By: Director of Education – Jessica Cook MS, RD, LD, CDE
Many people believe being diagnosed with diabetes means big changes ahead! And even though you may need to make changes in order to have better blood sugar control it doesn’t mean you have to overhaul your life. Even the smallest of changes could lead to better blood sugar, weight loss, more energy and better health. Here are a few tiny tips:
Our education team has helped countless patients lose weight, reduce blood glucose levels, reduce medication use and feel better. If you would like to learn more steps to take to controlling your blood sugars you can schedule an appointment with a diabetes educator or dietitian at any of our four conveniently located office locations. Please call (561) 513-5100 to schedule your appointment today!
Thank you for taking time to read our Living Well with Diabetes October 2015 Newsletter. Enjoy!
By: Dr. Kathryn Reynolds
Type 2 diabetes is a major global health problem. By the year 2012, there were 29 million Americans living with diabetes (21 million diagnosed and 8 million undiagnosed). The incidence of new cases was 1.7 million cases per year (2012) with 86 million people in the country with pre-diabetes. The prevalence (diagnosed and undiagnosed cases) is projected to increase to approximately 25% of the U.S. adult population by the year 2050.
Diabetes carries a significant burden of morbidity and mortality. Serious complications and co-morbid conditions include:
Thus, early and aggressive intervention is necessary in order to try to prevent the development of the above complications. Type 2 diabetes is primarily due to a combination of factors. The first of these is insulin resistance, meaning that the organs involved in peripheral glucose disposal (liver, skeletal muscle, and fat cells) do not respond normally to the body’s insulin, leading the pancreas to have to “overwork” in order to try to control blood glucose levels. This is turn leads to the major defect in type 2 diabetes: progressive failure of the insulin-producing pancreatic beta-islet cells. This leads to a progressive decline in the body’s ability to make insulin, and this process begins early in the pre-diabetes phase of the disease. In fact, by the time type 2 diabetes in clinically diagnosed, an individual has typically lost >50-75% of his/her insulin-producing capacity. As a result, the majority of individuals will eventually need insulin replacement in order to keep their blood sugar levels controlled.
A major question that often arises in during the treatment of diabetes is when to begin insulin therapy. Many barriers often interfere with timely insulin administration. Patients express “fear of the needle,” apprehension about the burden of taking an injectable regimen, fear of hypoglycemia, fear of weight gain, or fear of the progression of diabetic complications once starting insulin due to prior experience of family members. Physicians may be reluctant to begin insulin therapy due to fear of hypoglycemia, concern about weight gain, or due to the “burden” of teaching insulin use and avoidance of adverse reactions.
In addition, we now have many additional classes of effective medications for type 2diabetes in the treatment arsenal, and this can make the decision of when insulin should be started more difficult. The American Diabetes Association (ADA) recommends a hemoglobin A1C of ≤7%, while the American Association of Clinical Endocrinologists (AACE) recommends an A1C of ≤6.5%. However, it is very important to keep in mind that these guidelines are not “one size fits all.” An appropriate treatment regimen needs to be tailored to each individual, taking into account the patient’s age, co-morbid conditions, diabetic complications, risk of hypoglycemia, and life expectancy. This concept is important to keep in mind when beginning an insulin regimen, in terms of both the type of insulin, number of injections, and target blood glucose ranges.
Most patients with type 2 diabetes are started on one or more oral medications, with metformin typically being the most common first-line agent. The patients should be evaluated at appropriate intervals, so that if the sugars are not controlled on the current medication(s) the treatment regimen can be escalated. For patients on one or more oral agent not at goal, options include the addition of another oral agent, a non-insulin injectible agent, or basal (long-acting insulin). For patients with an entry A1C of ≥7.5%, initiating dual therapy is recommended, with basal insulin being one of the options. For patients with an A1C of ≥9% with associated hyperglycemic symptoms (visual change, weight loss, uncontrolled thirst or urination), beginning insulin therapy is recommended. While some providers favor early insulin therapy, others favor exhausting non-insulin regimens prior to initiating insulin. Factors that must be considered are patient desire, patient motivation, support system, and comprehension of prescribed treatments, contraindications to particular classes of medication, and cost.
In terms of choosing among available insulin regimens, I think it is important to try to tailor the regimen to the individual person’s blood glucose patterns. For example, someone with insulin resistance and the “Dawn phenomenon” will have the highest blood sugars in the morning. This is generally best treated with long-acting basal insulin (Lantus®, Levemir®, Toujeo®). People who experience a large rise or “spike” in their glucose levels following meals are typically more insulin-deficient, and usually need mealtime or prandial insulin as well as basal insulin. Options include a more labor-intensive but more physiologic MDI (multi-dose injection) regimen of basal insulin plus rapid-acting insulin with meals, or else a “pre-mix” insulin generally dosed twice daily at meals.
In summary, in patients with early diabetes or moderately well-controlled diabetes, insulin may be started early or later in the treatment algorithm. For patients with diabetes not controlled on non-insulin agents, insulin therapy needs to be started with the type of insulin and number of injections tailored to patient specifics. I feel that it is important to educate patients on the natural, progressive history of diabetes, so that my recommendation to begin insulin therapy does not come as a “shock” or make people feel that they failed to comply with recommendations. When patients participate as partners in their diabetes care, finding treatment regimens that work, including insulin, is usually easier than anticipated.
By Rosemarie Steinsapir MS, RD,CDE
Fear of Diabetes in itself is more than common, it’s rational. Who wouldn’t groan when the physician walks into the exam room and the dreaded word is first heard with your own name attached. These are some of the dreads I hear most commonly:
—My mother/father had it and I watched them suffer with it.
—I don’t want to have to watch what I eat so closely
—I don’t want to be given a diet.
—I’ve heard the complications are terrible.
—I hate the idea of needles.
—It’s going to change the way my family has to eat.
—It’s going to change the way people think of me.
—I don’t drink milk or eat breakfast and I don’t want to start. (This is actually a common one I hear.)
—I hate doctors.
—I don’t want to learn about it.
And that’s just the surface. But the one I’ve heard most frequently is I’m afraid of needles. I can’t take that away, but maybe I can weaken the fear a little.
Let’s start with insulin itself. It’s a protein that is easily digestible in the GI tract, and therefore, it’s delivery into the body has to bypass the GI tract. Insulin is required to allow food to pass through the cell membrane. Then you are fed and the food is used to produce energy, heal and maintain the cells. It’s delivery into the bloodstream is linked with meals.
For now at least, take oral insulin off the table. It debuted a few years ago and was taken off the market because it was not effective enough to control blood sugar. It is still undeveloped and may yet reach the market. Insulin was discovered in 1923 and prior to that, if you had diabetes you dieted and then you died. Very harsh outcomes. But with the discovery of insulin, the hope for a normal life for diabetic patients, soared. I’ve met some of the early patients taking insulin during the 1930’s. They talk about having to boil syringes. In the 1960’s the use of plastic/disposable syringes took away the headache of turning your kitchen into a clinic. It was a big improvement to be able to toss a used syringe (minus the needle) into the garbage. As late as the mid 1990’s, we were still teaching people when to change needles and draw up two different types of insulin in the same syringe.
And then came the insulin pen. What an improvement! No more public demonstrations. It was discreet and with much smaller needles. At the same time, late 1990’s, the insulin pump joined the choices of delivery. For Type 1 patients, this meant renewal as a human being. It reduced injections/initial delivery to once every 24 hours at first, and then to once a week. Now it can be used with Type 2 patients as well. The latest breakthrough of insulin delivery is inhaled insulin. The insulin dose required has to match the delivery available, but for those patients who require the matching dose, it is in use.
Join us at our healthy holiday meal planning refresher class in West Palm Beach December 21st from 10am-12pm. This fun, holiday class includes how to plan healthy holiday meals, tips for weight loss, smart grocery shopping as well as dining out, healthy substitutions and receive a free recipe booklet during class! We also make healthy snacks in class for you to sample. Don’t let this holiday season sabotage your weight loss or A1c and come join us for this healthy holiday event!
If you have tried losing weight on your own without success why not try our Healthy Holiday Meal Planning with Diabetes Refresher Course to help you get back on track with your weight loss goals. If interested attending this program please contact our scheduling department at (561) 513-5100 today!
At Healthy Living with Diabetes we want to ensure that you are satisfied with all services received. We also would like your input on educational workshops that you would like us to offer, information you would like to read about in Healthy Living with Diabetes Monthly or feedback on any workshop that you may have attended. You can contact the director of education personally by email jcook@PBDES.COM or leave a message at (561) 513-5100(561) 513-5100. We would love to hear from you!