Diabetes: Finding the Right Drugs – Diet Balance

Different drug-free treatment strategies you can consider if you are diagnosed with type 2 diabetes, or are at risk for it

If you are diagnosed with type 2 diabetes, or are at risk for it, you have different treatment strategies you can consider. You can depend on medicine alone, or you can focus on improving your diet and exercising more so you can work toward increasing your body’s ability to metabolize glucose. Many type 2 diabetics can lower their dependence on medicine by changing their lifestyle. But why bother when a pill can probably do the same thing? Because fewer meds mean fewer side effects. At the same time, a healthier diet and a fine-tuned exercise program can also improve your overall health.

Even though it may seem easier to rely on prescription medicines, most doctors would urge their patients to use drugs as a last resort. That’s because there’s a clear-cut link between being overweight 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.

Number of Americans with DiabetesUnfortunately, changing one’s diet, exercising and losing weight all prove to be challenging, and sometimes ineffective, for many people. Many patients give up and opt for a pill alone. 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. It’s a valid choice, but one that comes with risks.

Taking Medication for DiabetesMost commonly, oral medications for type 2 diabetics may increase the risk of hypoglycemia (low blood sugar) in those who take insulin, either alone or in conjunction with oral drugs. 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.

In its latest report, the CDC cites that more than 29 million Americans have diabetes, up from an estimated 26 million in 2010. The CDC also predicts that, given current trends, at least 1 in 3 people will develop type 2 diabetes in their lifetime. Those with type 2 diabetes are unable to effectively use insulin, 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. Experts believe that type 2 diabetes is almost entirely preventable by weight loss and exercise.

Global growth of Diabetes Medications and DevicesBy 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.

More Diabetics = More Drugs

Although the number of new cases of diabetes dropped , new drugs are routinely being developed. In 2013, the FDA approved 2 new drugs for the treatment of type 2 diabetes; in 2014, 5 more drugs were approved. In 2015 the FDA approved 2 new diabetes drugs (Tresiba and Ryzodeg, both injectable forms of insulin). (For more details, see drug chart.)

But some doctors and healthcare practitioners are wary of prescribing new medications before they have been on the market for a few years. Why? In the past 15 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.

Caroline Trapp, MSN, CDE, a certified diabetes educator and nurse practitioner and director of diabetes education and care for the Physician’s Committee for Responsible Medicine, has been working with diabetic patients for more than 20 years. She currently sees patients at Premier Internists in Southfield, MI. “When I got my first prescription pad, I thought, ‘Wow, I can really turn this disease around and make a difference,’” she says. “But back when I was prescribing Rezulin, I began to see patients with serious side effects. They were supposed to be improving, but they were getting worse, experiencing liver problems and other issues. Now I won’t prescribe anything 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.”

Inhaled Insulin: Ongoing Concerns

afrezzaAnother drug that continues to make headlines is the inhaled insulin, Afreeza, which has been on the market since early 2015. Inhaled insulin, which is used to treat type 1 and type 2 diabetes, is thought to work faster than oral medications or injected insulin. However, since Afreeza is delivered via a powdered form through an inhaler and is rapidly absorbed into the lungs, some experts are reluctant to prescribe it and confirm research that cites coughing and lung complications as a common side effect.

Says Trapp, “I can’t speak to this inhaled insulin, but I know I won’t prescribe it yet. I prescribed the earlier inhaled insulin a few times, though I found it challenging for patients to use — in part because of the device and in part because of the concern around respiratory side effects,” she adds.

In clinical trials, Afrezza was seen to trigger such side effects as hypoglycemia, cough and throat pain or irritation. Acute bronchospasm was observed in patients with chronic lung diseases, such as asthma or chronic obstructive pulmonary disease (COPD).

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, post nasal drip) among others.

The Problem With Drug Research

As new drugs continue to enter the market, it’s reasonable to wonder why a drug’s risks aren’t fully known before it is made available. The PCRM believes one of the problems is that research on type 2 diabetes drug treatments is focused on animal studies. Each year approximately 72,000 animals are used in some 1,400 government-funded experiments, with an annual price tag of $560 million, says the PCRM.

Unfortunately, these animal tests have failed to highlight the potential dangers of the drugs on humans, says Dr. Barnard. That’s why so many drugs have been pulled off the market due to side effects ranging from liver disease to heart failure. Dr. Barnard and others speculate that the rodent models do not clearly mimic human diabetes, which is why side effects in humans aren’t fully realized before these drugs are sold to consumers.

“Our government invests hundreds of millions of dollar a year in studies that involve mice, all in an effort to develop and seek approval for new drugs,” says Anne Bunner, PhD, former diabetes researcher and associate clinical director at the PCRM and currently a program analyst at Information Innovators. “We suggest that US taxpayer dollars be better spent on clinical studies that look at the behaviors and lifestyles that can prevent and reverse diabetes — and how we can encourage patients to follow them. This kind of research provides a more promising future for patients.”

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. Though the link between diabetes and obesity isn’t entirely clear, experts speculate that abdominal fat causes fat cells to release inflammatory chemicals that disrupt the cells’ ability to take in insulin (known as insulin resistance). By losing weight, diabetics reduce insulin resistance, thus allowing the insulin to work more effectively in the body.

Says Dr. Barnard: “People with type 2 diabetes find themselves on a road toward increasing weight, rising blood sugar and increased dependence on drugs.” But by making specific changes to the diet and by losing weight, type 2 diabetics can see blood sugar levels improve to the point where diabetes is no longer diagnosable, he adds. The benefit: antidiabetic medications can be lowered or stopped altogether and common symptoms of type 2 diabetes (like nerve pain in the legs and feet) can entirely disappear, Dr. Barnard explains. 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. Dr. 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.)

PCRM’s short documentary about how a plant-based diet helped Native American communities turn the tide on diabetes

Aside from providing overall health benefits, a low-fat diet has been found to reduce or eliminate the symptoms of type 2 diabetes. In a study conducted on nearly 25,000 Seventh Day Adventists over a 20-year period and published in the journal Diabetes Care, researchers found the prevalence of type 2 diabetes in vegans and lacto-ovo-vegetarians (those who eat no animal flesh but do eat eggs and dairy products) to be half that of non-vegetarians.

Researchers speculate this is due to the fact that those who consume a vegetarian diet typically take in fewer calories than those who eat a meat-based diet. Fewer calories lead to weight loss, which reduces the risk of diabetes. Eating fruits, vegetables, whole grains, legumes and nuts — the focus of a vegetarian diet — can also improve blood sugar control and make the body more responsive to insulin.

Prediabetics (those whose blood sugar levels are higher than normal but not yet in the diabetes range) may also benefit from eating nuts. A new Spanish clinical trial found that people with prediabetes who ate 2 ounces of pistachios a day showed a significant drop in blood sugar and insulin levels and improvements in insulin and glucose processing.

From a patient perspective, the idea of being able to address type 2 diabetes with diet first can be appealing. “I work in metro Detroit and many of my patients had great health care coverage up until a few years ago,” says Trapp. “They weren’t really concerned about paying for their diabetes medications, and there wasn’t a great deal of incentive to get off the drugs.” But today with higher health care costs being passed on to the consumer, the approach has changed. “Patients want to hear first about what they can do with diet and exercise in order to get — or stay — off medication,” she says. “Of course, avoiding the idea of having to give yourself injections is huge. But diabetes medications can cost patients hundreds of dollars a month out of pocket — so all of a sudden changing your diet becomes much more appealing.”

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.

The Value of Exercise

Exercise is another important element in the type 2 diabetes-prevention arsenal, as research shows that regular exercise lowers and regulates blood sugar levels. Three studies indicate that exercise can improve the health of diabetics (and those at risk for the disease) — and save them money in health care costs.

Prevention

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%.

Savings

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.

Exercise Snacks

Some type 2 diabetics may avoid exercise due to time constraints or the comorbidities of diabetes, such as arthritis, hypertension and peripheral neuropathy (nerve damage). However, new research shows that the best exercise benefits may be gained from short activity sessions —  some as brief as 12 minutes, 3 times a day. In a study published in Diabetologia, the journal of the European Association for the Study of Diabetes, researchers at the University of Otago in New Zealand found that these quick bursts of exercise — called “exercise snacks” — controlled blood sugar better than 1 continuous 30-minute session. An exercise snack might consist of 6 1-minute intense incline-walking intervals, interspersed with 1 minute of slow-walking recovery time in between each intense exercise. The “exercise snacks” were completed 30 minutes before breakfast, lunch and dinner.

Researcher Monique Francois said in a statement, “The notion of doing small amounts of interval exercise before meals is a unique and very important feature of this study. Sustained hyperglycemia [high blood sugar] following meals is an important feature of insulin resistance. Reducing these post-meal spikes [through exercise] is important for reducing the risk of developing type 2 diabetes and its associated complications.”

Medical experts make a strong case that changing one’s diet and adding more effective exercise strategies should not be a diabetic’s last line of defense.

But More Excercise Needed

Diabetics Need More Exercise for Same Benefit. If your doctor has recommended exercise, and you feel like you’re trying, but not getting results, it may not be your imagination. A study published this fall in the Journal of Applied Psychology found that those with an increased risk of type 2 diabetes may need to exercise more to achieve the same results as those who aren’t at risk for the condition. The participants (half of whom were at risk for diabetes and half who weren’t) were offered three training sessions per week during which exercise intensity and energy consumption were measured. The researchers found that those in the “at risk” group had to exercise more to achieve the same results as those in the control group.

Weight Loss is Key, But Wine May Be Fine

While the link to weight loss remains key to diabetes prevention, there may be good news on the wine front for diabetic oenophiles: Just released research from a 2-year study which was published in the Annals of Internal Medicine found that a glass of red wine each night with dinner may offer heart-health perks for those with type 2 diabetes. That’s potentially significant since those who suffer from the condition are at increased risk for heart problems, and typically have lower HDL (“good cholesterol”). It was found that over 2 years, red wine helped improve the cardiac health of those in the study by modestly increasing HDL and lowering cholesterol overall. The benefit is thought to come from what are known as red wine’s non-ethanol ingredients like resveratrol, phenols, and tannins, all of which deliver a heart-health benefit.

The study participants had generally abstained from wine prior to the trial and were randomly assigned to drink 5 ounces of red wine, white wine, or mineral water (the control group) with dinner during that 2-year period. They were also asked to follow a Mediterranean diet, but had no calorie restrictions. Similar benefits were not seen with white wine. Researchers say this is not license to drink too much, which can be deadly for diabetics: They caution 1 to 2 glasses of red wine for men and up to 1 glass of red wine for women, daily, with dinner is sufficient to reap the heart benefits without risking damage to the pancreas, a serious concern for those with diabetes.

On the Horizon

Contact Lens Insulin Monitoring

Google has announced that Verily (formerly its Life Sciences Unit) would make contact lenses with embedded glucose sensors. The tiny sensor will measure the body’s glucose level via tears and transmit the readings to a hair-thin antenna embedded in the lens, which will in turn send the data to a smartphone or other wireless device.

While experts say it could still take years before products like this reach consumers, Google is clearly committed to the venture. This fall they announced a partnership with Sanofi, makers of an insulin inhaler and other diabetic-focused products. In addition, they’re partnering with Johnson & Johnson, Novartis and Dexcom on other high-tech products for the diabetes market.

Artificial Pancreas

According to a British study published in the New England Journal of Medicine, the latest results of a trial of an artificial pancreas is yielding positive results. The product, which is designed for those with type 1 diabetes, has been shown to lower blood sugar levels without increasing the risk of dangerously low blood sugar, the most common side effect of most diabetes meds.

According to study researchers, the artificial pancreas combines existing technology, insulin pumps and continuous glucose monitors, with a computer algorithm that tells the devices what to do when blood sugar rises or falls. The artificial pancreas administers insulin according to blood glucose levels that are constantly monitored by an internal sensor. Researchers are currently working on conducting a longer trial and are working on refining the product to minimize the size and weight of a version that would be brought to market. Experts are hopeful that the artificial pancreas will be available to consumers in the next 2 to 3 years. And, when it is, it’s expected that it will be affordable and at least partially covered by most insurance.

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Geri Anne Fennessey

Geri Anne Fennessey

Geri Anne Fennessey is a New York City-based freelance writer and communications consultant.


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