Type 2 Diabetes
What is Type 2 Diabetes?
Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin to meet its needs. In type 2 diabetes (formerly called non-insulin-dependent diabetes or adult-onset diabetes), the pancreas continues to produce insulin, sometimes even at higher-than-normal levels. However, the body develops resistance to the effects of insulin, resulting in not enough insulin to meet the body’s needs.
Causes and Symptoms
Type 2 diabetes, once rare in children and adolescents, has recently become more common. However, it typically begins in people older than 30 and becomes progressively more common with age. About 26% of people older than 65 have type 2 diabetes. Obesity is the chief risk factor, with an estimated 80 to 90% of people with this chronic disease being overweight or obese. Certain race and ethnic groups are also at increased risk such as: African Americans, American Indians, and Latinos who live in the United States – all have a twofold to threefold increased risk. Type 2 diabetes is also hereditary and tends to run in families.
People with type 2 diabetes may not experience any symptoms for years or decades before they are diagnosed. Initial symptoms may be subtle and include:
- Increased urination and thirst
- Blurred vision
Diagnostic criteria by the American Diabetes Association (ADA) include the following :
- A fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or higher, or
- A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during a 75-g oral glucose tolerance test (OGTT), or
- A random plasma glucose of 200 mg/dL (11.1 mmol/L) or higher in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis
- A hemoglobin A1c (HbA1c) level of 6.5% or higher can also be used as a diagnostic criterion.
The goals of type 2 diabetes management and treatment include reducing the risk of both micro and macrovascular disease risk. Goals of treatment are as follows:
- Microvascular (i.e., eye and kidney disease) risk reduction through control of blood sugar and blood pressure
- Macrovascular (ie, coronary, cerebrovascular, peripheral vascular) risk reduction through control of blood lipids and hypertension, smoking cessation
- Metabolic and neurologic risk reduction through control of blood sugar
Approaches to help prevent diabetic complications include the following:
- HbA1c every 3-6 months
- Yearly dilated eye examinations
- Annual microalbumin checks
- Foot examinations at each visit
- Blood pressure < 130/80 mm Hg, lower in diabetic nephropathy
- Statin therapy to reduce low-density lipoprotein cholesterol
What is the Conventional Treatment?
Diet, exercise, and education are the cornerstones of treatment of diabetes and often among the first recommendations for people with mild diabetes. Because complications are less likely to develop if blood sugar levels are tightly controlled, the goal of treatment is to keep blood glucose levels within a normal range as much as possible. In addition, the treatment of high blood pressure and high cholesterol levels are also an important part of preventing diabetes complications such as having a heart attack and/or stroke.
Diet: A healthy diet is important for controlling blood sugar levels and preventing diabetes complications. Eating a consistent, well-balanced diet high in fiber and low in saturated fats and concentrated sweets is recommended. Carbohydrates tend to have the greatest effect on blood sugar therefore to control blood sugar individuals should know which foods contain carbohydrates, the size of “a serving” of different foods and how many carbohydrate servings to eat each day. A registered dietitian can help individuals work out a diet/meal plan that works best for them. For more detailed information about nutrition therapy recommendations set forth by the American Diabetes Association go to Nutrition Therapy Recommendations for the Management of Adults With Diabetes.
A low glycemic diet which focuses on foods that are low on the glycemic index have been shown to lower postprandial glucose and insulin levels and improve lipid profiles and are thought to reduce the risk of both diabetes and cardiovascular risk. As of yet, no intervention studies have been performed, but evidence available from epidemiological studies suggest a protective effect to lower glycemic diets.
Exercise and Weight Control: Regular exercise, in any form, can help reduce the risk of developing diabetes. Physical activity helps move sugar from the blood into the cells of the body. The more active the individual, the lower the blood sugar level. Physical activity can also help reduce the risk of diabetes complications such as heart disease, stroke, kidney failure, blindness and leg ulcers. As little as 20 minutes of walking, three times a week has found to be beneficial. Individuals taking insulin may need to lower their insulin dose before exercising. Working with a doctor will help determine if medication adjustments are necessary. If an individual is overweight, modest weight loss (i.e. 10 lbs.) can reduce the risk of developing diabetes and help normalize blood sugars and/or reduce the need for diabetes medication.
Self-Monitoring Blood Glucose: Careful monitoring of blood sugar levels is the only way to make sure blood sugar levels remain within recommended target levels. Checking blood sugar levels using a glucometer is generally recommended before each meal and again at bedtime. A range of 90-130 mg/dl before meals is suggested for most people with diabetes. However individuals should work with their doctor to set their particular target.
Early initiation of pharmacologic therapy is associated with improved glycemic control and reduced long-term complications. However there are many different types of medications that may be used alone or in combination to treat diabetes. Examples include:
- Biguanides – help lower blood sugar by making sure the liver does not make too much. They also help lower the amount of insulin in the body. Metformin is an example of a biguanide.
- Sulfonylureas– help the pancreas make more insulin, which then lowers blood glucose. They also help the body make use of the insulin it already makes. Glimepiride, glyburide, glipizide are all sulfonylureas.
- Meglitinide derivatives-help the pancreas make more insulin right after meals and is often used in combination with metformin. Repaglinide is a meglitinide.
- Alpha-glucosidase inhibitors– these work by decreasing the absorption of carbohydrate from the intestines, slowing the absorption and lowering the rise of blood sugar throughout the day. Acarbose and miglitol are alpha-glucosidase inhibitors.
- Thiazolidinediones (TZDs) – help make cells more sensitive to insulin. Examples of TZD’s include piogliazone and rosiglitazone.
- Incretin mimetics- work by mimicking incretins such as GLP-1. GLP-1 is a hormone that increases insulin secretion by the pancreas, slows absorption of glucose from the gut and reduces the action of glucagon. All three actions reduce blood sugar levels. Exenatide (Byetta®) is an injectable medication that mimics GLP-1.
- Dipeptidyl peptidase IV (DPP-4) inhibitors- works by inhibiting the body’s ability to control blood sugar. After eating, this medication reduces the amount of sugar produced by the liver. Sitagliptin (Januvia®) is a DPP-4 inhibitor.
- Insulin – acts like the insulin produced by the body and may be necessary in patients with type 2 diabetes to overcome insulin resistance. There are several types of insulin classified by how soon and how long they act. Premixed combinations are also available. For more information about the different types of insulin available, go to: diabetes.org
Banaba (Lagerstroemia speciosa) is an herbal medicine traditionally used in the Philippines for blood sugar stabilization. The hypoglycemic effect, which pre-clinical trials have suggested is due to insulin-mimetic and anti-adipogenic properties, is thought to be attributed to corosolic acid and ellagitannins. Clinical trials of Banaba, though, are lacking. A small (n=31) study of diabetics and non-diabetics, using 10mg of corosolic acid before a glucose tolerance test, showed reduction of blood glucose levels at 60, 90, and 120 minutes, but only reached significance at 90 minutes. 
Bitter Melon (Momordica charantia) is both a food and a medicine native to South America, Africa, and Asia. Active ingredients appear to be charantin, vicine, and polypeptide-p. These ingredients appear to have effects on insulin secretion, glucose uptake, and gluconeogenesis in pre-clinical studies. A 2009 review found few clinical trials of good quality to comment on effectiveness, but thought pre-clinical data was intriguing enough to call for more trials. A 2012 Cochrane review found four clinical trial involving 479 participants, two were uncontrolled and open-label. They found no significant effect for Bitter melon on blood glucose parameters.
L-carnitine is an amino acid that plays a role in metabolism as a modulator of fuel utilization in cells through insulin-mediated glucose disposal.  Carnitine appears to assist in the removal of fatty acyl CoA derivatives/metabolites that are present in muscle mitochondria and lead to inhibition of both insulin signaling and glucose oxidation (leading to insulin insensitivity). A 2012 review suggests that carnitine’s actions are especially present in insulin-resistant states. The acetylated version (acetyl-L-carnitine) is the version seen most often in research.
Chromium is a trace element that has an active role to play in both carbohydrate and lipid metabolism, it is also a component of glucose tolerance factor. Chromium deficiency has been known for a long time to cause a reversible insulin resistance and diabetes (especially during parenteral feeding). A 2007 meta-analysis reviewed 41 trials (N = 1198) at dosages ranging from 200 to 1000 mcg/day. Fourteen of these trials (N = 431) investigated type 2 diabetics with HbA1c levels between 7.0-10.2 and were able to show a 0.6 percent drop in HbA1c over the study periods. A 2014 Review analyzed 25 studies that met inclusion criteria and concluded that chromium (especially chromium picolinate) using dosages of or greater than 200 mcg/day improved glycemic control (as evidenced by HbA1c and fasting blood glucose levels) along with improve triglyceride levels in diabetics.
In other studies, when chromium in combined with biotin (2mg/day), the results were better (1.76 percent reduction in HbA1c level) for a sub-set of patients with levels above 10 (poorly controlled). Although other studies using biotin and chromium combination showed no results.
Cinnamon (Cinnamomum cassia) is a commonly used spice, but it also has medical properties. Pre-clinical trials have demonstrated cinnamon’s ability to activate insulin receptors and increase glycogen synthase activity.  A 2008 meta-analysis of five clinical trial (n=282) evaluated doses of cinnamon from 1 to 6 grams daily and reported no changes in hemoglobin A1C, or lipid parameters, although one of the studies did show a decrease in fasting blood glucose. A 2012 Cochrane review of ten randomized controlled trials found a high degree of potential for bias, and could not recommend cinnamon for use in diabeteics. A 2013 review of 10 randomly controlled trials (n=543) of 120mg -6g dose for 4-18 weeks showed an overall reduction of fasting plasma glucose (-24.59 mg/dl), total cholesterol (-15.60 mg/dl), LDL-C (-9.42 mg/dl), triglycerides (-29.59 mg/dl) and increased HDL-C (1.66 mg/dl) but no significant effect on hemoglobin A1c levels.
Fenugreek (Trigonella foenum-graecum) is a spice and an herbal medicine. Preliminary trials suggest hypoglycemic and antihyperlipidemic properties. A 2014 meta-analysis of 10 randomly controlled trials, in patients with diabetes, demonstrated a pooled response of significant changes in blood glucose 0.96 mmol/l, 2 hour postload glucose by -2.19 mmol/l and HbA1c by -0.85% as compared to control interventions.
Epidemiological and cohort studies have long suggested an association between cereal grain fiber and reduced incidence of type 2 diabetes. A 2000 study published in New England Journal of Medicine evaluated a high fiber diet (50 grams) and concluded that soluble fiber, especially, helps to improve glycemic control, while decreasing hyperinsulinemia, and lowering plasma lipid concentrations in patients with type 2 diabetes. A 2001 Review of patients with type 2 diabetes who consumed a diet high in fiber (50 g fiber/day) for six weeks showed significant improvements in glycemic control and lipid panels when compared with patients who consumed a diet with moderate amounts of fiber (25 g fiber/day) but they questioned whether the diet could be maintained long-term because of compliance issues. A recent (2013) systematic review/meta-analysis of randomly controlled trials for effect of fiber on glycemic control, chose 11 trials that met inclusion criteria, (n=605). They concluded that high fiber diets (up to 42.5 g/day) or supplements containing soluble fiber (up to 15.0 g/day), were able to reduce reduced HbA1c, by 0.55% and fasting plasma glucose by 9.97 mg/dL.
Most pre-clinical and epidemiological studies support an association between fish oil/fish intake and reduction in incidence of type 2 diabetes, although in some cases, negative associations are present. Omega-3 fatty acids have a known beneficial association in heart disease, including improvement in blood lipids (especially triglycerides – which have an association with glycemic control and inflammation). These associations, however, have not translated into positive clinical trials in persons with diabetes or metabolic syndrome using fish oil supplements. In humans, the majority of randomly controlled studies have failed to show improvements in glycemic control or insulin sensitivity. 
While traditional use along with pre-clincal studies have suggested garlic (Allium sativum), and garlic extracts may have an effect on both insulin and glycemic parameters, no large randomly controlled trial exists in the treatment of type-2 diabetics. Garlic does contain volatile sulfur compounds (alliin, allicin, diallyl disulfide, diallyl trisulfide, diallyl sulfide, S-allyl cysteine, ajoene and allyl mercaptan, among others) that appear to have effects on insulin resistance. Garlic also has known antioxidative, anti-inflammatory, and antiglycative properties.  One randomly controlled trial (which demonstrated the most dramatic effect on glycemic parameters) was designed to examine thrombocyte aggregation in non-diabetic populations.
The polyphenol catechins (especially epigallocatechin gallate, EGCG) has been the focus of numerous studies. These catechins appear to improve both insulin sensitivity and reduce beta-cell damage in per-clinical trials.  Caffeine, also present in green tea, is known to initially impair glucose metabolism, but longer use stimulates lipolysis and increases basal energy expenditure along with mobilizing glycogen from muscle stores. Population studies suggest a reduction of Type 2 Diabetes risk of up to 48 percent for regular tea consumers.  To date, few clinical trials have taken place to test the association. A small randomly controlled trial (n = 49) supplemented green tea catechins for three months and reported no changes in Hemoglobin A1c levels. Another crossover study followed sixty borderline diabetics who received a green tea-extract powder containing 544 mg polyphenols (456 mg catechins) daily for 2 months and then were crossed over to the non-intervention arm for a 2-month period. A significant reduction in hemoglobin A1c levels were reported.
Ginseng has been investigated in pre-clinical trials that have demonstrated reduced carbohydrate absorption, increased glucose transport, and modulation of insulin secretion. The saponins (panax notoginseng saponins – PNS) are thought to be anti-inflammatory and help decrease postprandial glycemic response.   A few short clinical trials have been performed to assess American ginseng’s effects on the glucose tolerance test in both diabetic and non-diabetics participants and was found to significantly reduce GTT.  In a longer trial, decreases in both fasting blood glucose and Hemoglobin A1c levels have been reported.
Gymnema (Gymnema sylvestre) has found use in Ayurvedic medicine to help diabetes, high cholesterol, and obesity. In pre-clinical trials, Gymnema has been shown to decrease the uptake of glucose from the small intestine.  Several components present in Gymnema appear to prevent the accumulation of triglycerides in muscle and liver.  A few small clinical trials have shown significant effects on fasting blood glucose and HemoglobinA1c levels. An unpublished trial used 200 mg of an ethanolic extract daily for 18 months in 22 persons with type 2 diabetes showed improvements in blood sugar control. Two, uncontrolled trials (n=65 and n=27), using 400-800 mg for 3-12 months also showed significant improvements.  A 2007 review suggested that none of these trails meet standard inclusion criteria, but pre-clinical research is very promising and, therefore, warrant further investigation. 
Magnesium is a co-factor in many enzymatic pathways involved in glucose regulation including glucose oxidation and modulation of glucose transport across cellular membranes. Hypomagnesemia is a common presentation in diabetics (especially those with glycosuria), and magnesium deficiency is known to increase insulin resistance. A review of epidemiological studies suggests a strong role for magnesium in the prevention of diabetes and metabolic syndrome. Clinical trials have been mixed, with some showing improvements in fasting blood glucose  and fructosamine levels, but most showing no response. A 2012 review cites the strong observational studies, but points out that good clinical data are lacking, perhaps due to length (years) and cost of such studies. Magnesium also may play a role complications of diabetes such as retinopathy, neuropathy, thrombosis and hypertension.
In pre-clinical trials, vanadium appears to exert an insulinomimetic effect.  A 2008 meta-analysis discovered 150 potential trials, but non met inclusion criteria, they then considered five uncontrolled trials (N= 48), using 50-300 mg vanadium for 3-6 weeks that demonstrated significant reductions in fasting blood glucose levels and suggested that, while promising, must be interpreted with caution.
Vitamin E has well known antioxidant activities, with potential influences of protein glycation, lipid oxidation, as well as insulin sensitivity and secretion, but whether this translates into effective treatment or prevention of diabetes is unknown. A 2011 review of nine clinical trial (N = 418) vitamin E supplementation appeared to help a sub-set of diabetes (those with poor glycemic control and whose baseline vitamin E levels were low).  Further trials are needed to understand vitamin E’s role in blood sugar regulation and control.
Other Professional Resources:
American Diabetes Association’s Standards of Medical Care in Diabetes
American Diabetes Association Nutrition Therapy Recommendations
 National Diabetes Statistics Report, 2014
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