Type 2 Diabetes: Finding the Right Drugs – Diet Balance

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Carol Gee had been using two different types of insulin injections as well as a pill to control her type 2 diabetes  successfully. Then her insurance company told her doctor they’d no longer cover the combination of drugs unless the doctor could show that no other options were suitable. When she tried a new formulation, however, she broke out in itchy hives and her heart started to race. She begged her doctor to make a special request to her insurance company to cover her previous treatments. She did, and now Gee is managing her diabetes without the hives and racing heart.

If you are diagnosed with type 2 diabetes, or are at risk for it, there are steps you can take to help prevent progression of the disease. In some cases, you may be able to avoid medications completely by focusing on diet and physical activity. If, like Gee, you do need medicine to maintain healthy glucose levels, diet and exercise can still help you minimize the amount of medication you need — and the side effects you may endure.

There’s a well-known link between carrying extra weight and having an increased risk of developing diabetes. “Obesity is a driving force behind type 2 diabetes. By losing excess weight, you automatically lower your risk for diabetes and its severe complications — loss of vision, foot amputations, kidney disease and, in some cases, an early death,” says Neal Barnard, MD, a diabetes researcher who is the founder and president of the Physicians Committee for Responsible Medicine (PCRM) and the author of Dr. Neal Barnard’s Program for Reversing Diabetes: The Scientifically Proven System for Reversing Diabetes Without Drugs.

A diagnosis of type 2 diabetes means that your body is unable to effectively use the insulin that you produce. Insulin is a hormone in the body that regulates blood sugar. Hyperglycemia, or high blood sugar, is the distinguishing characteristic of uncontrolled diabetes, and over time leads to serious damage to major organs such as the heart, kidneys and liver, as well as to the nerves and blood vessels. 

By contrast, those with type 1 diabetes are unable to make insulin and must rely on medication, typically insulin injections. Type 1 diabetes accounts for about 5% of all diagnosed cases of diabetes in adults, says the CDC. There is no known way to prevent it, although researchers speculate that genetic and environmental factors such as toxins or viruses contribute to the disease.

Experts believe that in many cases, type 2 diabetes can be prevented or mitigated through weight loss. Changing your diet, exercising and losing weight is challenging and the typical American diet and lifestyle make it difficult. Even with successful weight loss, in a minority of people it isn’t enough to reverse diabetes. Those patients who don’t lose weight or still have diabetes despite weight loss must rely on drugs to manage diabetes. 

In its National Diabetes Statistics Report, 2014, which includes data from the years 2010 to 2012, the Centers for Disease Control and Prevention (CDC) reports that 11.9 million adults were taking oral drugs and 3.1 million were taking a combination of insulin and oral medication to manage their diabetes.

Side Effects

Oral medications for type 2 diabetics are designed to help you manage blood sugar, as a result, they can increase  your risk of hypoglycemia (low blood sugar). Other common side effects are headaches, blurry vision, flu-like symptoms, fluid retention, weight gain and gastrointestinal problems. Because of continued fluctuations in blood sugar levels, some of the side effects of insulin may mirror the symptoms of diabetes.

The drugs can also interact with several prescription drugs like steroids, birth control pills, antibiotics, statins, as well as over-the-counter NSAIDs. It’s important to discuss any other medicines or supplements you may take with your doctor, because your dosages may need to be adjusted. For more specifics about the risks associated with diabetes drugs, see MedShadow’s Need to Know article on diabetes drugs.

More Diabetics = More Drugs = More Risk

New drugs for diabetes that promise to reduce the need for injections and make life easier for patients hit the market every year, but some healthcare practitioners are wary of prescribing new medications before they have been on the market for a few years. Why? In the past 20 years at least 3 drugs have been found to have serious side effects. Actos and Avandia have been given the FDA “black box warnings” though haven’t been pulled from the market. Actos is thought to increase the risk of congestive heart failure in diabetes patients and research shows Avandia may increase the risk of heart failure, heart attack, and bladder cancer. More seriously, Rezulin (a member of the thiazolidinedione (TZD) drug family — the same as Avandia and Actos — has been pulled from the market altogether due to concerns over risk of severe liver damage and toxicity.

One of the doctors who avoid prescribing drugs new to the market is Caroline Trapp, DNP, a certified diabetes care and education specialist and nurse practitioner is the director of diabetes education and care for the Physicians Committee for Responsible Medicine. She has been working with people with diabetes for more than 25 years. 

Trapp said, “When I was first able to write prescriptions, I thought, ‘Wow, I can really turn this disease around and make a difference,’” she says. “There was a new medication called Rezulin, which was lauded as a safe and effective treatment, worth its price of $5 a pill. But I began to see patients experience serious side effects. They were supposed to be improving, but they were getting worse, experiencing liver problems and other issues. Rezulin was taken off the market, and other diabetes medications have also come and gone. Since that experience, I’ve become much better at prescribing safe and effective lifestyle interventions, and I won’t prescribe any medication until it’s been on the market for 3 years. Many doctors say a year — and that used to be my standard — but I’ve seen these awful side effects firsthand. The bottom line for me is that medications are not a cure for a disease that is due primarily to the standard American diet. Patients trust their clinicians to prescribe what works, and I want to maintain that trust.”

Inhaled Insulin for Type 2 Diabetes: Ongoing Concerns

Another drug that continues to make headlines is the inhaled insulin, Afrezza, which has been on the market since early 2015. Inhaled insulin, which is used to treat type 1 and type 2 diabetes, is taken immediately before eating and works faster than oral medications or injected insulin. However, since Afrezza is a powder delivered through an inhaler and is rapidly absorbed into the lungs, some experts were reluctant to prescribe it concerned that it might have respiratory side effects.

In clinical trials, Afrezza triggered hypoglycemia, cough and throat pain or irritation. Some patients reported wheezing and difficulty breathing.

This is the second time an inhaled insulin has reached the market. Back in 2006, the FDA approved the use of a drug called Exubera. But within a year, Exubera was pulled due to lack of consumer demand and amid concerns it caused lung and respiratory side effects, such as respiratory tract infection, cough, pharyngitis (discomfort, pain and scratchiness in the throat), and rhinitis (runny nose, sneezing, postnasal drip) among others.

The Importance of Weight Loss

While antidiabetic drugs and insulin play an important role in helping to regulate blood sugar, researchers like Dr. Barnard cannot stress strongly enough the benefits of losing weight and getting exercise. By losing weight, you can reduce insulin resistance, thus allowing the insulin to work more effectively in the body. When you do lose weight, you may be able to discontinue taking drugs to control your blood sugar, like Janice Zayon. After five years of regularly taking medication, her doctor suggested that her disease seemed to be under control and that with some lifestyle modifications, she could try managing it without drugs. It worked.

Two years ago, she says, “I changed my diet around entirely, and I’ve been off of all diabetic medicines since then.” She focuses on fruits, vegetables, and lean meat like chicken. “I eat red meat once a month,” she says and while she allows herself sweets on occasion, she mostly limits her intake of starchy carbohydrates.    

Barnard says that making specific changes to your diet and losing weight can improve your blood sugar levels to the point where diabetes is no longer diagnosable. Then, he says, antidiabetic medications can be lowered or stopped while common symptoms of type 2 diabetes (like nerve pain in the legs and feet) can entirely disappear. Even better, serious comorbidities that accompany diabetes like heart disease can be reversed, reducing the need for those medications as well.

Meghan Jardine, MS, RD, CDE, the associate director of diabetes nutrition education at the PCRM, suggests that diabetics who want to safely and effectively lose weight begin with a whole-foods, plant-based diet that is rich in high-fiber foods and low in foods that are processed. Barnard also advocates a diet that minimizes fat, especially animal fat, found in meat, eggs and dairy. (For more nutrition information, including healthy recipes for diabetics, visit the PCRM’s Food for Life Diabetes Initiative.)

The National Institute of Diabetes and Digestive and Kidney Diseases also suggests that those with diabetes consider keeping track of their carbohydrate intake. When processed in your body, carbohydrates become glucose, which affects your blood sugar more than other foods. Keeping track of carbohydrate intake can help you determine how much insulin to take at a time.

Certified Diabetes Educator

Some diabetics work with a certified diabetes educator (CDE), a health professional who specializes in the treatment and care of diabetes. CDEs can help people who are prediabetic, at risk of developing type 2 diabetes, have a family history of diabetes, or are diabetic and on medication. The cost is often covered by insurance. The National Certification Board of Diabetes Educators can help locate CDEs by area.

Medicare also offers an oft-forgotten nutritional component that covers consults with nutritionists for patients with diabetes or kidney disease.

The Value of Exercise in Type 2 Diabetes Patients 

Increasing your physical activity may enhance the effects of a healthy diet. We’ve known for decades now that exercise is an important part of preventing and treating type 2 diabetes. The Diabetes Prevention Program (DPP), a federally funded clinical research project, studied more than 3,000 people at high risk for diabetes. In results published in the New England Journal of Medicine in 2002, the DPP found that participants who lost 5 to 7% of their body weight and engaged in low-intensity physical activity (including walking) decreased their risk of developing type 2 diabetes by 58%.

In 2010, American College of Sports Medicine and the American Diabetes Association issued a joint statement that 150 minutes of exercise per week positively impacts lipids, blood pressure, cardiovascular events, mortality, and quality of life in people with type 2 diabetes

More recently, a 2019 study published in Diabetic Medicine found that when people with type 2 diabetes lose 10% or more of their body weight in the first year after diagnosis, the likelihood that their diabetes will be undetectable in five years doubles.

Exercise doesn’t just improve your health, it decreases the cost of your healthcare. A study by the Wake Forest Baptist Medical Center, published in the journal Diabetes Care, found that overweight people with diabetes who lost weight and increased their physical activity reduced out-of-pocket health care costs by an average of more than $500 a year. The study tracked more than 5,000 people, ages 45 to 76, over the course of 10 years and measured 2 groups: one which engaged in an Intensive Lifestyle Intervention plan, and another which participated only in programs focused on Diabetes Support and Education. Those who made the lifestyle changes had 11% fewer hospitalizations, 15% shorter hospital stays, and used fewer prescription drugs, saving each person $5,280 in health care costs over the 10-year period.

An important caveat, however, is that you’ll need to check your blood sugar before and after exercising so you understand how your blood sugar responds to different types and amounts of physical activity. You’ll need to make sure your blood sugar isn’t too high or too low to exercise safely. The more strenuously you exercise, the more likely it is that your blood sugar will drop. You’ll also need to check it when you finish your workout. If it’s low, you may need a snack.

Diabetes is a chronic illness, and it’s important that you work with your healthcare provider to determine the best strategies to manage your blood sugar safely. For some, medicine may be a necessity, while others may be able to forgo drugs. What’s clear is that no matter which group you’re in, maintaining a healthy diet, monitoring carbohydrates, and exercising are beneficial.