Type 2 Diabetes: Start Early!

By Professor Philip Home

Early action after a type 2 diabetes diagnosis is key to managing your glucose levels, staying healthy, and avoiding complications. Prof. Phillip Home shares his tips for those newly diagnosed – from starting conversations with your healthcare team to finding the right medications for you.

Start early, continue long

Being diagnosed with diabetes can bring someone face-to-face with their health, whether the diagnosis comes from routine screening, is in the context of another medical event (such as a heart attack), or from the onset of symptoms. The reality is that poorly managed type 2 diabetes carries with it major health risks to the heart, eyes, kidneys, feet, and indeed nearly every organ. The good news is that plenty can be done to address those risks.

Recent articles in the leading ADA clinical research journal Diabetes Care have underlined an important message for people with either type 1 or type 2 diabetes. It is so important, and I had the pleasure of working with a team to summarize the findings in an editorial in the same issue.

Most healthcare professionals, like myself, agree that the message should be simple: start early. The primary goal is proper management of your glucose levels (and maintaining them for decades). However, other evidence points to successful and powerful interventions to help you manage cholesterol (which reduces your risks of heart attack and stroke directly). And there are also interventions which can reduce your risk of kidney damage and heart failure (if there is already evidence of a problem).

Trying to stay healthy and lower your risk for a number of conditions can seem daunting at first, and to some extent it is. Health-care professionals can find these goals complicated too. But the pathways to good health have become much better mapped in recent years.

Managing glucose (blood sugar) levels       

Managing glucose levels is core to the management of diabetes of any type and huge strides have been made in recent years with both lifestyle management and medications to help you do this.

Being the person who has diabetes means that it is you who ultimately has control over making these lifestyle changes, and it is you who must take the medications! But healthcare professionals also have a duty to provide the advice, motivation, and knowledge to guide you – and this can be supplemented by your own reading and knowledge through reputable sources.

As healthcare professionals, we are not always perfect, and at times we seek to avoid burdening the people we advise too much. You should be encouraged to ask the questions you want answered about your health and make sure you get complete answers. It is completely fine to ask your healthcare team to repeat them if you need clarifications. See diaTribe’s article on this subject: “Just Diagnosed with Type 2 Diabetes? What To Ask Your Healthcare Professional.”

Recent studies have shown that, if implemented at diagnosis or shortly thereafter (particularly within about two years), a low-calorie nutrition plan (followed by a stable weight-calorie matched plan over 1 year), has the potential to put over 50% of people with type 2 into remission.

Remission means achieving an A1C of 6.5% or lower and then maintaining that level for at least three months without the use of any glucose-lowering drugs, including metformin.

The principle behind this is simple. Fat (and fat turnover – the metabolism of fats) in the liver leads to resistance to your own insulin. Meanwhile, fat (and fat turnover) in the pancreas reduces insulin production. A double whammy! But by cutting your total calorie intake, you can lose weight and in turn lower the amount of fat buildup in your liver and pancreas, leading to your glucose levels falling back to normal levels.

As HCPs, we like it when people are able to bring their glucose levels down using just lifestyle interventions, such as a low-calorie diet. But we do not belittle the personal effort involved. And for some people, following a strict nutrition plan can be difficult.

Fortunately, in addition to professional nutritional advice and lifestyle changes, there are medications that can help. I write “help,” not “do the job instead,” because with any of these medications, making healthy lifestyle changes is still key.

The best of these currently is semaglutide, which you probably know as either Ozempic (a weekly injection) or Rybelsus (daily tablet), and for weight management alone as Wegovy.  These are a type of medication called a GLP-1 receptor agonist, and other medications in this class are also effective, as are another type of drug, SGLT-2 inhibitors. Plus there are exciting future advances in this field on the horizon, notably semaglutide at higher doses, and the approval of tirzepatide. 

Remember, glucose management is not just about weight loss, though. If your diabetes is diagnosed late, then more medications may be required. And over time almost certainly even more will be necessary. Taking medication (as I do for other things) is a pain, but it is worth it.

Finally, monitoring your glucose levels closely is key – otherwise imagine trying to control the speed of a car without a speedometer. This means using fingersticks or a continuous glucose monitor (though not everyone is able to access a CGM). But importantly it also means understanding and acting on the results.

Closely monitoring your glucose levels from day one – and trying to stay in a target range of 70 to 180 mg/dL – will decrease the risk of complications.

Medications to lower glucose 

The good news is that there are now plenty of medicines to help you manage your blood sugar from the very first day. Often, they are eventually needed in combination. The stalwart first line therapy is metformin – effective, but prone to cause gut upset in 10-20% of people. (If it does, there are plenty of alternatives.) Metformin is usually started as soon as it is known that lifestyle changes alone cannot produce near-normal blood sugars,  and often it is continued life-long, including in combination with insulin.

Recently, other choices have been proposed (in certain circumstances) as a first line option instead of metformin.

The class of medications called GLP-1 receptor agonists, which include semaglutide (discussed above), but also liraglutide (Victoza) and dulaglutide (Trulicity), can reduce future heart and stroke events in people who have already had one, and therefore should be offered to all those who have experienced this complication or are at risk for it.

Another class of medications, called SGLT-2 inhibitors (there are several on the market, including Invokana, Steglatro, Farxiga, and Jardiance), protects against the very common and important decline of kidney function in people with diabetes, and should be offered to anyone with declining kidney function or impaired kidney function (see our article on monitoring kidney function here). These drugs also protect against heart failure and should be started in anyone, at any time, who is at risk.

And yes, all three of these types of medication (including metformin) can work well together.

Finally, insulin is the natural hormone which controls blood sugar. In people with type 2 diabetes, high doses of insulin may be needed, because of the liver fat issue discussed above. Thankfully, hypoglycemia is much less of a problem in type 2 diabetes than in type 1 diabetes.

Newer tools of glucose monitoring are a great help in managing insulin doses, which vary a lot from person to person. If you aren’t able to achieve the results you and your healthcare team want after trying to manage your glucose levels with other medications, you will most likely be offered insulin (you can also ask your HCP about it at any time). Indeed, after 5-15 years, it is very common to need insulin anyway to manage your glucose levels and to stay healthy for another 20-plus years.

Other important interventions

Outside of glucose management, there are other things of importance that can help you stay healthy from the time of diagnosis and for years to come. Notably, since the average person with type 2 is at a much higher risk for heart attack and stroke, talk to your healthcare team about being prescribed a statin as soon as you are diagnosed. These have been used now by hundreds of millions of people (including myself) and are safe and effective.

If you already have some degree of kidney damage, talk to your healthcare team about a medication in the class of RAS (renin-angiotensin system) blockers. These medications lower blood pressure too, which is essential to protect against stroke as well as kidneys.

Lastly, apart from treatments, make sure that from day one, you and your healthcare team regularly monitor your kidney function and blood pressure as well as the health of your eyes, feet, liver, and heart. Yearly is the minimum interval.

The burden

There is no doubt that this all can be a burden. But by managing your diabetes early and actively, you can live a very healthy life. The inventor of cognitive behavioral therapy (Aaron Beck – he should really have won a Nobel prize) believed that by actively thinking through the reasons for doing things, and why things happen, it could suppress the automatic thoughts that can depress and distress us, and lead us to neglect positive behaviors. So, I encourage you to aim to actively understand and think about these interventions that can help you manage your diabetes.

Start early, continue long, and engage your brain (and your HCP advisors) in managing your diabetes.