Diabetes Mellitus (DM) is a chronic metabolic disorder that is characterized by persistent hyperglycemia (high blood sugar levels) and disturbances in carbohydrate, fat, and protein metabolism. These disturbances arise from defects in insulin secretion, insulin action, or a combination of both. Approximately 422 million people live with diabetes worldwide, the prevalence of which continues to rise each year. (1) Between 2000 and 2019, there was a notable 3% increase in diabetes-related mortality, with an estimated 2 million recorded deaths attributed to the condition in 2019 alone. (2)
There are three main types of diabetes: Type 1 Diabetes (which is an autoimmune condition), Type 2 Diabetes (which is often influenced by obesity and lifestyle factors), and Gestational Diabetes (which is diabetes that is typically diagnosed between 24- and 28 weeks gestation). In this blog post, we will explore the ins and outs of diabetes management, placing a special focus on Type 2 Diabetes.
OVERVIEW
Type 2 Diabetes Mellitus (T2DM) is a progressive disorder that is often characterized by the body’s inability to produce and utilize insulin efficiently and effectively, resulting in consistently raised blood glucose levels. Unlike Type 1 Diabetes, which is an autoimmune condition in which the body produces little to no insulin, Type 2 Diabetes is often the result of insulin resistance, resulting in a gradual decrease in insulin production over time, and is often associated with and influenced by obesity and poor lifestyle factors.
While genetics can play a significant role in the development and onset of Type 2 Diabetes, it can often be prevented and managed through lifestyle changes, including eating a healthy balanced diet, regular physical activity, and weight management. Type 2 Diabetes accounts for about 90-95% of global diabetes cases.
SYMPTOMS AND DIAGNOSIS
Symptoms of diabetes can occur very suddenly, however, in Type 2 Diabetes these symptoms are often mild and even remain unnoticed for many years. Common signs of diabetes include frequent urination (polyuria), excessive thirst and dry mouth (polydipsia), increased hunger (polyphagia), blurred vision, tiredness/fatigue, recurrent skin infections, poor healing wounds, and in some cases, tingling or numbness in the hands and feet. Symptoms may differ depending on whether your blood sugar levels are elevated (hyperglycemia) or low (hypoglycemia). If you notice that any of these symptoms are occurring frequently, it is essential to get screened for diabetes.
Screening for diabetes is a crucial step in the early detection and management of Type 2 Diabetes. Individuals at risk – such as those with a family history of diabetes, those experiencing symptoms, or those who are overweight or lead sedentary lifestyles – should be screened for diabetes every 1 to 3 years. Screening involves a simple blood test to measure blood glucose levels. Regular screening can help with early diagnosis allowing for timely intervention, such as dietary changes, medications, and lifestyle modifications, which can help reduce the risk of diabetes-associated complications. Common diagnostic tests include HbA1c, fasting blood glucose levels, and a 2-hour- plasma glucose test. If you are concerned about diabetes, consult with your healthcare provider or dietitian to discuss screening options.
DIABETES-ASSOCIATED COMPLICATIONS
Diabetes-associated complications can be categorized into acute and chronic conditions, both of which can significantly impact a person’s health if not managed properly. Acute complications include immediate issues like hypoglycaemia (low blood sugar), hyperglycaemia (high blood sugar), and diabetic ketoacidosis (DKA).
Hypoglycaemia occurs when blood glucose levels drop too low, often due to incorrect medication usage, skipping snacks and meals or intense physical activity. Symptoms of hypoglycaemia include confusion, weakness, sweating, seizures, or unconsciousness. We can manage hypoglycaemia using nutrition therapy by following the ‘Rule of 15’. If your blood glucose levels are low you must consume 15 grams of a fast-acting carbohydrate (such as Coke, 100% fruit juice or glucose sweets), then recheck your blood glucose levels 15 minutes later. If your blood glucose levels remain low, repeat the process until your blood sugar stabilizes.
On the other hand, hyperglycaemia, occurs when the blood sugar levels remain consistently elevated and can be caused by overeating (especially a carbohydrate-rich meal), taking the incorrect medication dosage or not taking your medication at all, and during times of stress and illness. Symptoms of hyperglycaemia include excessive thirst and subsequent frequent urination, fatigue, and headaches. Managing hyperglycaemia cannot be done through nutrition therapy alone and requires you to take your medication, stay hydrated, and closely monitor your blood glucose levels. DKA is a severe consequence of hyperglycaemia requiring hospitalization and can be life-threatening without prompt treatment.
In contrast to acute complications, chronic complications develop over time due to prolonged, poorly controlled blood glucose levels. Cardiovascular disease, diabetic nephropathy (kidney damage), diabetic retinopathy (eye damage), and peripheral neuropathy (nerve damage) are common chronic issues associated with poorly controlled diabetes. Regular monitoring and maintaining stable blood glucose levels are essential to preventing both acute and chronic complications, ensuring better long-term health outcomes for people living with diabetes.
MANAGING DIABETES
Managing diabetes involves a multifaceted, comprehensive approach that integrates medical treatment, medication, dietary adjustments, and lifestyle modifications to ensure lasting and effective results. By adopting a holistic strategy, individuals can achieve sustainable changes that improve their overall health and well-being.
Medical Treatment
When it comes to diabetes management, many individuals can effectively manage their blood glucose levels through lifestyle changes, and delay or even prevent the need for medications. However, for some, medical management is essential in controlling blood sugar levels, reducing the risk of complications, and maintaining quality of life. The medical management and treatment of diabetes offers a range of options, including oral agents and injectables to name a few. Due to the plethora of options available, selecting the right type of medication will depend on the specific outcomes you are looking for and the symptoms you are experiencing. Since diabetes affects everyone differently, working with a team of healthcare professionals to individualize your treatment plan is essential.
Role of healthcare providers
Managing diabetes requires a collaboration between a multidisciplinary team of healthcare providers, each of which plays an important role in addressing specific aspects of the condition:
Doctors/General Practitioners (GP) – A doctor is often the first point of contact in diabetes management and is generally responsible for diagnosing the condition. A doctor will oversee the patient's general health, monitor blood glucose levels, prescribe medications, and refer to specialists when needed.
Registered Dietitians (RD) – A dietitian plays a very important role in the nutritional management of diabetes, creating personalized and individualized nutrition care plans that help manage blood sugar levels, and meet the patient’s specific needs. Dietitians also play an important role in educating the patient on key aspects of diabetes management (like portion control, carbohydrate counting, and making healthy food choices.
Endocrinologist – An endocrinologist may need to get involved when diabetes becomes more complex. They specialize in managing the hormonal imbalances associated with diabetes and offer guidance on advanced treatments, including insulin therapy and other medication options.
Podiatrist – If left uncontrolled, diabetes often leads to foot complications such as diabetic neuropathy or poor circulation which can result in foot ulcers, infections or even gangrene. Podiatrists help to prevent and manage these complications, providing specialized care to maintain foot health.
Diabetes Nurses – A specialist nurse can help assist and provide hands-on support for the self-management of diabetes, including guidance on blood glucose monitoring, medication adherence and preventing complications. They are crucial in helping patients manage day-to-day challenges associated with diabetes management.
Psychologist – Living with diabetes can be emotionally challenging, leading to anxiety, depression, or burnout. Mental health professionals, like psychologists, support patients in coping with the psychological aspects of managing a chronic illness, helping to improve their overall well-being and quality of life.
Each member of the multidisciplinary team plays a pivotal role in managing both the physical and emotional needs of the individual.
Medication options
There are many different medication options available for individuals with diabetes, designed to lower blood glucose levels and prevent long-term complications:
Oral Glucose-Lowering Medications – Oral glucose-lowering medications, like Metformin, are often considered the first-line treatment for Type 2 Diabetes. Metformin, along with other medications like thiazolidinediones, works by improving insulin sensitivity, helping the body utilize insulin more effectively. Other oral medications, such as sulfonylureas, stimulate the pancreas to release more insulin, while DPP-4 inhibitors increase insulin production. These medications play a key role in reducing insulin resistance and promoting better blood glucose control.
Non-Insulin Injectable Medications – Medications like GLP-1 Receptor Agonist and Amylin Analogs work by stimulating insulin release, suppressing glucagon release (a hormone that raises blood glucose levels) and slowing down gastric emptying, thus helping to lower blood sugar levels.
Insulin Therapy – Insulin is usually reserved for patients whose blood sugar levels cannot be adequately controlled with oral medication or non-insulin injectables, or for those who have an absolute insulin deficiency (as in Type 1 Diabetes). The specific type of insulin chosen depends on a patient’s specific requirements (i.e. long-acting, rapid-acting, or a combination of both).
New and emerging treatment options
Recent advancements in diabetes management have introduced new treatment options onto the market that not only aid in improving blood sugar control but also assist in weight management and help to reduce the risk of diabetes-related complications. Ozempic and Saxenda, both of which contain semaglutide, a GLP-1 Receptor Agonist, are among the more popular treatment options. These medications work by enhancing insulin release, reducing glucagon levels, and slowing down digestion, ultimately leading to better glycaemic control.
While Ozempic and other “new-wave” injectables have significant benefits for managing diabetes, it is imperative that individuals who take this medication also adopt healthy lifestyle changes, such as following a balanced diet, taking part in regular physical activity, and maintaining healthy lifestyle habits. These medications are indicated for certain conditions (i.e. Diabetes) and therefore should be taken exactly as prescribed by your doctor, for their intended purpose.
LIFESTYLE MANAGEMENT
Overview of key dietary factors
The cornerstone of Diabetes management is a healthy, balanced lifestyle that prioritizes both nutrition and other lifestyle factors. Proper nutrition not only plays a role in managing blood sugar levels but also contributes towards overall health and well-being. A well-structured diet can reduce the risk of diabetes-related complications, such as hypertension, kidney disease, and cardiovascular disease, by promoting blood glucose control.
All About Carbs
Carbohydrates are the primary nutrients that affect blood glucose levels. When you eat foods containing carbohydrates, they are broken down into glucose and absorbed into the body, causing a rise in blood glucose levels. Because of this, individuals with diabetes need to monitor three key aspects when it comes to carbohydrate intake: the type of carbohydrates consumed, the amount, and how the carbohydrates are distributed throughout the day.
Carbohydrate distribution is effective in keeping your blood sugar levels controlled and balanced throughout the day and can be achieved through carbohydrate counting. Carb counting involves tracking the amount of carbohydrates consumed at each meal and snack, making it easier to track blood glucose levels and adjust your insulin/medication accordingly. Your dietitian will consider carbohydrate distribution when designing an individualized meal plan.
The type of carbohydrate is also important, and this is where the glycemic index (GI) comes into play. The glycemic index ranks foods based on how quickly they increase blood sugar levels. High GI foods cause a rapid spike in blood glucose levels and low GI foods cause a slow, steady increase in blood glucose levels. For better blood sugar control, individuals with diabetes should focus on low-GI foods, such as whole wheat and whole grains, which help maintain stable blood glucose levels throughout the day.
Another key aspect to consider is incorporating fiber-rich carbohydrates into our meals. Dietary fiber which is mainly found in whole grains, fruits, vegetables, and legumes, slows down digestion and the absorption of glucose, resulting in a slow and steady increase in blood glucose levels, as opposed to rapid blood sugar spikes. Including fiber-rich foods with every meal can help support a more controlled and balanced glucose profile. Women should aim for 25g of fiber per day, while men should consume 38g of fiber per day.
Choose Quality Fats
Healthy fats play an important role in regulating and managing blood glucose levels, but it is important to focus on high-quality fats. Incorporating good fats, such as those found in plant sources like avocados, nuts, seeds, olive oil, and fatty fish can help to support heart health and improve insulin sensitivity. Pairing these fats with carbohydrates at meals and snacks can also help slow down digestion and prevent spikes in blood glucose levels.
Lean Protein
While protein does not directly affect blood glucose levels, it can still play an important role in blood glucose management. Pairing a protein with carbohydrates is especially effective as protein slows down digestion, ultimately slowing down the absorption of glucose into the blood, leading to more stable blood glucose levels. To optimize blood sugar control, incorporate lean protein sources such as lean meats, chicken, fish, and low-fat dairy products into your meals and snacks.
Portion sizes
Portion control plays an important role when it comes to balancing carbohydrate intake and controlling blood glucose levels. Using techniques such as the MyPlate model, hand-size portion estimation guides or utilizing the portion sizes calculated by your dietitian in your individualized nutrition plan are imperative for effective blood glucose management.
Meal Timing and Consistency
Individuals with diabetes who are taking insulin or glucose-lowering medication need to carefully monitor their carbohydrate distribution and meal timing throughout the day. Eating at regular intervals throughout the day can help to prevent blood glucose spikes and fluctuations. Aligning your mealtime with your medication regimen can help to support balanced blood sugar levels. Skipping meals and not eating sufficient food can lead to adverse complications, such as hypoglycemia and should be avoided.
Physical activity
Physical activity can be defined as any deliberate muscle movement that results in energy expenditure. This can include simple movements such as walking, cleaning the house, gardening, and more. Physical activity is not only beneficial for weight loss and management, but it also helps to prevent and manage conditions like diabetes, cardiovascular disease, and even some cancers.
Physical activity is essential for diabetes management. It can help improve insulin sensitivity, lower blood sugar levels, aid in weight loss and weight management, improve cardiovascular health, and help improve mood and energy levels. The World Health Organization recommends at least 150 minutes of moderate-intensity exercise per week. Individuals with Type 2 Diabetes should perform a combination of aerobic and resistance training exercises every week. Aerobic activities like walking, swimming, dancing, and cycling can improve cardiovascular health and lower blood glucose levels, by utilizing glucose for energy. Resistance training, like weightlifting, or bodyweight exercises helps to build mass, which improves insulin sensitivity, as insulin functions more effectively in muscle tissue.
Mental health
Diabetes and mental health are often closely interconnected, due to the psychological and emotional challenges that accompany managing diabetes. One significant aspect is “diabetes distress” which refers to the emotional burden of constantly managing blood glucose levels, medication regimens, lifestyle changes, and the potential complications of diabetes. For some, this ongoing stress may lead to frustration and result in burnout.
Individuals with Diabetes are two to three times more likely to develop depression, which can make it harder to manage blood sugar levels effectively. (3) This in turn may contribute to poor blood glucose control, increasing the risk of diabetes-related complications. Anxiety and stress are also common, and these can directly affect blood glucose levels by triggering the release of stress hormones, like cortisol, which increases blood glucose levels.
Managing mental health is a crucial part of diabetes care. Receiving help and support from healthcare professionals, like psychologists, and maintaining communication with other members of the healthcare team can be very effective. Joining support groups with other individuals with diabetes can also be very impactful as it allows the opportunity to share experiences and practical tips and is also a valuable source of emotional support. Establishing a routine, including physical activity, and mindfulness techniques like yoga or meditation can also help to improve emotional well-being, leading to better diabetes management.
RESOURCES AND SUPPORT
A key aspect of diabetes management is knowing where to find reliable information, support, and resources. A diabetes diagnosis may initially feel overwhelming, but it doesn't mean life as you know it is over. In fact, there are many tools and communities available to help manage the condition effectively:
Healthcare Providers – Healthcare providers remain one of our top sources for information, care, and support. Dietitians, in particular, can help alleviate a lot of the burden surrounding diabetes management by creating personalized meal plans to help manage blood glucose levels.
Support Groups and Communities – Support groups are a great option for individuals with diabetes to connect, share practical tips, and discuss challenges. Many hospitals and medical centers offer in-person support groups. Social media platforms, like Facebook and WhatsApp, are excellent tools to connect individuals regardless of location, with numerous ‘virtual’ support groups available to join. Sweet Life (https://sweetlife.org.za/) is a registered NPO in South Africa that aims to connect and empower individuals with Diabetes. They provide scientific-based information and facilitate support groups for people across South Africa.
Online Resources – The internet offers a wealth of information, however navigating reputable sources can be confusing. When looking at information on the internet, look for resources shared by registered healthcare professionals, like Registered Dietitians, and medical doctors, or from governmental organizations. Trusted sites include the International Diabetes Federation (https://idf.org/) and CDE Diabetes (https://www.cdediabetes.co.za/), to name a few.
Other Resources – Additional valuable tools include self-help books (like The Diabetes Solution by Dr. Richard Bernstein), mobile apps (often linked to continuous glucose monitors, which provide real-time tracking of blood glucose levels), podcasts, webinars, and many more.
Although managing diabetes may present its challenges, with the right information, support, and resources it is possible to live a healthy and fulfilling life. Following a healthy balanced diet, exercising, and taking your medication as prescribed by your doctors is imperative in the management of Type 2 Diabetes.
References:
World Health Organization (WHO), 2024. Diabetes. [online] Available at: https://www.who.int/health-topics/diabetes?gad_source=1&gclid=CjwKCAjwtNi0BhA1EiwAWZaANOSQuEf5ZTfIs1Bvn_hLNUe1Y6znABDEAKOR2WI4iZc8uTJubvtyehoCBRUQAvD_BwE#tab=tab_1 [Accessed 16 July 2024].
World Health Organization (WHO), 2023. Diabetes. [online] Available at: https://www.who.int/news-room/fact-sheets/detail/diabetes [Accessed 16 July 2024].
Gonzalez, J.S., Peyrot, M., McCarl, L.A., Collins, E.M., Serpa, L., Mimiaga, M.J. & Safren, S.A., 2008. Depression and diabetes treatment nonadherence: a meta-analysis. Diabetes Care, 31(12), pp.2398-2403. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863499/ [Accessed 2 Sep. 2024].