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16 January 2023

Managing Type 2 Diabetes – Diet, Exercise & Medication

Living With Diabetes

Dr Katie BlogWritten by Dr Katie Stephens, GP

Dr Katie graduated from the University of Manchester in 2007 (MBChB) and completed her GP training in the West Midlands in 2012 (MRCGP). 

 

Management

With T2DM being linked directly to carrying extra body fat, it is no surprise then that the first step to managing it is lifestyle changes that address this. The national organisation DESMOND (Diabetes Education for Self-Management for Ongoing and Newly Diagnosed) has some great resources and educational programmes, and is available in many places in the country for GPs to refer patients into.

Diet

Ideally someone newly diagnosed with Diabetes should have an individualised plan made with a healthcare professional who has access to their medical records. Generally, though, the following principles apply for most people:

  • Choose complex carbohydrates over simple: think high fibre, wholegrain bread instead of white; fruit; vegetables; low-fat dairy products; oily fish; pulses. These low Glycaemic Index (GI) foods tend to release sugar more slowly into the bloodstream rather than the sudden spikes you can get with simple, high GI carbs.
  • Avoid high sugar drinks and foods.
  • Minimise foods high in salt and trans-fats (bad fats e.g., anything fried).
  • Have regular meal patterns (for people treated with medication that can cause a hypo, this can reduce the chance of that happening).
  • Avoid excess energy intake (taking in more calories than you spend). Having a low-calorie diet (provided it is safe for you, of course!) can aid weight loss and improve outcomes for people with diabetes.
  • Avoid processed food marketed specifically for people with diabetes.

For more information, Diabetes UK has a great guide on a healthy, balanced diet for diabetes here, and a guide to understanding the Glycaemic Index here.

Exercise

First the disclaimer: exercise lowers blood sugar levels. Because of this, anyone taking medication that can cause blood sugar levels to drop should be aware of any adjustments needed to their medication or dietary intake when exercising, in order to avoid triggering a hypoglycaemic attack.

Then, the good news: exercise (especially when combined with a healthy diet) can lead to weight loss which can not only prevent people from developing T2DM as well as improve outcomes for someone who has been diagnosed, but can even go so far as to completely reverse Type 2 DM.

It makes sense – we know that it’s the extra fat we carry that damages our insulin sensitivity and insulin levels. So it follows on that losing that excess fat takes away the damage and can restore our body’s normal functioning. Unfortunately, not many people are aware that Diabetes doesn’t need to be a condition that you only do your best to live with, but is actually possible to cure. And of course, many people’s relationship to food and exercise can be a complex one with multiple factors at play and weight loss sometimes feeling like an unattainable goal.

Saying all of that, if you’re someone who has been newly diagnosed, hopefully this knowledge will motivate you to get organised with a healthcare professional-approved diet and exercise plan that may not only improve your outcome but potentially even take you into remission.

Alcohol

Alcohol affects how your body manages blood sugar levels and can make getting a hypo more likely. This is especially true if you take sugar-lowering medication like insulin or some of the oral anti-diabetic tablets. (If you flick back to the section on how our blood sugar is normally controlled, the process that alcohol interferes with is glycogenolysis – when the liver released glucose from it’s stores.)

For this reason, and also because having a hypo can sometimes look a bit like being drunk, NICE recommends wearing some sort of bracelet or carrying a card that identifies you as having Diabetes. Of course, eating a snack before and after having a drink can also help reduce the risk of getting a hypo.

It’s also important to remember that alcohol does still have calories and carbs that can interfere with weight loss plans and blood sugar control.

So, while Diabetes doesn’t need to stop you from enjoying a drink, it’s important to be wise about what this looks like for you, and what you can do to reduce the risk of harm from alcohol. Diabetes UK has a great resource that looks at this topic in more detail here.

Smoking

You may be surprised to learn that smoking actually increases blood sugar levels, by making blood cells less responsive to insulin. It also increases the risk of developing excess abdominal fat, even for people who aren’t overweight, which (as we all know now from reading this guide!) damages our body’s levels of insulin and sensitivity to it. So, not only can smoking lead to Type 2 DM, it can make existing Diabetes worse.

The other important thing to know about smoking and Diabetes is that both of these are independent risk factors for serious medical conditions like strokes and heart attacks. Smoking also makes it more likely that some of the other complications from Diabetes will happen, such as kidney failure, visual loss and nerve damage. If you are even just contemplating one day quitting smoking, please visit the NHS’s Smoke Free website for further information and support.

Recreational Drug Use

The main thing to be aware of here is that using recreational drugs when you have Diabetes may affect your ability to keep your blood sugar levels in a safe range. For instance, if you are so sedated as a direct result of the drugs, or indirectly through them affecting your mental health, that you don’t eat or take medication when you should. Or if you become so over-active that you consume more energy than normal, causing your blood sugar levels to drop.

Diabetes UK, while advising against recreational drug use, recommends that you ensure that you are with a friend who knows both about your Diabetes and how to treat a Diabetic Emergency, should you decide to use them.

Read: Lifestyle changes to manage diabetes

Medication

The number of different types of anti-Diabetic medication on offer for T2DM has increased significantly in the last few years. It can get a little confusing trying to remember which type does what, so hopefully this will be a handy guide. Rather than go through every single option (there are numerous!), I’ve highlighted some of the main ones. If you’d like a more exhaustive reference, this one should do the job. An important note here too – if you need medication to treat your Diabetes, you should be entitled to free NHS prescriptions. Read more about how to set this up here.

Metformin (e.g., Glucophage)

If your GP advises that you start Metformin, I’d probably take them up on the offer. Besides being a relatively safe option (Metformin cannot cause hypo’s, unlike many other medication options), there is strong evidence that Metformin can improve your long-term prognosis even over and above the impact it has from lowering your blood sugars.

In fact, one meta-analysis showed that people taking Metformin for Diabetes lived longer than the general population (and longer than people taking other medications for Diabetes), with lower cancer rates than non-Diabetics and lower rates of cardiovascular disease compared to Diabetic patients taking other forms of medication.

Metformin works by attenuating the effects of what insulin is present in the body, reducing the formation of new glucose in the liver, and getting glucose out of the bloodstream and into cells where it can be used up.

The most common side effect of metformin is an upset tummy. This may settle with time but, if not, sometimes switching to a modified-release formation (where the medication levels in the blood stream are a bit more slow and steady) can help.

Sulfonylureas (e.g., Gliclazide, Glimepiride).

These tend to be second line and are sometimes added in to be used with Metformin, or potentially on their own. They work by stimulating the pancreas to release more insulin. Because of this, they can cause a hypoglycaemic attack. They can also cause weight gain.

DDP-4 Inhibitors (e.g., Alogliptin, Sitagliptin)

These increase insulin secretion and reduce secretion of insulin’s ‘opposite’ hormone, glucagon. They don’t seem to cause either hypo’s or weight gain as often as sulfonylureas.

SGLT2 Inhibitors (e.g., Canagliflozin, Dapagliflozin)

Makes the kidneys secrete more glucose into the urine, meaning there is less in the bloodstream. This is a particular group of interest as it may help with weight loss and potentially improve cardiovascular health, but is not without risks, including a serious condition known as Diabetic Ketoacidosis.

Insulin

Starting insulin is usually reserved for those patients who have not been successful using a combination of two or even three different oral anti-Diabetic tablets. Insulin is always injected and cannot be taken in tablet form.

There are many different types of insulin, some short-acting, others longer-acting, and some a combination of the two. Taking too much insulin can lead to a hypo and there is extra education offered to someone, including how to adjust a dose during intercurrent illnesses, prior to starting.

If someone is on insulin, they can usually keep taking Metformin, but may have to stop any other anti-Diabetic tablet.

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