By Paola Acevedo, PharmD, as told to Kendall Morgan
I'm a pharmacist by training. This means that I specialize in medications. I also separately have my certification as a diabetes care and education specialist. Helping people understand their diabetes care and how to make treatment work for them is my specialty. In general, what people can expect is a multifaceted approach to their treatment for type 2 diabetes. Treatment will most likely include several classes of medications. It also should include education on lifestyle interventions that they can put into practice.
Treating Type 2 Diabetes and Related Conditions
When you have type 2 diabetes, medications for the diabetes are going to be the mainstay of medical treatment. We need to bring the blood sugars down to protect all our organs.
We have conventional medicines such as metformin and insulin. Nowadays, we also have many new therapies, including GLP-1 agonists, which also are being used for weight loss. We have medicines that are injected under the skin and others that can be taken as pills. You should expect to take a couple of different types of diabetes medications to control your A1c, lower your blood sugars, and help prevent complications.
Because diabetes comes with so many complications and risk factors — in particular, cardiovascular disease, heart attack, and stroke as well as chronic kidney disease — you should also expect to take medicines aimed at treating those conditions or lowering your risks for them.
For example, it’s likely you’ll use statins, which lower cholesterol and have the added benefit of reducing the risk of heart attack and stroke that we see with folks who have diabetes. You may take blood pressure-lowering medicines, too, which have the added benefit that they protect the kidneys as well. You might take other preventive medications, such as low-dose aspirin.
Challenges of Type 2 Diabetes Treatment Plans
A common challenge I see that people with type 2 diabetes have is related to these long lists of medications. They may not have a basic understanding as to why all the medications are being prescribed. Patients often will tell me that their doctor has started them on a new medicine, and they don’t really know what it’s for. They might be hearing stories of other folks who have had some challenges or side effects from a medication. So there can be a lot to learn and a lot of misinformation or noise to overcome.
Another common challenge is trying to keep all the medications organized. I typically recommend keeping a list of all your medicines and taking it to every doctor's appointment. Even more importantly, for day-to-day management, have a pill organizer that will allow you to set out all your medications for the week. Use phone alarms as reminders to take your medication on schedule. One of the things I often do is to show people the tools they have available to them to manage this complexity.
How to Know Your Treatment Is Working
In order to know how you're progressing and whether you’re meeting your treatment goals, you’ll need some additional tools. One of the most important tools is a glucose meter. You may have a traditional glucose meter, which means you’ll poke your finger to check blood sugar at specific times of the day.
We now have updated technology: You can wear a sensor and even check your numbers on your phone to track your sugars throughout the day. In this way, you can understand how your therapy is working as well as how food, stress, and exercise are affecting your blood sugar over time.
To address concerns about your cardiovascular health, blood pressure is another thing that you can check at home. You may see your doctor every three months or so, but it’s important to know what happens in between those visits. While you will get your blood pressure checked at the doctor's visit, I don't recommend using that as your only information. It’s good to have your own tools at home.
Another way to get an indication as to how well your treatment is working is to monitor your weight. You may receive counseling on weight loss because we know for type 2 diabetes that losing weight can help improve outcomes. So tracking weight is another good way to understand if your therapies are working.
These indicators can help you determine if you need to adjust or add to your medications or consider a change in the dose.
Where Do Lifestyle Interventions Fit In?
I love talking about lifestyle because I think we tend to sleep on it a little bit. I break this down into two buckets, which are nutrition and physical activity. There is a lot that can be done in both areas. One of the first things I encourage my patients to do is to assess their diet. What are you eating right now? What are you drinking? Are you cooking at home? Are you having outside food? Basically be a detective and do an initial assessment of your eating habits and nutrition.
If you’re drinking sugary beverages, including sodas, juices, sweetened iced tea, or lemonades, this will keep blood sugars high. This can be one of the best places to start. Let’s increase water intake and cut back on the sugary drinks. Next, consider what you’re having at each meal and your snacks. Based on this, we can provide additional recommendations.
The No. 1 thing I recommend is increasing fiber in the diet. Many people don’t know why fiber is so important for diabetes, but fiber is one of these amazing substances that can help to lower glucose levels. It can help lower bad cholesterol. It can help to improve good cholesterol, and it can also help lower blood pressure. These are all issues that we're typically seeing in someone with type 2 diabetes. Through diet and nutrition in combination with the medications, we can help to improve blood sugar and reduce these other risk factors.
Dietary Recommendations
We can increase fiber in the diet by incorporating non-starchy vegetables and whole grains. Non-starchy vegetables include leafy greens, broccoli, tomatoes, cucumbers, zucchini, mushrooms, peppers, and asparagus. Oatmeal is a good example of a whole grain. It could be steel cut, rolled, or instant. Stay away from instant oatmeal that is preflavored and heavily sweetened. Other options include whole-grain breads, pastas, or crackers. Replace white rice with brown, black, or wild rice. We also have quinoa, barley, and farro.
You can see that the list of non-starchy vegetables and whole grains is quite long, which gives you many options and flexibility to choose what you like. Avoid refined grains in many breads, pastries, or cakes. These have the fiber and nutrients removed and will only give you a glucose spike with no nutritional benefits.
I want folks to understand how doable this is. One of the things I coach is to use the plate method. Envision that your lunch or dinner plate should be half full of non-starchy vegetables. On the other side, cut the plate in half again into two quarters for your whole grains and lean proteins. This is a simplistic way of approaching meals that tends to work for a lot of people. You don’t have to do a lot of counting. You can visualize what a healthy meal should look like to create that balanced plate.
Move More — for Diabetes and Your Heart
When it comes to exercise, everybody is a little different. You may have different abilities and limitations. If needed, ask your care team for advice and alternatives. But in general, we're encouraging folks to get at least 150 minutes of exercise each week. It may sound like a lot at first, but it can be split up into manageable increments and done in many ways.
We're recommending a mixture of different types of exercise that can be moderate or more vigorous. We’re also recommending strength exercise, especially to address the cardiovascular piece. There is some good data showing strength exercises can reduce complications from cardiovascular disease.
Strength exercises can look like weights. It can look like yoga or Pilates. You might go to the gym and use the machines or use resistance bands at home. There are lots of ways that folks can access strength exercises. For moderate or vigorous aerobic exercises, you might imagine yourself running on a treadmill at the gym. Of course that’s an option, but it doesn't have to be that at all. Moderate-intensity exercise could be a brisk walk. It could be dancing. It could be housework or gardening.
This combination of moderate or vigorous exercise plus the strength training helps with a lot of different things. It's going to lower your glucose levels. It's going to lower your blood pressure. It's going to strengthen your heart and lungs and improve overall endurance. Those things together can help reduce the risk of those cardiovascular complications.
I always tell folks that exercise is free medicine. Especially for my patients who have those continuous glucose readings on their phone, they can visually see their numbers going down when they're exercising. Exercise works to lower your blood sugars, and you can see it happening in real time.
Keys to Feeling Better
As your treatment begins to work for you, the positive feedback will come from feeling better. You might have more energy or feel less sluggish. I know my folks with diabetes, especially at the beginning, when the numbers are higher than they need to be, they're sluggish, they're fatigued, they're tired. They might have brain fog. It's coming from the elevated sugars.
Once these positive changes start to happen, they will notice that they're just feeling better. The feedback that treatment is working also comes from those tools I mentioned. If you have a blood pressure monitor at home, you're going to notice improvements in your readings. If you have a glucose meter or sensor, you're going to notice that your numbers are getting better with your treatment and the changes you are making.
I encourage people to make small changes. Focus on one thing at a time that you think you can do, and don’t forget stress management. Stress can worsen the glucose levels. It can cause glucose spikes, and it can cause blood pressure elevations, which are not good for your heart or your kidneys. To ease stress, practice good self-care and activities you find relaxing, whether it’s a puzzle, a walk out in nature, or deep breathing.
Remember that you don't have to do this alone. There are so many more people like me, certified diabetes care and education specialists, throughout the country. We're embedded in primary care clinics. We're embedded in the hospitals. We're in private practice and telehealth. Most health insurance plans cover a certain amount of diabetes education with a certified educator, and I encourage folks to take advantage of that resource.
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SOURCE:
Paola Acevedo, PharmD, CDCES, primary care clinical pharmacist and spokesperson, Association of Diabetes Care and Education Specialists, Washington, D.C.
