstrated that people taking semaglutide were more likely to overcome nonalcoholic fatty liver disorder (New England Journal of Medicine, March 25, 2021).

Elon Musk and Wegovy:

When Elon Musk was asked on Twitter in 2022 how he had lost weight, he at first responded: “Fasting.” A follow-up tweet added “And Wegovy.” Social media, Hollywood stars and Tik Tok videos added fuel to the fire. It did not take long for overweight people to start asking for Wegovy and other GLP-1 agonists. The publicity also created shortages for patients with type 2 diabetes.

What About Side Effects?

Adverse reactions associated with semaglutide include nausea, vomiting, diarrhea and stomach ache. About 5 percent of volunteers in clinical trials dropped out because of these complications. All the GLP-1 agonists have side effects:

• Digestive distress that can be violent! One person described these symptoms as “intestinal apocalypse.”
• Heartburn, indigestion
• Headaches
• Dizziness
• Injection site irritation for drugs that are self-injected (itching and redness)
• Thyroid tumors/cancer
• Pancreatitis (severe abdominal pain/distress); jaundice requires immediate medical attention!
• Kidney trouble
• Gastroparesis (slow stomach emptying)
• Depression
• Gallbladder problems

Speaking of Gallbladder Issues:

FDA scientists conducted an analysis of serious side effects reported to the FDA Adverse Event Reporting System (FAERS). Unfortunately, the FDA scientists found a number of reports of acute gallbladder attacks associated with these GLP-1 agonists (JAMA Internal Medicine, Aug. 29, 2022).

Not only are such attacks extremely painful, they can be dangerous. Most of the 36 cases in the database required surgery, and some of them resulted in patient death. According to the authors, FAERS data may represent no more than the tip of the iceberg (“underreporting”). However, this case series supports the findings of an earlier meta-analysis of randomized controlled trials (JAMA Internal Medicine, March 28, 2022).

As a result of these findings, doctors and patients should be on the lookout for gallbladder problems. Symptoms include abdominal pain, nausea and or vomiting, persistent diarrhea, light colored stools, jaundice (yellow skin or eyes), fast pulse and/or lower blood pressure and dark urine. Fever and/or chills require immediate medical attention. In fact, all these symptoms require prompt medical attention!

Keep in mind that the most common side effects of this class of diabetes drugs include nausea, vomiting, diarrhea and stomach ache. Such adverse reactions might be dowplayed by a prescriber as “normal.” Au contraire! If these symptoms are as a result of gallbladder problems or pancreatitis, they require rapid oversight and prompt discontinuation of the medicine.

Avoiding Meds that Might Increase Insulin Levels

It’s possible that some drugs actually trigger the onset of diabetes. If you’re diagnosed with diabetes, you should talk to your doctor about the medications you’re taking, and ask if one or more of them might have influenced your diagnosis. He might be able to prescribe an alternative that will bring you back into a normal range. It’s not always possible to switch, unfortunately. And you should of course never stop taking any medications before consulting your physician. Below is a partial list of some drugs that may raise blood sugar levels in some people.

Statins & Blood Sugar

Statin cholesterol-lowering medications such as atorvastatin, lovastatin, pitavastatin, rosuvastatin and simvastatin are frequently prescribed to people with diabetes or metabolic syndrome, who are at higher risk of heart disease. New research suggests, however, that statins may actually increase the risk of type 2 diabetes and could make blood sugar more difficult to control for those with diabetes (Diabetes Care, Dec. 17, 2012). Many physicians think the benefits of these drugs still outweigh the risks. If you are having trouble controlling your blood sugar, discuss the statin connection with your doctor. Do not stop such a drug on your own.

Drugs That May Boost Blood Sugars:

Bariatric Surgery

Surgery for Weight Loss

As we all know, losing weight is one of the best ways to manage, prevent, or even reverse diabetes. But losing weight isn’t easy, which is why some people have sought to lose weight through bariatric surgery.

One fascinating outcome of the surgery is that many diabetics who have gotten it have experienced “a rapid lowering of blood sugar, often enabling patients to go off most or all of their diabetes medicines” (WSJ, July 9, 2012). When they say rapid, they mean before anyone had time to actually lose much weight.

It can also help prevent diabetes. In one randomized, controlled study—the gold standard for scientific trials— Swedish participants were followed for up to 15 years after undergoing surgery. None had diabetes beforehand. Those who got the surgery were more than three and a half times less likely to develop diabetes (N Eng J of Med, Aug. 2012).

An analysis of long-term effects utilizing evidence from ten studies concluded that bariatric surgery helps reverse type 2 diabetes and reduces complications, including the risk of premature death, for at least five years (Obesity Surgery, Oct. 2017). A variety of procedures, including vertical sleeve gastrectomy, Roux-en-Y gastric bypass and laparoscoptic gastric banding, each has its own pros and cons (International Journal of Environmental Resaerch and Public Health, Aug. 30, 2019).

Surgery is of course a very major decision, with the risk of quite serious complications, not to be undertaken lightly. But it may be worth discussing with your doctor. Keep in mind, too, that some folks experience relapse within 5 years (Obes Surg., Jan. 2013).

Getting the Help You Need

Managing Stress

We all know that stress is bad for our physical and mental health. But not everyone knows that stress can have a negative impact on blood sugars. While a recent study has found that untreated depression has an even more profound impact on glycemic control than does stress (BMC Res Notes, June 2012), managing stress can of course help with depressive symptoms (and vice versa).

Everyone gets stress relief from something different. Big, broad factors that tend to help include: having a structure and routine that you can count on and that gives you a sense of control and empowerment over your health; feeling engaged and connected—with your support network, your medical team, and yourself; getting regular exercise that you enjoy; and doing some degree of “mindfulness work,” whether this is weekly spiritual practice, daily meditation, an occasional yoga class, or some other form of self-reflection.

Other techniques will be more personalized. Some find relaxation tapes soothing. Our favorites are by Dr. Emmett Miller. His recordings Letting Go of Stress and the Ten-Minute Stress Manager are available at www.DrMiller.com, or 800- 528-2737.

Other people may benefit more from talk therapy with a psychologist, psychiatrist, or life coach. Still others may benefit from biofeedback. If you prefer to do self-work on your own, there are also lots of resources for that. We are fond of both Richard Surwit’s book The Mind-Body Diabetes Revolution, and Dr. Polonsky’s Diabetes Burnout.

Non-human companions may also be extremely beneficial for many. You need not get an official “companion animal” to get great psychological benefit from a pet. And if that pet is a dog, you may get great physical benefit, too, when you take her for daily walks.

A diabetes diagnosis can feel very overwhelming, not to mention isolating. There’s a lot you have to do to manage diabetes, and that, coupled with big lifestyle changes, can seem intimidating at first, not to mention depressing. People with both types of diabetes are at a 50 to 60 percent increased risk for depression. That’s one in five people with diabetes. And the depression, coupled with the diabetes, can be a really challenging combination over time if the depression isn’t treated.

When we spoke to Dr. Bill Polonsky, who is the author of Diabetes Burnout: What To Do When You Can’t Take It Anymore, he told us that the key is getting and staying connected to people who can give you the help and support you need.

Social Support

It’s of primary importance that a diabetic’s friends and family get on board as the first line of defense.

While nagging is of course never helpful, offering to help in various ways can be a great boon: helping (if requested) with reminders about blood-sugar monitoring and keeping on top of doctor’s appointments; offering to go walking or biking or dancing together; making dietary changes; just listening and talking. And of course, the families of diabetics reap benefits, too: a “diabetes-friendly” way of living is a healthy way of living.

But as great as family and friends can be, it can also be useful for diabetics to have other outlets. A diabetic support group, whether online or in “real life” can be a truly helpful resource: creating a community where you can share tips and ideas, and where you can feel less alone with the setbacks and triumphs of daily treatment.

Doctor’s Support

Naturally, having a smart, encouraging, and well informed doctor is also vital. Dr. Polonsky shared with us that there is fairly good evidence that if your physician is interested enough, and engaged with you, you will do better.

That may sound like common sense, and it is. It’s really important to have a great medical team that you like and trust. And that includes mental health support, too. One of the challenges of treating depression in people with diabetes is that some antidepressants can actually cause diabetes. (See the list of drugs that may boost blood sugars on p. 7.) But not all antidepressants have this effect. What’s more, other treatments, like cognitive-behavioral therapy and regular exercise, may be even more effective— and don’t come with the same serious side effects.

The key to having a fruitful doctorpatient relationship is to have a very, very clear and concrete plan with your doctor about exactly what steps you need to take in your diabetes treatment, and to have a way to measure if those steps are working. There are several tests you should be getting every 3 to 6 months, like the A1C (average blood sugars over the past 12 weeks), blood pressure, and cholesterol. Your doctor should be able to explain the meaning and significance of your readings to you, and help you to understand if you’re in a safe or unsafe place with your diabetes.

Dr. Polonsky told us that the top three things to know after a diabetes diagnosis are: 1. Odds are very good that if you put effort into your care and have a good doctor, you’re going to be fine. 2. That every patient needs to have specific goals and a plan with their doctors for long-term health. And 3. If there’s any way possible, don’t go it alone. Get everyone important in your life in on your diabetes treatment and care. With those things in mind, and with a sense of optimism and hope, the prognosis for a long, healthy, and happy life with diabetes is very good.

Online Support

There are also lots of ways to harness the power of technology, if that’s a resource you feel comfortable using. Not only online support and chat groups, of which there are multitudes, but other tools. “The Mayo Clinic, for instance, has developed an online tool for patients that takes account of such factors as weight change, cost, low blood-sugar risk, blood-testing requirements and side effects.” (WSJ, July 9, 2012). And there are literally hundreds of diabetes-related apps for smartphones and computers.