Managing Type 2 Diabetes


The aims of diabetes management are threefold:

  • To achieve good blood glucose control
  • To minimise the risk of developing long-term complications
  • To enable you to lead a normal well-adjusted life

If you have Type 2 diabetes then the daily activities that make up your 'diabetes management' will largely depend on your own individual circumstances.  You may need to consider some lifestyle changes; how you fit these into your daily life will have a large bearing on the overall success of your diabetes treatment. You might find that it is a bit of a juggling act, getting everything just right. Don't worry if it doesn't all come together immediately; there are a lot of things to learn about before you can apply the principles of diabetes management to your own life.

This section deals with the principles of managing Type 2 diabetes and looks at the effects of diet, exercise, tablets, insulin and illness on blood glucose and fat (lipid) levels. For more information on the practicalities of achieving good blood glucose control you should also see the section "Blod Glucose Control". And since much of Type 2 management is based on living a healthy lifestyle, you should also take a look at the "Healthy Eating" and "Healthy Living" sections.





What's covered on this page


The basic principles of managing Type 2 diabetes

"Diet and Exercise"

Oral Medication - Tablets

Insulin

Sick Days

Controlling Lipid Levels

Your lipid profile
LDL-cholesterol and atherosclerosis
Managing dyslipidaemia
Lipid-lowering drugs
Treatment goals




The basic principles of managing Type 2 diabetes

Your ultimate aim is to keep blood glucose levels close to the normal range in order to feel good from day to day and to give you the best possible odds in the fight against long-term complications.

Most people with Type 2 diabetes still produce insulin. However, the insulin is often not very effective at controlling blood glucose levels and the body is unable to produce enough insulin at the right times.

The reduced activity of insulin is known as insulin resistance. Insulin resistance is often related to being overweight and inactive, which leads us to the mainstay of managing Type 2 diabetes - 'diet and exercise'.

Overweight; is diabetes my fault?

Although being overweight and inactive may contribute towards developing diabetes, this does not, by itself, cause it. Many people who are overweight have insulin resistance but do not develop diabetes. See "Causes of Type 2 Diabetes" for more information.



Many people successfully manage their diabetes by paying careful attention to their diet and increasing their level of activity. However this is not always sufficient to keep blood glucose levels tightly controlled - sometimes tablets and/or insulin injections are needed as well.

Alongside watching your diet, exercising regularly and possibly taking medication you will also need to understand what makes the blood glucose rise and fall, so that you can learn how to minimise the swings in your own blood glucose levels.

Food, stress and illness all raise the blood glucose level. Diabetes tablets (known as oral hypoglycaemics), insulin and exercise lower the blood glucose level. Normally your pancreas would produce just the right amount of insulin at just the right time to cope with the fluctuations in blood glucose level that all of these factors cause. However, when you have diabetes this fine control over insulin production is lost. Good diabetes management involves continually juggling these factors and assessing what's going on by regular finger-prick blood glucose testing. In order to keep on top of your diabetes, you may sometimes need to try to second-guess what's going to happen.

There is no 'special diet' as such. People with diabetes are usually advised to eat small meals at regular intervals throughout the day. Your diet should be healthy and nutritious. You will need to consider how much you eat and when you eat it. You will also need to look at the types of foods that you eat and assess the effects that they will have on your blood glucose level.

Much of your diabetes management will be centred around lifestyle changes, such as changing the types of foods that you eat, increasing your level of activity and so on. Another important aspect of managing Type 2 diabetes is controlling blood fats (lipids). People with Type 2 diabetes often have high levels of blood fats, which increases the risk of heart disease and circulation problems. You may therefore need to consider this when looking at your lifestyle changes.

Illness plays havoc with the workings of most of our body systems, so it is not surprising that diabetes control is affected during periods of illness. It is very important that blood glucose levels don't become dangerously high if you are ill or have an infection of some sort. So, in order to prevent diabetic emergencies it is wise to follow sick day management guidelines.

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What things will need to be considered?

Important factors may include the following:

  • Making healthy food choices
  • Reducing daily calorie intake
  • Increasing daily level of physical activity
  • Losing weight
  • Taking medication regularly, as prescribed
  • Making appropriate adjustments (e.g. to food intake) to cater for changes in the daily routine (e.g. strenuous exercising)
  • Using blood glucose monitoring results effectively

In addition to the above, the management of your diabetes will also depend on:

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Setting targets

An important element of diabetes management is setting targets or goals for yourself. This can be especially useful in the early days or if you feel that you're not in control of things.

First, you will need to identify your goals, and then prioritise them. If you have just been diagnosed, then your goals will be different from someone who has had diabetes for some time, but has decided to take steps to improve their control.

Make sure that your goals are realistic. Remember, Rome wasn't built in a day!

For more guidance on setting and achieving goals, see "Setting Goals and Making Changes".

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"Diet and Exercise"

We are all advised to live healthier lifestyles – eat more healthily, lose weight, exercise more, stop smoking… and so on. For people who have Type 2 diabetes this advice forms an important part of the management plan. You may be surprised to learn that you actually have the potential to reduce the harmful effects of diabetes, purely by making some changes to your lifestyle.

You can learn more about adopting a healthy lifestyle from the “Healthy Living” section.

Here, we focus on the role of diet and exercise in the management of Type 2 diabetes. In particular, we will take a look at the way in which diet and exercise can improve:

  • Blood glucose levels
  • Blood fats
  • Blood pressure

Diet and blood glucose levels

Blood glucose levels are mainly kept in check by insulin. Type 2 diabetes usually occurs as the result of a combination of problems with insulin activity (insulin resistance) and insulin secretion. Diet and exercise can help to combat both of these problems.

Insulin resistance

The majority of people with Type 2 diabetes are ‘insulin resistant’. This means that the insulin that is produced does not work very efficiently and large amounts are needed to keep blood glucose levels down. If the beta cells are under too much strain they may not be able to produce these large amounts of insulin; the blood glucose levels rise and diabetes results.  People who are overweight and/or inactive tend to be more insulin resistant than lean people who exercise regularly.

The opposite of insulin resistance is insulin sensitivity. The more sensitive the body is to insulin, the less insulin is needed to control blood glucose levels.

The body can be made more sensitive to its insulin in a number of ways:


Often a few simple changes to your eating and exercise habits can make all the difference.

If insulin sensitivity is increased through weight loss and an increase in activity level then less insulin is needed to keep blood glucose levels controlled. If less insulin is needed, then less strain is put on the beta cells.

Food, blood glucose and insulin

Carbohydrate foods have the greatest direct effect on blood glucose levels. Carbohydrates are broken down into glucose by digestive enzymes. The glucose is then absorbed from the intestine into the bloodstream (usually 1 – 2 hours after eating) and this causes the blood glucose level to rise after a meal. Insulin is needed so that the body’s cells can take this glucose from the bloodstream and either use it for energy or store it for later. People who do not have diabetes will produce just the right amount of insulin to cope with the rise in blood glucose that occurs after a meal. Insulin on demand allows the person without diabetes to keep blood glucose levels within the normal range, even after a meal rich in carbohydrates.

If you have Type 2 diabetes then your body no longer produces enough insulin on demand to keep blood glucose levels within the normal range. Many people with Type 2 diabetes do not produce enough insulin to cope with the sharp rise in blood glucose that happens after a meal.

Choosing food types that are more slowly digested can reduce the ‘post-meal spike’ in blood glucose, which in turn reduces the demand on the beta cells for insulin.

So, a three-pronged attack on the situation can help you to control your blood glucose levels:

  • Increase your daily level of activity – this helps to reduce insulin resistance
  • Reduce you daily calorie intake and try to lose some weight – this helps to reduce insulin resistance
  • Choose carbohydrate foods that are digested more slowly – this takes the strain off the beta cells after a meal (see “Different food types” below)
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Blood fats

Many people with Type 2 diabetes have unhealthy levels of blood fats – this is commonly referred to as an unhealthy ‘lipid profile’. Too much of the wrong types of fat in the blood increases the risk of heart disease and circulation problems. Another important aim of diet and exercise in the management of your diabetes will therefore be to help keep your blood lipid levels normal.

Reducing your intake of saturated fat and not drinking too much alcohol can help to bring down levels of cholesterol and triglycerides in the blood.

Do note that, in addition to healthy eating, regular exercise can also help to improve your blood lipid profile.

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Blood pressure

Type 2 diabetes is often accompanied by high blood pressure and this increases the risk of diabetic eye and kidney damage, as well as heart disease and circulation problems. Regular exercise, eating a low-fat and low-salt diet, and reducing alcohol intake can all help to lower blood pressure.

You can learn more about managing high blood pressure (hypertension) from the page “High Blood Pressure” in the section on long term complications of diabetes.

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Different food types

You will need to learn about different food types so that you can make healthy choices when it comes to meal planning.

The overall effect of a meal on the blood glucose level will depend on the different types of foods making up the meal. Carbohydrate foods have the greatest effects on blood glucose levels because they are mostly digested to glucose, which is absorbed from the intestine straight into the bloodstream. However, proteins and fats in the diet do affect blood glucose levels too.

You will need to pay attention to the amount and type of fat that you eat. Fatty foods tend to be high in calories and eating too much of some types of fat can raise your blood fat levels, increasing the risk of heart disease and circulation problems.

Glycaemic Index

Different types of carbohydrate foods are digested at different rates and therefore have different effects in terms of raising the blood glucose level after a meal. Some foods are quite rapidly digested to glucose (e.g. cornflakes), whilst others take longer for the glucose to hit the bloodstream (e.g. All-BranTM). The effect of different carbohydrate foods on blood glucose levels has been quantified by the Glycaemic Index (GI). Foods with a low GI cause less of a spike in post-meal blood glucose than those with a high GI.

You can learn more about the GI in "Food Choices".

Sugar

It is still widely believed amongst the general population that people with diabetes should avoid eating sugar because it causes a rapid increase in blood glucose levels. This is not true! Table sugar, which we sprinkle on our cornflakes, actually causes less of a spike in blood glucose than the cornflakes themselves. Sucrose*, surprisingly, has a lower GI than cornflakes.

As part of healthy eating, we are all advised to cut down on sugar – this is because it has little nutritional value, it does little to satisfy the appetite and it’s a source of ‘empty calories’.

SUGAR vs. GLUCOSE

*Important:

Table sugar is not the same as glucose. Table sugar is called sucrose and is a disaccharide - it contains two sugar molecules: one fructose and one glucose. Table sugar needs to be broken down by digestive enzymes before the fructose and glucose can be absorbed. Glucose is absorbed quickly because it does not need to be broken down (digested) first.


Fats

The most significant effect of fat on blood glucose levels is probably to slow down the rise in blood glucose after a meal. Fat delays the rate at which the stomach empties – this has the knock-on effect of slowing down the absorption of glucose from digested carbohydrate foods. You might think that this is a good thing, but remember that a high-fat diet is not necessarily a healthy diet.

There are different types of fats – some can be beneficial to our health, but others can increase the risk of high blood pressure and heart disease. Too much saturated fat and cholesterol in the diet can result in unhealthy levels of blood fats. However, monounsaturated fats may improve your lipid profile.

Protein

Excess protein in the diet that is not needed by the body is converted to glucose by the liver. This means that consuming large amounts of protein can result in an increase in blood glucose levels several hours after eating.

Currently there is no strong evidence that a high protein diet is particularly beneficial for people with diabetes. Remember that animal sources of protein - meat and dairy products - are high in saturated fat.

Which types of foods contain protein, fat and carbohydrate? See "Food Choices"

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Putting the theory into practise

So far, we have looked at the different ways in which diet and exercise can help you to manage your diabetes. This is all well and good – but how do you actually go about using this information? There is a lot to consider and you may well be feeling totally overwhelmed by it all. So where do you start?

Talk to your dietitian. Together you should be able to work out a food plan that is suitable for you and takes into account your tastes and lifestyle, in addition to financial and cultural considerations.

Look at your usual eating and exercising patterns and see where you could make small changes for the better. Set yourself achievable targets.

Use blood glucose monitoring to find out whether your diet and exercise approach is working; make a note in your diary of the changes you made and learn from experience. The most informative times to test are first thing in the morning, before eating and 1 – 2 hours after your meal.

If you are taking tablets to help control your blood glucose level then you will  need to eat regular meals and make sure that you take your tablets at the times prescribed.  Remember, your tablets will only be successful in controlling your diabetes if you pay attention to your diet and engage in regular exercise.

If you are injecting insulin to help control your blood glucose levels then you should also look at the principles of dietary management in Type 1 diabetes – this will help you to understand more about the relationship between your blood glucose levels and the food that you eat, and the insulin that you inject.

Summary

  • Learn about different food types and eat a healthy, nutritious diet
  • Consider what you eat and how it might affect your blood glucose level – learn about the effects of different types and amounts of food on YOUR blood glucose level using blood glucose monitoring
  • Use a calorie counter, or similar book, to assess the carbohydrate, fat and protein content of foods
  • Use food labels
  • Use the Glycaemic Index
  • Cut down on saturated fats
  • Cut down on alcohol and salt, particularly if you have high blood pressure
  • Increase your level of activity

Important:

If you take certain tablets or have insulin injections…

An additional role of diet in managing diabetes is preventing low blood glucose levels (hypoglycaemia). This is particularly important if you take tablets that increase your insulin production, or if you have insulin injections.

Some insulin and tablet regimens require you to have snacks in between meals in order to prevent hypoglycaemia. Snacks are not always necessary though, so check with your doctor and/or dietitian to see if you need to snack between meals.

Delayed or missed meals are probably the most common cause of hypoglycaemia. Take steps to avoid low blood glucose levels if you know that you are not going to be able to eat your usual meal. Have an extra snack to keep you going and keep an eye on your blood glucose level.

A bedtime snack is, however, essential for all people who have insulin injections. This ensures that blood glucose levels don’t fall too low during the night.

Snacks are also very important before exercising, especially if the activity does not form part of your regular daily routine. This is to prevent exercise-induced hypoglycaemia. See the section on "Exercise" in "Managing Type 1 Diabetes" for more details if using insulin.



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Oral Medication - Tablets

There are a number of tablets available that can help control blood glucose levels; these are known as ‘oral hypoglycaemics. Type 2 diabetes usually occurs as the result of a combination of problems with insulin activity (insulin resistance) and insulin secretion. Oral medication, alongside diet and exercise, can be used to tackle both of these problems.

Important note:

Oral hypoglycaemics are NOT insulin and cannot replace insulin. They can only help your body make or use its own insulin. If your beta cells cannot make enough insulin then tablets alone will not be able to help you to control your blood glucose levels.

There are currently several different classes of oral hypoglycaemic drugs:

Some people may be prescribed a combination of drugs (sometimes also in addition to insulin). Different tablets have different action profiles.

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Taking the tablets

For diabetes tablets to work properly they must be taken regularly and at the appropriate times – particularly with respect to meals. Follow the prescription instructions carefully. If you are unsure about what to do if you miss a dose then ask your doctor or pharmacist.

Never stop your medication without first consulting your doctor or a member of your diabetes team.

If you find that you are suffering from some side effects of your medication then speak to your doctor about it. There are always different alternatives that you can try.

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Insulin

Type 2 diabetes is a naturally progressive condition – as the years roll on the body makes less and less of its own insulin. For many people this means that insulin injections are eventually needed to keep blood glucose levels controlled.

Unfortunately oral medications are only of use if the body is still making some of its own insulin. If your body is no longer producing enough insulin then there is no alternative but to start on insulin injections.

Remember, this is not a failing on your part – it is down to the natural course of the diabetes.

Although your body may not respond to tablets aimed at increasing insulin secretion, your doctor may continue to prescribe tablets aimed at reducing insulin resistance (e.g. metformin).

Learn more about the use of insulins in the treatment of diabetes from the following sections:

Using Insulin

Management of Type 1 Diabetes (many of the principles are the same when diabetes is treated with insulin, whether Type 1 or Type 2)

In contrast to people with Type 1 diabetes, since you may still be producing a small amount of your own insulin, you may only need one injection per day.

You may need to pay closer attention to your diet - you will need to consider how much you eat and when you eat it. You will also need to look at the types of foods that you eat and assess the effects that they will have on your blood glucose level. It may help you to look at the principles of dietary management in Type 1 diabetes – this will help you to understand more about the relationship between your blood glucose levels and the food that you eat, and the insulin that you inject.

You will also need to perform blood glucose monitoring on a regular basis.

Injecting insulin increases the risk of low blood glucose levels (hypoglycaemia) – especially if meals are missed or delayed, or if you exercise. Learn about the signs and symptoms of hypoglycaemia and remember to carry some glucose and diabetic identification with you at all times.

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Sick Days

Illness can play havoc with your diabetes and you may need to pay special attention to your blood glucose levels if you are ill or have an infection.

Illness and blood glucose levels

When we are sick our bodies are under stress and this leads to the release of a number of hormones that can raise the blood glucose level. For this reason your body may need significantly more insulin during periods of illness or if you have an infection. This will put an added strain on your beta cells to produce more insulin. Watch your blood glucose levels carefully, testing every 3 or 4 four hours.

Continue to take your diabetes medication – tablets or insulin - even if you are not eating much.

If you have very high blood glucose levels then contact your doctor. Drink plenty of fluids (sugar free).

Insulin injections may be needed on a temporary basis if blood glucose levels remain high – this sometimes happens in the case of a severe infection.

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Illness and food

You may not feel like eating your usual diet if you are unwell. That’s OK. You can replace your normal foods with sugary drinks or foods that slip down easily – soup, ice cream, yoghurt or custard, for example.

Keep an eye on your blood glucose levels – you may be able to spread out your usual food intake, having little and often.

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Illness and vomiting

Vomiting is a danger signal for people with diabetes and it can quickly lead to dehydration. Sickness (or diarrhoea) may also mean that tablets are not absorbed properly. If vomiting persists for more than a few hours you should call your doctor. In the meantime, try to keep up your fluid intake.

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Sick-day action plan

You and your diabetes team should prepare a sick-day plan – a set of guidelines to help you manage your diabetes whilst you are unwell. This should include advice on the following:

  • Testing your blood glucose levels
  • Foods that can substitute your normal diet
  • When to call for help
  • Who to call for help or further advice if you are worried

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Controlling Lipid Levels

Type 2 diabetes is often associated with abnormal levels of fats in the blood. The clinical term for this is 'dyslipidaemia'. An unhealthy lipid profile increases the risk of heart disease and large blood vessel disease.

Your lipid profile

Fats are packaged up and carried around the body in the bloodstream. The term 'lipids' collectively describes these packages of fat in the blood.

A series of blood tests, known as a lipid profile, usually contains the following:

  • Total cholesterol (= HDL-cholesterol + LDL-cholesterol)
  • Triglycerides

Cholesterol is a vital component of our body cells and is used in making a number of important hormones. Cholesterol comes from the diet and is also made from saturated fats. It is packaged up for transport in the liver as either HDL-cholesterol or LDL-cholesterol.

HDL-cholesterol is Healthy cholesterol

LDL-cholesterol is Lethal cholesterol

Triglycerides are fats made up from glycerol and three fatty acids. Most fats are transported and stored as triglycerides.

You can learn more about different types of fat and dietary sources of fat in "Food Choices".

The most common form of dyslipidaemia in people with diabetes is a high level of LDL-cholesterol, low level of HDL-cholesterol and a high level of triglycerides.

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LDL-cholesterol and atherosclerosis

High levels of LDL-cholesterol increases the risk of heart disease and circulation problems. This is because LDL-cholesterol contributes to hardening of the arteries or 'atherosclerosis'. Gradually blood vessels become narrowed as LDL particles and other material start to stick to the inside of the vessel walls. This reduces blood flow and also favours the formation of blood clots. If a blood clot forms and becomes lodged in the heart it can cause a heart attack. A blood clot blocking the way in the brain can cause a stroke. Reduced blood flow in the legs can cause a lot of pain and is often referred to as 'claudication'. It also increases the risk of foot problems in people with diabetes.

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Managing dyslipidaemia

A diet low in saturated fat*, weight loss and an increase in your level of physical activity can raise HDL-cholesterol levels and lower triglyceride levels. Reducing alcohol intake and improving blood glucose levels will also help to lower triglyceride levels.

*Note:

There is currently a certain amount of controversy as to whether saturated fat should be replaced with monounsaturated fat or carbohydrate in the diet. Increasing monounsaturated fat intake may help the overall lipid profile, but it tends not to favour weight loss.  If carbohydrate intake is increased then we suggest that foods with a low Glycaemic Index should be the preferred choice.

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Lipid-lowering drugs

There are a number of drugs available to treat dyslipidaemia if diet and exercise interventions are unsuccessful. The most commonly used types are statins and fibrates.

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Treatment goals

So what sort of lipid levels should you be aiming for? These are general guidelines only; your doctor will advise you on appropriate targets for yourself.

Total cholesterol

less than 5.0 mmol/l

LDL-cholesterol

less than 3.0 mmol/l

HDL-cholesterol

more than 1.2 mmol/l

Triglycerides

less than 1.7 mmol/l


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