John Tuohy's Me vs. Diabetes: The American Diabetes Association Applauds Stronger Screening Guidelines for Type 2 Diabetes

The American Diabetes Association Applauds Stronger Screening Guidelines for Type 2 Diabetes

ALEXANDRIA, VA--(Marketwired - Oct 7, 2014) - The American Diabetes Association (Association) applauds the U.S. Preventive Services Task Force (USPSTF) for elevating the draft recommendation for Screening of Type 2 Diabetes Mellitus in Adults, released yesterday. The USPSTF's draft recommendation will now include multiple risk-factor based type 2 diabetes screening for asymptomatic patients in addition to screening those who have high blood pressure, which was previously the only screening guideline under the existing recommendation last updated in 2008.

In issuing today's draft recommendation, the USPSTF has taken into consideration the abundance of evidence demonstrating that risk-factor based screening for type 2 diabetes will identify more individuals with the disease. Today, 8 million of the nearly 30 million children and adults in the U.S. living with diabetes have not been diagnosed with the disease. The estimated economic cost of undiagnosed diabetes is a staggering $18 billion annually. It is crucial to identify these cases in order for patients to engage in proper diabetes management and prevent costly and dangerous complications, including cardiovascular disease, stroke blindness, amputation and kidney disease.

"The American Diabetes Association is thrilled with the decision of the U.S. Preventive Services Task Force to strengthen their recommendation and take into consideration the wealth of research pointing to the need for risk-factor based screening in type 2 diabetes," said Robert Ratner, MD, Chief Scientific & Medical Officer, American Diabetes Association. "Early diagnosis of both type 2 and prediabetes is essential in improving the outcomes for these patients. Undeniable data show the efficacy and cost effectiveness of preventing diabetes. This new draft recommendation is a step in the right direction in the ongoing fight to Stop Diabetes®."

The American Diabetes Association has long advocated for risk-factor based screening for type 2 diabetes in our annual Standards of Medical Care in Diabetes. There are a number of factors associated with type 2 diabetes, including advanced age, being overweight or obese, family history of type 2 diabetes, and being a member of certain minority population that increase a patient's risk for type 2 diabetes. Using risk-factor based screenings will lead to diagnosing more individuals who are living with undiagnosed type 2 diabetes, but also help to identify those with prediabetes who are at high risk for developing type 2 and once diagnosed, can work to prevent the development of type 2 diabetes.

A 2013 study in the American Journal of Preventive Medicine found screening using the current USPSTF recommendations results in missing more than half of those who have undiagnosed diabetes. The decision to broaden the screening recommendation is an essential step to improving diabetes health outcomes, as these recommendations offer guidance to health care providers on providing appropriate preventive care. Additionally, under the Affordable Care Act, preventive services that receive A or B ratings are covered through private insurance without cost-sharing. This means individuals at risk will have greater access to diabetes screening if the draft recommendation stands. As the USPSTF continues the process of developing the final recommendation, the Association applauds the efforts to improve screening guidelines and urges the USPSTF to uphold the draft recommendation.

The American Diabetes Association is leading the fight to Stop Diabetes and its deadly consequences and fighting for those affected by diabetes. The Association funds research to prevent, cure and manage diabetes; delivers services to hundreds of communities; provides objective and credible information; and gives voice to those denied their rights because of diabetes. Founded in 1940, our mission is to prevent and cure diabetes and to improve the lives of all people affected by diabetes. For more information please call the American Diabetes Association at 1-800-DIABETES (1-800-342-2383) or visit www.diabetes.org.

CONTACT INFORMATION

• Contact:

Susan McCarthy

(703) 549-1500 ext. 1637

smccarthy@diabetes.org

Diabetes: type 2

Type 2 diabetes is the most common variety of diabetes. It is a disorder of carbohydrate metabolism in which the body effectively becomes resistant to the hormone insulin.

Type 2 diabetes is a disease in which the person initially develops insulin resistance resulting in high glucose levels in the blood. This is also called impaired glucose tolerance. Initially individuals experience high blood glucose levels after eating and eventually this may lead to constant hyperglycaemia.

• The metabolic derangement is called insulin resistance because patients require higher levels of insulin to move glucose in the blood to the inside of cells such as muscles, the heart, the liver and the brain where it is needed for functioning of the cells.

• Insulin resistance is the main metabolic event leading to type 2 diabetes and the reduction of it should therefore also be the major aim of affected individuals and the treating physician or advising dietician.

• It is the most common form of diabetes and its incidence is rising in all population groups around the world.

• It is strongly associated with obesity, a sedentary lifestyle, and abnormal lipid levels.

• Those with a family history of the disease are more at risk than the general population.

• Symptoms are more those of a high glucose level than those of starving cells and include excessive thirst and urination, whereas weight loss is a late feature suggesting serious deficiency of insulin.

• It is treated, and can often be prevented, with a combination of lifestyle changes, diet and drugs – increased levels of exercise and a decrease in the intake of calories and especially lipids being the most important steps to improved health and longevity.

• There are many potential complications of type 2 diabetes if it is not correctly controlled (such as heart disease), since most organ systems in the body are affected by the disease.

Alternative names

Non-insulin dependent diabetes (NIDDM) or adult onset diabetes – now rarely used.

What is type 2 diabetes?

Type 2 diabetes is the most common variety of diabetes. It is a disorder of carbohydrate metabolism in which the body effectively becomes resistant to the hormone insulin. Initially, the person with this disorder has impaired tolerance to glucose. This develops into high blood glucose levels after eating and eventually high blood glucose levels even when fasting.

However, some people with type 2 diabetes remain relatively sensitive to insulin, while others have little or no insulin sensitivity. This difference affects treatment of the disease. In general, those type 2 diabetics who are not obese retain some sensitivity to insulin.

What causes type 2 diabetes?

The causes of type 2 diabetes are complex. Insulin resistance is the main metabolic abnormality leading to the development of type 2 diabetes. The most recent research suggests that type 2 diabetes can be seen as a consequence of a series of physiological disruptions, each of which makes the person vulnerable to subsequent disruption of normal glucose metabolism.

Insulin resistance is common and is usually caused by obesity. There are effectively three stages in the development of type 2 diabetes:

• Insulin resistance, for which the body compensates by increasing the secretion of insulin to allow the liver and muscles to continue to function normally.

• Eventually the pancreas is unable to produce enough insulin to compensate for the insulin resistance. This leads to a sequence of impaired glucose tolerance, high blood glucose after eating (postprandial hyperglycaemia) and finally, high blood glucose levels even when fasting (fasting hyperglycaemia) and worsening postprandially. These high glucose levels are toxic not only to the large and small blood vessels but also to the cells producing insulin, the so-called beta-cells of the pancreas.

• This damage to the beta-cells leads to a decline in their function and eventually less insulin is produced as the disease progresses.

The raised fasting and postprandial glucose levels result in complications which affect the small and large blood vessels of the body, and this contributes to renal failure, eye complications and more importantly, accelerated atherosclerosis leading to strokes and heart disease. The artherosclerotic complications are responsible for 80% of the deaths in diabetics.

Who gets type 2 diabetes and who is at risk?

The percentage of the population with diabetes is highly variable among geographical regions and populations, so estimates are often inaccurate. A recent figure is 110 million people around the world with diabetes, most of whom (75 – 80%) have type 2 diabetes. There are particular populations with a very high incidence of type 2 diabetes. For example, 40% of Pima Indians in North America have type 2 diabetes. The South African Indian population also have amongst the highest incidence in the world.

The risk factors for type 2 diabetes are:

• Obesity

• Lack of exercise

• An abnormal lipid profile

• A family history of the disease

Who would be the typical person at risk for type 2 diabetes?

The typical person would be:

• an overweight adult

• older than 40 years

• an individual who does not exercise regularly

• the pattern of obesity is usually a predominance of central fat deposition, which means that the belly or waistline are disproportionally enlarged compared to the limbs

• a person with a family history of obesity. (Many type 2 diabetics have a family history of obesity and possibly even “late onset diabetes”)

What are the symptoms and signs of type 2 diabetes?

The main features and symptoms of type 2 diabetes are:

• Overweight

• Excessive thirst

• Excessive urination

• Loss of weight

However, these are late signs that occur when the person is already seriously hyperglycaemic.

Early in the course of the disease there are more subtle signs such as fatigue, greater susceptibility to illness and poor wound healing.

A very common early sign in men is erectile dysfunction, as is candida infection of the tip of the penis (candida balanitis). In women, persistent vaginal candida may be an early sign of type 2 diabetes, particularly in older women.

How is type 2 diabetes diagnosed?

Diabetes is diagnosed quite simply by measuring the levels of glucose in the blood. The normal levels are between 3,3 mmol/l and 5,9 mmol/l.

The World Health Organisation defines diabetes as being when one or more of the following are present:

• Fasting blood glucose (blood glucose measured before breakfast) is over 6.7 mmol/l on two separate occasions

• Random blood glucose (blood glucose measured at any time) is over 10 mmol/l

• 2 hour blood glucose during glucose tolerance test is over 10 mmol/l

• Corresponding values for plasma glucose are 7.8 mml/l and 11.1 mmol/l

• In some laboratories the glucose level is measured in plasma and not in blood and the concentration of glucose measured in plasma is 10% greater than that in whole blood

What is a glucose tolerance test?

• After an overnight fast, 75 mg of glucose is taken in 250-300 ml of water

• Blood samples are taken in the fasting state and two hours after the glucose has been taken

• It is used to diagnose glucose intolerance

When is glucose tolerance impaired?

• It is present when the fasting blood glucose is below 6.7 mmol/l and the 2 hour blood glucose value is between 6.7 and 10 mmol/l

• Corresponding values for plasma glucose are 7.8 mml/l and 11.1 mmol/l.

Can type 2 diabetes be prevented?

Type 2 diabetes is a disease of lifestyle in most cases, and can thus often be prevented. There is good evidence to show that controlling weight, getting plenty of exercise and eating a diet low in fats and high in complex carbohydrates – fruit and vegetables – lowers the risk of type 2 diabetes in most people.

Many medical authorities recommend that anyone who has a family history of type 2 diabetes should have their blood glucose checked regularly, particularly once they are older than 40. Some doctors recommend that anyone over the age of 40, regardless of family history, should have regular blood glucose checks.

If impaired glucose tolerance is detected, then early prevention such as weight loss, exercise and a change of diet may well prevent or at least delay the onset of type 2 diabetes.

How is type 2 diabetes treated?

The mainstay of treatment in type 2 diabetes is lifestyle change – weight loss, a structured exercise programme and a diet low in fat and with plenty of fruit and vegetables. Any diabetic should consult a dietician early in the disease to work out the correct diet for their lifestyle. It is of utmost importance that individuals attempt to stop smoking, and if it is not possible to stop, reduce the habit to an absolute minimum.

However, recent research has shown that in most people, even the correct diet along with exercise will eventually not be sufficient to control their blood glucose and that drugs have to be used.

The broad range of metabolic defects present often requires treatment with combinations of more than one drug. Furthermore, with time, as the ability of the pancreas to produce sufficient insulin wanes, increasing doses of medications and insulin injections may be required to control the blood sugar. The blood sugar levels should be reviewed by the patients doctor on a regular basis.

The medications used for treating type 2 diabetes have the following aims:

1. To regulate blood sugar levels.

2. To prevent or treat complications due to type 2 diabetes.

1. Medication to lower blood sugar levels

Medications available to lower blood sugar can be divided into two groups, namely insulin, which can only be injected or delivered by glucose pump, and all other anti-diabetic medication except insulin.

So, if you have been diagnosed with type 2 diabetes, how will your doctor start your medication?

This is the step-by-step action plan for type 2 diabetics, based on 2009 guidelines, courtesy of the National Diabetes Advisory Board of SA.

Step1: Lifestyle modification + metformin (for obese people, 1-3 doses per day), or

Lifestyle modification + sulphonylureas (for non-obese people).

If good blood glucose control is not achieved within 3 months (HbA1 > 7%), your doctor will proceed to step 2A.

Step 2A: Add a second drug from a different class. The second drug may be one of the following: Metformin or sulphonylurea or basal insulin or pioglitazone (a thiazolidinedione).

NOTE: Although not incorporated into the 2009 guidelines, a much more aggressive approach to blood sugar control is now becoming the norm. Newer medications such as DPP-4 inhibitors and incretin mimetics (see below) are more and more used as the second drug, while many experts advocate the use of insulin sooner rather than later.

Step 2B: If blood sugar levels are still not controlled within another 3 months, add a third drug from a different class.

Step 3. If blood sugar levels are still not controlled within another 3 months, your doctor will either start biphasic insulin or refer you to a specialist for intensive insulin therapy.

1.1 Non-insulin medication options

Most of these medications are available in tablet format (known as oral hypoglycaemic agents (OHAs), which literally means glucose-lowering medication taken by mouth). However, one of the newer generation anti-diabetic medications is only available as an injection.

There is an increasing array of tablets that are now effective in lowering glucose levels in type 2 diabetics. They differ in their modes of action, side-effects, cost and dosing schedule. The choice of the most suitable one needs to be made on an individual basis after a full medical assessment.

The main groups of oral blood glucose-lowering tablets are:

A. Biguanides (e.g. metformin)

B. 2nd generation sulphonylureas

C. Thiazolidinediones (relatively new)

D. Alpha-glucosidase inhibitors (a recently developed class)

E. Meglitinides (also new)

F. Incretin mimetics (GLP-1 agonists, also new)

G. DPP-4-inhibitors (the latest anti-diabetic medication)

H.. Amylin agonists

Let’s take a more detailed look at these medications

A. Biguanides, e.g. metformin

(Examples include Accord Metformin, Arrow Metformin, Austell Metformin, Mylan Metformin, Sandoz Metformin, Bigsens, Forminal, Glucophage, Glucovance, Metforel, Metored, Metphage)

Metformin is currently the most well-known and most used anti-diabetic tablet. It is one of the older anti-diabetic drugs, but still the first port of call.

How it works: Biguanides help lower blood glucose by making sure the liver does not produce too much glucose. Biguanides also lower the amount of insulin in the body. While biguanides act chiefly by decreasing the liver’s glucose-manufacturing and increasing the transportation of glucose from the bloodstream into the cells of your body, metformin functions only in the presence of some existing insulin. This medication will thus be of no use if your pancreas has ceased to produce insulin (as in the case of type 1 diabetes or advanced type 2 diabetes).

When will it be prescribed? Metformin is most often the first glucose-lowering medication prescribed to an overweight or obese type 2 diabetic, and usually forms the first step in the treatment plan along with lifestyle modification. Most often the doctor will prescribe a low dosage (some days of the week) and will slowly increase the dosage (and increase it to be taken seven days a week) over the first two months to lower the risk of side-effects. Individuals may lose a few kilograms when starting metformin. This weight loss can indeed help control blood glucose. Metformin can also improve blood fat and cholesterol levels, which are often not normal if the individual has type 2 diabetes. This medication does not generally cause sudden and huge drops in blood glucose levels (hypoglycemia), unless it is combined with other medications that increase insulin. It should not be prescribed to a diabetic with kidney problems.

What about side-effects? Metformin may cause nausea and vomiting if more than about two to four alcoholic drinks a week are consumed while on the medication. Other side-effects include nausea, diarrhoea, headache, weakness, a metallic taste in the mouth and keto-acidosis. (This is a condition caused by high levels of ketones in the body, due to lack of or ineffective insulin levels after a meal, which results in high blood glucose levels and fat being used as energy source. High levels of ketones are poisonous, and may damage the kidneys). Keto-acidosis is not common in people with type 2 diabetes, and warrants the urgent attention of a doctor.

B. 2nd generation sulphonylureas

Examples of second generation sulfonylurea medications include glyburide (Diabeta, Glycron, Glynase, Micronase), glipizide (Minidiab), gliclazide (Arrow Glicazide, Austell Glicazide, Diaglucide, Diamicron, Glycron, Glygard, Mylan Gliclazide, Sandoz Gliclazide), glibenclamide (Bio-glibenclamide, Daonil, Diacare, Glycomin, Sandoz Glibenclamide) and the newest agent, glimepiride (Amaryl, Aspen Glimepiride, Euglim, Glamaryl, Mylan Glimepride, Sandoz Glimeperide, Sulphonur.) Second-generation sulfonylureas are one of the two (the other is metformin) most commonly prescribed medications for treating type 2 diabetes. As a group, they are at least 100 times more potent with fewer side-effects than first generation sulponylureas.

First generation sulphonylureas include tolazamide, tolbutamide and acetohexamide which are no longer available in SA, but chlorpropamide (Hypomide) – also regarded as out-of-date medication because it may easily cause hypoglycaemia – is still available in our country. If you are still using Hypomide, ask your doctor about the newer medications.

How does it work? Sulfonylureas help the pancreas to produce and secrete more insulin, which then lowers blood glucose. They also help the body use the insulin it makes to better lower blood glucose. For these medications to work, the pancreas has to make some insulin.

When will it be prescribed? It is most often prescribed in the second step of treatment, or as the first drug in non-obese type 2 diabetics. Glyburide should not be prescribed for the elderly and patients with compromised renal function, since it may cause hypoglycaemia. Glipizide or glimepiride is safe in the elderly and in those with kidney problems. Sulphonylureas may cause weight gain and should rather not be prescribed for overweight patients.

What about side-effects? Possible side effects include hypoglycemia (low blood sugar levels), an upset stomach, a skin rash or itching, and weight gain.

C. Thiazolidinediones

Examples of thiazolidinediones include pioglitazone (Actos, Cipla Pioglitazone) and rosiglitazone (Avandia), but Avandia must be used with care due to possible serious side-effects which may cause damage to the heart.

How do they work? This new class of drug helps overcome insulin resistance and may have some other beneficial effects on the underlying metabolic defects. Thiazolidinediones help make the cells more sensitive to insulin. The insulin can then move glucose more efficiently from the blood into the cells for energy.

When will they be prescribed? As the second or third drug with metformin or sulphonylurea, or both.

What are the possible side-effects? Side-effects of these medications may include weight gain, anaemia (less red blood cells which causes the blood to carry less oxygen than normal), and swelling (fluid retention). More serious side effects include liver damage, chronic heart failure and fractures in women. A doctor will monitor the individual's liver function while taking thiazolidinediones. Although rosiglitazone is restricted due to an increased risk of heart damage, few people using this drug actually die of heart disease – possibly because blood glucose levels are better controlled.

D.Alpha-glucosidase inhibitors

The alpha-glucosidase inhibitors are a new class of anti-diabetic medication and include acarbose (Glucobay) and miglitol (Glyset).

How do they work? Alpha-glucosidase inhibitors act by delaying the absorption of carbohydrates from the intestine, resulting in a slower and lower rise in blood glucose throughout the day, especially right after meals. Before carbohydrates are absorbed from food, they must be broken down into smaller sugar particles like glucose by enzymes in the small intestine. One of the enzymes involved in breaking down carbohydrates is called alpha glucosidase. By inhibiting this enzyme, carbohydrates are not broken down as efficiently and glucose absorption is delayed. This medication has a small but significant effect in lowering blood glucose and does not cause hypoglycaemia when used alone.

When will they be prescribed? Most often with sulphonylurea.

What are the possible side-effects? They may cause severe diarrhoea and nausea.

E. Meglitinides (D-phenylalanine derivatives)

Examples include repaglinide (Novonorm) and nateglinide (Starlix). These are newer and more expensive treatments that are used in combination with metformin. If you are the member of a medical scheme, their price may impact on your out-of-pocket payments.

How do they work? Meglitinides act the same way as sulphonylureas and should not be prescribed with this medication. They help the pancreas to produce and secrete more insulin right after meals, thus quickly and for a short time. This helps lower blood glucose after eating a meal.

When will they be prescribed: A doctor might prescribe a meglitinide medication by itself or with metformin.

What are the possible side-effects? These medications may cause blood glucose levels to drop too low. Doctors will check liver function while taking these medications. Weight gain might also be an unwanted side-effect.

F.Incretin mimetics (GLP-1 agonists)

Examples include exenatide (Byetta) and liraglutide (Victoza).

How does it work? Byetta is an injectable drug that reduces the level of sugar (glucose) in the blood. Users inject themselves with regulated doses using a pen-like device twice daily before meals. Incretin mimetics mimic the effects of incretins (such as human-glucagon-like peptide-1 also called GLP-1), which are hormones produced by and released into the blood by the intestine every time you eat. GLP-1 increases the secretion of insulin from the pancreas, slows absorption of glucose from the gut and reduces the action of glucagon, a hormone that increases glucose production by the liver. All three of these actions reduce levels of glucose in the blood. In addition, GLP-1 reduces appetite. Exenatide is a synthetic (man-made) hormone that resembles and acts like GLP-1. In studies, exenatide-treated patients achieved lower blood glucose levels and experienced weight loss.

When will they be prescribed? Possibly as the second or third medication to be added, but not with insulin.

Possible side effects: A common side effect is nausea, which typically diminishes with time. The drug is perhaps best known for the weight loss it causes in users.

G.DPP-4 inhibitors

Examples include vildagliptin (Galvus), sitagliptin (Januvia) and saxagliptin (Onglyza). This is the latest class of anti-diabetic medication. They are more expensive than the older classes of antidiabetics.

How do they work? DPP-4 (dipeptidyl-peptidase-4-inhibitor) enhances the body's own ability to control blood sugar levels and can thus increase insulin when blood sugar is high, especially after eating, and reduce the amount of sugar made by the liver after eating. It heightens the GLP-1 effect (see explanation about incretin mimetics above).

When will they be prescribed? Most often as the first drug, or the second drug to be added.

Possible side-effects? Side effects of DPP-4 inhibitors include a runny or stuffy nose, sore throat, headache, nausea, stomach pain, or diarrhoea.

H. Amylin agonists

Examples include pramlintide (Symlin) as an injection.

How does it work? This medication decreases the effect of amylin, a hormone thought to be associated with insulin resistance. It enhance the effect of injected mealtime insulin. It’s effect is similar to rapid acting insulin injections.

When will they be prescribed? For patients with type 1 or type 2 diabetes, already using insulin.

Possible side-effects: This medication may increase the risk of extremely low blood glucose levels within the 1st 3 hours after use, because it is used with mealtime insulin. It causes weight loss.

Combination medication

There is some medication available where two of the above classes of medication are combined in a single tablet. One of the classes is usually metformin or sulphonylurea. Combination medication is easier to use, and often shows better diabetes control.

1.2 Insulin

Insulin injections may be necessary in controlling the sugar levels and are usually started when non-insulin medications become ineffective. Insulin treatment should not be delayed once the sugar levels are not adequately controlled on tablets.

Although insulin injections are usually associated with type 1 diabetes, chances are that a person with type 2 diabetes will eventually need insulin therapy. Insulin injections are usually started when your pancreas does not produce any more insulin at all. Insulin is often combined with metformin (or some of the newer non-insulin diabetic medication) as this increases the patient’s sensitivity to insulin and often reduces the dose of insulin that is needed.

For years, doctors only prescribed insulin therapy for diabetics when all else has failed. However, things have changed. Now, some experts advocate earlier introduction of insulin in the treatment of type 2 diabetes because it actually protects the remaining insulin-producing cells in the pancreas.

There are different types of insulin; in fact insulin can be categorised according to its origin (human, animal or synthetic) and its function (rapid-acting, intermediate-acting or slow-acting ect). Your doctor will determine which one will best suit your needs.

Types of insulin according to origin

Insulin was previously harvested from the animal pancreas (mainly bovine and porcine), but this form of insulin included impurities, which lead to allergies in some people. Current insulin preparations are manufactured using recombinant DNA technology and can be broadly classified into two categories:

• Human insulin, which is identical to human insulin in structure.

• Human insulin analogues, in which one or two amino acids of human insulin are changed or substituted in a laboratory.

Human insulin (Actrapid, Humulin N, Insuman, Humulin 30/70, Actraphane and Insuman 30/70) injected beneath the skin (with a fine and short needle) is not the best option. This is due to variable absorption, which makes proper and effective glucose control quite difficult. This led to the development of the human insulin analogues, which have a more consistent absorption and distribution profile. Examples are Apidra, Humalog, Novorapid, Lantus, Levemir, Novomix 30 and Humalog 25. Insulin aspart (Novolog) and insulin glargine (Lantus) are both human insulins that have had their chemical composition slightly altered. Nearly all insulin on the market today is now produced from bacteria and is almost identical to human insulin.

Types of insulin according to duration of action

A. The quick and fast ‘bullet train” insulins (also known as the ‘before-meals’ insulins) are insulins that act quickly, peak about an hour later, but the effect soon wears off

1. Rapid-acting insulins act quickly (within 15 minutes), peak at 30 to 90 minutes, but their effect lasts only 3 – 5 hours.

Examples include insulin analogues such as Apidra, Biosulin R, Humalog, and Novorapid.

Their use: The rapid-acting insulins are used 5 to 10 minutes prior to or at mealtimes (pre-prandial, with pre= before and prandial = eat) and typically cover the post-meal blood-glucose surges, provided that the dose is correct. The dose is adjusted in accordance to blood-glucose levels.

2. Regular short-acting insulins also act fairly quickly (within 30 – 60 minutes), peak after 1 to 2 hours, and a duration of action of more or less 3 to 5 hours, or a bit longer.

Examples of regular human insulins are Insuman, Actrapid and Humulin R.

Their use: They can be used as before-mealtime insulin instead of rapid-acting insulins.The regular insulin is typically taken 30 minutes prior to a meal. The dose depends on the blood-glucose levels.

B. The '12 hour trucker’ insulins. Intermediate-acting insulins (also known as biphasic insulin).

They act after approximately 2 - 3 hours, they peak at more or less 4 – 12 hours, and they have a duration of action of about 20 hours.

Examples: (Humulin N , Actraphane, Protophane HM) are regular insulins that, when attached to zinc or NPH (Neutral Protamine Hagedorn), have an altered onset, peak and duration. Lente insulin is also insulin with an intermediate duration of action.

Their use: These insulins are usually taken every 12 hours, always beneath the skin.

C. The slow but long-haul 'oil tanker’ insulins are long-acting insulin.

Their action starts slowly but lasts about 24 hours without a peak level.

Examples: long-acting insulin analogues are Lantus and Levemir. Ultra-lente insulin is long-acting insulin with an onset of action four to eight hours after injection, a peak effect 10-30 hours after injection, and duration of action of more than 36 hours.

Their use: This form of insulin is taken once or twice a day, depending on the degree of control that is needed.

Then there are the fixed-dose combinations (also called premixed insulins) of rapid or short-acting insulin and intermediate-acting insulin in fixed-dose combinations of 25%:75%, 30%:75% or 50%:50%. The first number of the ratio applies to the percentage of rapid- or short-acting insulin in the mixture.

Examples are: Novomix 30, Humalog mix 25, Humalog mix 50, Novolin 70/30, Humulin 30/70, Insuman Comb 30/70,

Their use: They are usually taken 10 - 20 minutes before a meal.

How will insulin therapy work for a person with type 2 diabetes?

Most people with type 2 diabetes will start treatment with the oral medications metformin or a sulphonylurea (the ‘gli’-drugs). However, if your blood glucose levels are not controlled within three months, a second drug will be added. This second (or third drug) may be insulin.

Also, if your are identified as a high-risk patient, you will need to start insulin therapy immediately after diagnosis.

When insulin needs to be added as second or third drug, it will probably be basal insulin (either intermediate-acting or long-acting insulin injected at the same time every day and to mimic the basic fasting glucose levels in your blood). Your doctor will start you on a low dose and increase the dose every 3 – 7 days until your fasting glucose is controlled at levels between 4 – 7 mmol/litre as in healthy people.

If this basal insulin plus the anti-diabetic tablets is not enough to control your diabetes properly, your doctor will add rapid-acting insulin, to be injected before meals to cover meal-time surges in glucose. This usually involves a further three injections during the day. So, this regimen usually involves four injections per day. It will give you some flexibility, better blood-glucose control and fewer hypoglycaemic episodes (when there's too little glucose in the bloodstream), especially if the insulin analogues are used.

Another option is to use a twice-daily premixed insulin at breakfast and supper. In some diabetics a third dose may be needed at lunchtime. Doses are best worked out by the prescribing doctor. Note that every diabetic has his or her own appropriate dose. Don't compare your dose to that of another diabetic as his or her circumstances may be very different to yours.

Insulin devices

Insulin can be administered by syringe, insulin pens and insulin pumps.

Syringes are used by most South Africans.

Insulin pens are easy to use. Their fine needles usually don't cause pain.

Insulin pumps are battery-operated pumps about the size of a cell phone that are worn by diabetics and which continuously deliver short- or rapid-acting insulin into the tissue beneath the skin on the stomach via a narrow gauge tube. This provides a continuous basal supply of insulin at the programmed dose. At meal times, the diabetic can then dial a bolus of insulin to cover the surge of glucose elevation that's caused by the ingestion of food. These devices are fairly expensive and the tubes need to be changed every third day, and the user needs to be aware of the initial risk of too high dosages of insulin in the first few months, but for many this offers more freedom and ultimately better diabetes control than daily injections.

2. Medications that help prevent or treat the complications of diabetes

It is imperative that the associated metabolic problems in type 2 diabetes are adequately treated as this has been shown to help prevent the serious cardiovascular and other complications for which the diabetic patient is at risk.

The most important conditions that require treatment are hypertension and the lipid abnormalities, both of which are commonly associated with type 2 diabetes.

Some of the commonly used medications which offer specific benifits in diabetes include:

• ACE Inhibitors: (E.g. ramipril/Tritace or Ramace, perindopril/Coversyl, lisinopril/Zestril, captopril/Capoten). These are antihypertensive medications which may offer additional protection against kidney and cardiovascular complications.

• ARB's (E.g. losartan/Cozaar, irbesartan/Approvel). These are used to treat hypertension and have also recently been shown to be of benefit in slowing the progression of the kidney complications in type 2 diabetics.

• "Statins": (E.g. atorvastatin/Lipitor, pravastatin/Prava, simvastatin/Zocor). While a low-fat and low-cholestrol diet is important in diabetics, it is often insufficient. The "statins" are a powerful group of cholesterol lowering agents that are useful in treating the abnormal lipid profile and helping to achieve the strict targets for cholestrol that need to be attained in order to lessen the risk of cardiovascular disease.

• Asprin has been shown to be of benefit in preventing cardiovascular events such as heart attacks and strokes and should be used in type 2 diabetics who are at risk or who have a history of previous cardiovascular events.

• Viagra®. Erectile dysfunction is a common problem in male diabetics and newer forms of treatment are becoming available. Viagra may be an effective, although expensive, option.

What is the outcome of type 2 diabetes?

Type 2 diabetics have a very high incidence of heart disease, and this is their main cause of death. However, this can be prevented, or at least controlled, by taking great care to control blood glucose, blood pressure and lipid levels.

There are also long-term complications of type 2 diabetes - potentially to every organ system in the body if blood glucose, blood pressure and lipid levels are not adequately controlled.

When to see your doctor

Consult your doctor if you develop symptoms of:

• Excessive thirst

• Excessive urination

• Weight loss

- particularly if you have a family history of diabetes, you must see your doctor as soon as possible.

If you are already diabetic and you develop these symptoms, then this is an indication that your blood glucose is out of control and you should see your doctor immediately.

(Reviewed by Dr Graham Ellis, updated November 2011 by Mari Hudson)

About this blog

This is a blog posted for people over fifty, who, like me, are struggling with diabetes.

In my case it’s about losing weight, eating less and eating the right thing and that’s going to be a long road….I’m only five foot eight inches and I weigh 267 pounds. I’m 42 pounds away from my ideal weight of 225.

The good news is that I lost 34 pounds since my first heart attack two years ago when I was 301 pounds.

My target is to eat 1100 calories a day spread across three meals and two snacks a day. So I’ve started to a keep track of what I eat and how many calories it is. So far, so good.

Causes, incidence, and risk factors

Diabetes is caused by a problem in the way your body makes or uses insulin. Insulin is needed to move blood sugar (glucose) into cells, where it is stored and later used for energy.

When you have type 2 diabetes, your fat, liver, and muscle cells do not respond correctly to insulin. This is called insulin resistance.

As a result, blood sugar does not get into these cells to be stored for energy.

When sugar cannot enter cells, high levels of sugar build up in the blood. This is called hyperglycemia.

Type 2 diabetes usually occurs slowly over time. Most people with the disease are overweight when they are diagnosed. Increased fat makes it harder for your body to use insulin the correct way.

Type 2 diabetes can also develop in people who are thin. This is more common in the elderly.

Family history and genes play a large role in type 2 diabetes. Low activity level, poor diet, and excess body weight around the waist increase your risk. See
also: Type 2 diabetes for a list of risk factors.

Signs and tests

Your health care provider may suspect that you have diabetes if your blood sugar level is higher than 200 mg/dL. To confirm the diagnosis, one or more of the
following tests must be done.

Diabetes blood tests:

· Fasting blood

glucose level -- diabetes is diagnosed if it is higher than 126 mg/dL two times

· Hemoglobin A1c test --

· Normal: Less than 5.7%

· Pre-diabetes: 5.7% - 6.4%

· Diabetes: 6.5% or higher

· Oral glucose tolerance test -- diabetes is diagnosed if glucose level is higher than 200 mg/dL after 2 hours

Diabetes screening is recommended for:

· Overweight children who have other risk factors
for diabetes, starting at age 10 and repeated every 2 years

· Overweight adults (BMI greater than 25) who have
other risk factors

· Adults over age 45 every 3 years

You should see your health care provider every 3 months. At these visits, you can expect your health care provider to:

· Check your blood pressure

· Check the skin and bones on your feet and legs

· Check to see if your feet are becoming numb

· Examine the back part of the eye with a special
lighted instrument called an ophthalmoscope

The following tests will help you and your doctor monitor your diabetes and prevent
problems:

· Have your blood pressure checked at least every
year (blood pressure goals should be 130/80 mm/Hg or lower).

· Have your hemoglobin A1c test (HbA1c) every 6
months if your diabetes is well controlled; otherwise every 3 months.

· Have your cholesterol and triglyceride levels
checked yearly (aim for LDL levels below 70-100 mg/dL).

· Get yearly tests to make sure your kidneys are
working well (microalbuminuria
and serum creatinine).

· Visit your eye doctor at least once a year, or
more often if you have signs of diabetic eye
disease.

· See the dentist every 6 months for a thorough
dental cleaning and exam. Make sure your dentist and hygienist know that you have diabetes.

Treatment

Self-testing means that you check your blood sugar at home yourself. Checking your blood sugar levels at home and writing down the results will tell you how well you are managing your diabetes.

A device called a glucometer can give you an exact blood sugar reading. There are different types of devices.

Usually, you prick your finger with a small needle called a lancet. This gives you a tiny drop of blood.

You place the blood on a test strip and put the strip into the device. Results are given in 30 - 45 seconds.

A health care provider or diabetes educator will help set up an at-home testing schedule for you. Your doctor will help you set your blood sugar goals.

· Most people with type 2 diabetes only need to
check their blood sugar once or twice a day.

· If your blood sugar levels are under control,
you may only need to check them a few times a week.

· You may test yourself when you wake up, before
meals, and at bedtime.

· You may need to test more often when you are
sick or under stress.

The results of the test can be used to change your meals, activity, or medications to keep your blood sugar levels in the right range. Testing can identify high and low blood sugar levels before you have serious problems.

Keep a record of your blood sugar for yourself and your health care provider. This will help if you are having trouble managing your diabetes.

LEARN THESE SKILLS

Youshould learn basic diabetes management skills. They will help prevent problemsand the need for medical care.

These skills include:·

How to test and record your blood glucose·

How to take medications, if needed·

How to recognize and treat low and high bloodsugar· How to handle sick days·

Where to buy diabetes supplies and how to storethemItmay take several months to learn the basic skills.

Always keep learning aboutdiabetes, its complications, and how to control and live with the disease.

Stayup-to-date on new research and treatments.

DIET AND WEIGHT CONTROL

Work closely with your doctor, nurse, and dietitian to learn how much fat, protein, and carbohydrates you need in your diet.

Your meal plans should fit your daily lifestyle and habits, and should try to include foods that you like.

Managing your weight and eating a well-balanced diet are important. Some people with type 2 diabetes can stop taking medications after losing weight (although they still have diabetes).

Very overweight patients whose diabetes is not well managed with diet and medicine may consider bariatric (weight loss) surgery.

REGULAR PHYSICAL ACTIVITY

Regular exercise is important for everyone. It is even more important you have diabetes.

Exercise in which your heart beats faster and you breathe faster helps lower your blood sugar level without medication.

It also burns extra calories and fat so you can manage your weight.

Exercise can help your health by improving blood flow and blood pressure.

Exercise also increases the body's energy level, lowers tension, and improves your ability to handle stress.

Ask your health care provider before starting any exercise program. People with type 2 diabetes must take special steps before, during, and after intense
physical activity or exercise.

MEDICATIONS TO TREAT DIABETES

If diet and exercise do not help keep your blood sugar at normal or near-normal levels, your doctor may prescribe medication. Since these drugs help lower your blood sugar levels in different ways, your doctor may have you take more than one drug. Some of the most common types of medication are listed below. They are taken by mouth or injection.

· Alpha-glucosidase inhibitors (such as acarbose)
· Biguanides (Metformin)

· Injectable medicines (including exenatide,
mitiglinide, pramlintide, sitagliptin,
and saxagliptin)

· Meglitinides (including repaglinide
and nateglinide)

· Sulfonylureas (like glimepiride,
glyburide, and tolazamide)

· Thiazolidinediones (such as rosiglitazone
and pioglitazone). (Rosiglitazone
may increase the risk of heart problems. Talk to your doctor.)

These drugs may be given with insulin, or insulin may be used alone. You may need insulin if you continue to have poor blood glucose control.

It must be injected under the skin using a syringe or insulin pen device.

It cannot be taken by mouth.

It is not known whether hyperglycemia medications taken by mouth are safe for use in pregnancy. Women who have type 2 diabetes and become pregnant may be switched to insulin during their pregnancy and while breast-feeding.

Expectations (prognosis)

After many years, diabetes can lead to serious problems with your eyes, kidneys,
nerves, heart, blood vessels, or other areas in your body.

If you have diabetes, your risk of a heart attack is the same as that of someone who has already had a heart attack. Both women and men with diabetes are at
risk. You may not even have the normal signs of a heart attack.

If you control your blood sugar and blood pressure, you can reduce your risk of death, stroke, heart failure, and other diabetes problems.

Some people with type 2 diabetes no longer need medicine if they lose weight and become more active. When they reach their ideal weight, their body's own
insulin and a healthy diet can control their blood sugar levels.

Complications

After
many years, diabetes can lead to serious problems:
· You could have eye problems, including trouble
seeing (especially at night), and light sensitivity. You could become blind.
· Your feet and skin can develop sores and
infections. After a long time, your foot or leg may need to be removed.
Infection can also cause pain and itching in other parts of the body.
· Diabetes may make it harder to control your
blood pressure and cholesterol. This can lead to a heart attack, storke, and
other problems. It can become harder for blood to flow to your legs and feet.
· Nerves in your
body can get damaged, causing pain, tingling, and a loss of feeling.
· Because of nerve damage, you could have problems
digesting the food you eat. You could feel weakness or have trouble going to
the bathroom. Nerve damage can make it harder for men to have an erection.
· High blood sugar and other problems can lead to kidney damage.
Your kidneys may not work as well, and they may even stop working.
Infections
of the skin, female genital tract, and urinary tract are also more common.
To
prevent problems from diabetes, visit your health care provider or diabetes
educator at least four times a year. Talk about any problems you are having.

Calling your health care provider

Call 911 right away if you have:

· Chest pain or pressure

· Fainting or unconsciousness

· Seizure

· Shortness of breath

These symptoms can quickly get worse and become emergency conditions (such as convulsions
or hypoglycemic coma).

Call your doctor if you have:

· Numbness, tingling, or pain in your feet or legs

· Problems with your eyesight

· Sores or infections on your feet

· Symptoms of high blood sugar (being very
thirsty, having blurry vision, having dry skin, feeling weak or tired, needing to urinate a lot)

· Symptoms of low blood sugar (feeling weak or tired, trembling, sweating, feeling irritable, having trouble thinking clearly, fast heartbeat, double or blurry vision, feeling uneasy)

Beat it

The American Diabetes Association Applauds Stronger Screening Guidelines for Type 2 Diabetes