Treatment of Diabetes

Treatment of diabetes is mainly dependent on Diet, exercise, oral medications (tablets) and injectable medications (including some newer medications like Liraglutide, Dulaglutide and the different types of insulin)

DIET - We are what we eat and what we “ate”. Diet is the MOST important aspect of management fo Diabetes. A lot of times we underestimate the importance of diet. For all practical purposes, 70% of your diabetes control will depend on your diet; another 15-20% is the contribution of exercise and the remaining 10% is with the medications/insulin. If your diet is not in place, none of the medications or insulins are going to work for you over a long term. In our routine clinical practice, effect of good diet is equivalent to that of two medicines for diabetes and exercise has the effect equivalent to one medicine for diabetes. So if you are following healthy diet and exercising regularly, it is equivalent to being on three of the most potent medications without the risk of side effects and also having a lot of additional benefits. Healthy diet and exercise not only helps manage your blood sugar better but has positive effect on other metabolic problems like high BP, PCOS (Polycystic Ovarian Syndrome), fatty liver, high cholesterol, obesity, etc to name a few. There is increasing amount of research and evidence available to show that diabetes can be reversed to a great extent especially in people who are obese by weight loss. People who are able to loose their excess weight with diet and exercise, are able to gradually reduce their diabetes medicine over a period of time.

A lot of times, we come across people who start following healthy diet and start exercising regularly and start experiencing symptoms of low sugar or what we call as “HYPOGLYCEMIA”. When they start experiencing this, they start taking sweets on a regular basis to help decrease chances of hypoglycemia. When these symptoms start happening on a regular basis, it becomes important to discuss with your doctor because you will need to reduce your medications or change them as per your doctors advise.

When we talk about diet, there are a lot of misconceptions which people have in their mind. Here I have tried to explain the basic layout and covered a few of the basic information which is important. Just like medications, diet for an individual has to be individualised according to their lifestyle and their requirements. So this is just a general guide.

1. Include lots and lots of raw vegetables in your diet. Raw vegetables are rich in antioxidants; fibre; essential vitamins; filling and do not increase our blood sugar levels. As a visual guide, half of your plate should be seasonal raw vegetables in each meal. Just to get a practical idea, it should take you good 10-15 minutes to finish your salad before you get on to your main meal 😊. Initially you will need a bit of time to get used to this but soon you will start enjoying it!
2. Cut down on oil intake. By this, I don’t mean that “fat” intake needs to be stopped or anything. “Fats” in form of nuts and seeds are very good for our body and are needed as a part of good healthy diet. Try to keep oil intake to a minimum and replace with nuts and seeds.
3. Protein intake - protein intake in your diet in form of plant proteins or animal protein is important. Difference between plant and animal protein is that plant protein sources inherently have lower fat content compared to animal protein. They are also more easily digestible and have been shown to help decrease inflammation in the body which is the primary underlying problem with a lot of chronic medical problems. Again to give an approximate idea, to fulfil the protein requirement of the body, you need six servings of protein each day. Adequate protein intake helps with reparative processes in the body. Just increasing your protein intake does not increase your muscle mass. Regular strength training exercises are needed to help improve the muscle mass in the body.
4. Carbohydrates - carbohydrates are the major source of energy in our body. They are required for our daily functioning for a lot of different processes which keep happening even when we are asleep. 60-70% of our energy requirement are fulfilled with the carbohydrates in our diet. There are a lot of myths about carbohydrates in our diet. Carbs are not all bad. We need to switch the carbs from processed carbs to whole grains and using different types of grains in our diet. This helps decrease the blood sugar spike in our body after food intake. You can mix fresh methi leaves or grated lauki into the dough that you make for your chapatis. Just to give you a rough idea, you should try to keep the dough ball for one chapati equivalent to the size of a table-tennis ball.
5. Processed foods - these are the major culprits behind the increasing problems with obesity and diabetes worldwide. The vast amount of different preservatives and chemicals in addition to refined carbs and sugars in them are significantly detrimental to everybody’s health, not just for people with diabetes. A lot of times we come across “sugar-free” biscuits; sweets; ice-creams and what not in the market these days. Get into a habit of reading their nutritional information - they typically replace sugar with other artificial sweeteners or at times higher fat content and still have other refined carbs in them which are just as detrimental for your health. So we advise staying off of any kind of processed food on a daily basis. I often tell my patients your better off taking “chole-bhature” once a week instead of taking biscuits and namkeens in daily basis as a snack. These are neither nutritious nor filling and add on to significant sugar load. Often when people cut down on processed foods, we can go down on their diabetes medications and it helps with weight loss also. Replace these on a regular basis with either a serving of fruit or with other healthy snacks like roasted Chana or roasted Makhana or pop corn in small amounts.
6. Water intake - water is very important for all body processes. Everybody’s requirements for water are going to be different. We recommend replacing any kind of sugary drinks with fresh water. Water is present in good amounts in fresh raw vegetables and fruits as well. How do we know if our water intake is adequate or not? The colour of your urine is a good indicator of whether your water intake is adequate or not. If the colour of your urine is clear during the day - it indicates your water intake is adequate. On the other hand dark coloured urine during the day indicates you need to increase your water intake. If you want, you may add lemon or cucumber or orange slices to water and have infused water to change the flavour of it if you feel like. Avoid taking fruit juices though because they are high on carbohydrate load and are deprived of the fibre.

What about the different “diets” out there?

---

There are different kinds of diets which are popular in the west and they are catching up in India too now. They are not all FAD diets, there are scientific basis behind different diets and most of them do have good amount of research backing them. I would be discussing about the common ones which are catching up in India now.

1. VEGAN DIET - Vegan diet is the one which in which only plant products are taken, no milk or milk products are allowed, no eggs or non vegetarian foods. While you are on vegan diet, it’s not just about “excluding” milk and milk products and non vegetarian foods but also about incorporating other plant based foods to ensure right amount of calorie intake, right proportion of your macronutrients - carbs, protein and fats with a significant emphasis on raw vegetables and fruits in moderation. Vegan has been shown to be very effective in weight loss and diabetes reversal. Believe it or not it has been tried for a long time in the US and is now spreading in Europe and slowly gaining popularity in India. For people who are vegetarian, it’s actually an easier transition to make provides they take care of adequate intake of other nutrients as I mentioned. With vegan diet, there can be some vitamin deficiencies particularly vitamin B12, we therefore advise taking a multivitamin regularly while you are on vegan diet.
2. KETO DIET - or the LOW CARB DIET - This kind of a diet essentially excludes all kinds of carbs including that from fruits - with a significant emphasis on good protein and fat intake keeping in mind the total caloric intake for the day. People who are non vegetarian might find this easier to follow compared to the vegan diet. When on keto diet, gradually the body’s metabolism kind of switches from using up the carbohydrates for energy to using the stored fat for energy which itself requires the body to burn calories (because now there isn’t any carbohydrate in your diet to give that instant energy).

As such, both vegan and keto diet have got good and comparable results if followed properly. You have to understand that diet change is a lifestyle change and that is the crux of management of these lifestyle associated medical problems. There is surely a lot of genetic predisposition to these medical problems but even with that, our lifestyle plays a significant role in keeping these in check and maintaining a better health over a long term.

EXERCISE - this is another important part of Diabetes management. But what do we mean by exercise? A lot of times people say that “I am very active”, “I am on my feet all day at work”, or “I am walking a lot at work”. Is that exercise? Here, I will be discussing about this.

What all of these count as is termed as “Physical activity”, which in medical literature is defined as any bodily movement produced by skeletal muscles that results in energy expenditure. Physical activity in daily life can be categorized into occupational, sports, conditioning, household, or other activities.

Exercise is a subset of physical activity that is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness.

So being physically active is surely good and you do get brownie points for that; but also do need to incorporate exercise on a regular basis.

BENEFITS OF EXERCISE:

---

Health benefits of exercise are way too many! There are books written on benefits of exercise, so of course it’s difficult for me to enumerate those in a few lines. Here are those:

1. Improved metabolism and insulin sensitivity in the body - this means that whatever insulin your body is making, tends to work better if you are exercising.
2. Improved energy levels and stamina- Exercise has been shown to help improve energy levels significantly and even small amounts on a daily basis can help you.
3. Help combat stress - exercise releases endorphins in our body which are the natural “feel-good” chemicals in our body. Exercise is like an anti depressant and helps improve your mood.
4. Helps improve medical conditions like arthritis, high BP, PCOS, metabolic syndrome, certain cancers, improves stability and memory as well.
5. Promotes better sleep. It helps you relax and get better sleep. Just don’t exercise too close to bed time!
6. Helps improve sexual health. Diabetes and ageing both have effect of sexual health over time. Exercise helps improve circulation in the body and boost confidence levels. In women it helps improve arousal. In men it has been shown help decrease problems with erectile dysfunction.

HOW MUCH SHOULD I EXERCISE?

---

When we talk about exercise, there are three different aspects of it - aerobic, strength training or toning exercise and breathing exercises. Examples of aerobic exercise include walking, running, cycling, dancing like Zumba or swimming. Aerobic exercises help improve our metabolism and improve our stamina overall. Strength training or toning exercises include body weight training with yoga or doing weight training in the gym. There are other ones nowadays like Pilates which can be done as well. Strength training exercises help improve our muscle strength, tone, improve stability and mobility as well. Breathing exercises help decrease stress hormone levels in the body and this further helps improve blood sugar levels in the body. A combination of these is required to help gain the most benefits out of exercise. Every individual’s requirements are different but in general, the guidelines are that you should do moderate aerobic activity 30 minutes a day; 5 days a week to help maintain your weight. Along with this, strength training exercises for all major muscle groups at least two times a week.

Spread your activities throughout the week. If you want to lose weight, meet specific fitness goals or get even more benefits, you may need to increase moderate aerobic activity to 60 minutes a day, six days a week.

DIFFERENT MEDICATIONS FOR DIABETES AND THEIR ROLE:

---

There are a lot of medications available for treatment do diabetes today compared to how it was even till 10 years ago. When I was doing my medical training, there were just two main categories of medications and two types of insulins available. So it was not as tricky to decide what medications to use. But now we have many more different categories of medications available and a lot of different insulin types as well. The main aspect of diabetes management is tailoring the treatment as per your specific requirements and understanding what is the most likely reason of your problem and understanding your body’s metabolism. Here in this chapter I will be discussing briefly about the different medications and how they work.

1. METFORMIN - This is one of the oldest oral medications for diabetes and the one which is most commonly prescribed. Metformin decreases the amount of glucose released from the liver, decreases the absorption of glucose from the intestine and improves insulin sensitivity in the body. It is best taken 15-30 minutes before your meal. Side effects include diarrhoea, excessive gas, vitamin b12 deficiency.
2. SULFONYLUREAS - These are the other conventional medications for diabetes. The ones which are commonly available in India are glimepiride and gliclazide. These are the agents which cause increased insulin release from pancreas. These medications are cheap and well tolerated. Main side effect is issue with sudden hypoglycemia - particularly in elderly people.
3. GLIPTINS - These medications work by blocking the action of DPP-4, an enzyme which destroys the hormone incretin. Incretins help the body produce more insulin only when it is needed and reduce the amount of glucose being produced by the liver when it is not needed. These medications are typically given once or twice a day. These do not have a tendency to cause any issues with hypoglycemia on their own. These are fairly well tolerated, two main things to watch out for are side effects with pancreatitis - which is inflammation of the pancreas. Other peculiar side effect is skin eruptions with these medications. They are available as sitagliptin, vildagliptin, linagliptin and tenegliptin.
4. Alpha glucosidase inhibitors - these work by slowing the action of certain chemicals that break down food to release glucose (sugar) into your blood. Slowing food digestion helps keep blood glucose from rising very high after meals. Side effects are abdominal bloating, flatulence, diarrhoea. The ones which are commonly available are voglibose, acarbose.
5. THIAZOLIDIENEDIONES - These work by making cells more sensitive to insulin, which is used to regulate the level of glucose in the body. Improving insulin sensitivity (or reducing insulin resistance) makes it easier for sugar (glucose) in the blood to get into the cells. They are available by the name of pioglitazone. For some people, they may cause issues with water retention and may cause weight gain related to that. Patients with heart problems, might not tolerate this medication very well.
6. SGLT -2 inhibitors - These are the latest medications available for diabetes. These work by a very different mechanism and have been noted to have other beneficial effects including helping with kidney problems and also certain heart problems as well. These work by getting rid of extra sugar in the urine. These medications sometimes can cause problems with urinary tract infections or vaginal infections in 5-7% patients. These do not have a tendency of causing issues with hypoglycemia on their own. They can be used as a add on to any of the other medications for diabetes.

In addition to these medications which are available in form of tablets, there are certain other medications are available in form of injections. These belong to a category called as GLP-1 agonists. Depending on which type you are advised, these might be needed twice a day; once a day or once a week dose. Although these are in form of injections, these are NOT any type of insulin. They work by a totally different mechanism. These help decrease appetite, so even with small amount of food your stomach feels full, it also helps modify insulin release in the body. One of them - Liraglutide is approved as a medication for weight loss as well in people without diabetes also.

Why medicines for Diabetes?

---

The oral medications for diabetes are essentially for people who have Type 2 diabetes. These are typically not being used in people wi type 1 diabetes although in some people they might be depending on their clinical features. Medicines are needed for diabetes when the sugars are not staying in check with diet and exercise. Over a period of time, as the insulin production in the pancreas decreases, your requirement for medications changes as well. Also, factors like other medical problems, medications, appetite and weight change over a period of time might also change your medication needs. So it’s not that whatever medications were prescribed to you 6 months ago would continue to be the same 6 months later as well. It is very important to monitor your sugars at home intermittently to have an idea regarding how you are coping up. Whenever you are sick or unwell because of any reason, check your sugars more often because they are expected to fluctuate around that time. For some people, they might go up and for some people they might actually go down also because of different reasons. You might need to make medication modification during periods of sickness.

If you are about to undergo any planned surgery for any problem, do consult your doctor beforehand as some medication modifications might be needed around that time. Before the surgery it is important that your sugars are staying well controlled so that surgery related complications can be minimised and at times the medication dose might need to be reduced soon after surgery as well.

If you are started on any medications belonging to the category called “steroids”, which might be prescribed for a variety of different reasons, your sugar levels are likely to go up with them so it would be important to monitor your sugars during that time and seek help if they are staying on the higher side.

It is important to understand that medications are an adjunct to diet and exercise for management of Diabetes. If your diet is not in place then whatever medications or insulins you keep using, none of them are going to work well for you. So if your sugar levels are staying on the higher side, do reflect back on your food intake and discuss with your doctor regarding the best way of approaching it. It’s not always about waiting for the diet and exercise to start showing its effect but at times a joint action is required so that you avoid the harmful effects of high sugar levels in the body while the diet is taking its effect. A lot of times people think that once medication for diabetes is started, it can never be stopped. It is not true - increasingly we are seeing people who are being able to go back down on their medications and even able to get off of them. This is particularly true for people who have issues with insulin resistance due to excess body weight. They can reverse their diabetes by losing weight with diet and exercise. Some people might also benefit with diabetes surgery or Bariatric Surgery which helps people by making them lose significant amount of excess weight and maintain it over a long term.

UNDERSTANDING INSULINS

---

Diabetes is a condition which arises due to problems with either insulin production or insulin resistance. So basically it is a “insulin problem”, not really a “sugar problem”, to put it in simple words. Depending on what is the cause of your underlying diabetes, insulin is something which might be needed at some point of time in management of diabetes. Not everybody needs it, not everybody needs it forever either. On the other hand there are individuals who have type 1 diabetes which is a condition where ONLY insulin is the available treatment option and nothing else works for them. Here in I will be discussing about the different types of insulins and also the different myths which people have about insulins.

Let’s talk about the different types of insulins:

Insulins belong to different categories depending on their duration of action:

1. Short acting - Short acting insulins are the ones which are effective for 4-6 hours or so in our body. They reach their peak levels in the body soon after injection and are to be taken before food to help control the rise in the blood sugar levels after food intake. Depending on which type of short acting insulin you are on, it might need to be taken 30 minutes before food; soon before food or might even be okay to take it soon after your food intake as well. When you are started on a short acting insulin, do check with your doctor or diabetes educator regarding the specifics about what time it has to be taken. This will ensure correct administration of insulin and avoid problems with hypoglycemia. Short acting insulin injection might be needed anywhere between once a day to 3-5 times a day depending on the type of diabetes and your requirements.
2. Intermediate acting - As the name suggests, it works for longer duration than the short acting insulin but less than that of long acting insulin. They are effective in the body anywhere between 10-16 hours. They are typically prescribed for once a day or twice a day dosing. They might be prescribed on their own or to be used as a mixed insulin along with a short acting insulin.
3. Long acting Insulins - As the name suggests, these are effective in the body for longer duration. Depending on the type of insulin you are on, they might be effective for anywhere between 20-36 hours. These are typically prescribed either once a day or at the most twice a day depending on your insulin requirements.
4. CONCENTRATED INSULINS - There is this third category of insulins which are available now. As the name suggests, these have higher dose of insulin in the same volume of insulin. These can either be short acting or long acting. These are typically being used in people who have higher insulin requirements secondary to significant insulin resistance. These have further helped improvise and tailor insulin treatment for people with diabetes these days.

ONE IMPORTANT THING TO UNDERSTAND IS THAT IN GENERAL, IF YOUR TOTAL DAILY REQUIREMENT OF INSULIN IS MORE THAN 150 UNITS PER DAY, IT MEANS THERE IS SIGNIFICANT INSULIN RESISTANCE AND THAT NEEDS TO BE ADDRESSED AS A PRIORITY. This would mean sitting down and discussing with your doctor and reviewing your other medications, diet and exercise. Of these, your diet is what would need to be modified the most to get the maximum benefits. Keep in mind that to see a “CHANGE”, you need to “PUT IN THAT CHANGE” too or else it’s not going to happen.

Whatever treatment you might be on for diabetes, even with the best possible insulins, nothing is going to work if your diet is not in place. Your medications might work for sometime but soon they will stop working as your body gets used to it and as the disease process progresses in the body. Only way of halting the progress of disease and improving your health is by making significant diet changes over a long term. Longer the duration of diabetes, more are going to be issues with glucose intolerance. Clinically, this translates into significant rise in blood sugar levels with even very small amount of intake of processed foods and sugars. So what your body was able to tolerate and metabolise adequately without raising your blood sugar levels much a few years ago, it might not be able to do so now.

For the best management, it is important to have a long term sustainable diet, exercise routine along with medications as required.