Diabetes Mellitus Type 2: Therapy

General measures

• Aim for normal weight!Notice. A weight gain of 8-10 kg increases the relative risk of diabetes mellitus by a factor of 3, and a gain of 11-20 kg by a factor of 5.Determine BMI (body mass index) or body composition using electrical impedance analysis and participate in a medically supervised weight loss program.
  • For BMI of 27 to 35 kg/m2: about 5% weight loss.
  • With BMI > 35 kg/m2: > 10 % weight loss

  Weight loss of 5-7% significantly reduces the risk of diabetes in obese people with glucose tolerance disorders!According to the current US guideline on obesity treatment for diabetes mellitus, weight loss should be more than 5% of body weight: Furthermore, possible measures such as diet, increased physical activity and behavioral therapy are discussed.

  • In one study, 300 overweight individuals with a median type 2 diabetes duration of three years received liquid meal replacement therapy (less than 900 Kcal per day) for three to five months, with the goal of losing 15 kg. In such a way, 46% of participants achieved clinical remission of type 2 diabetes, that is, HbA1c was less than 6.5%, without any pharmacological diabetes medication; the group of those who had more than 15 kg weight loss achieved 89% probability of remission.
  • Continuously deteriorating beta cell function is reversible by radical weight loss. In the Direct study, patients with a median duration of diabetes of three years were randomly assigned to either a weight-loss program or a standard therapy group for this purpose. The results were clear: clinical remission of type 2 diabetes was achieved in 46 percent of subjects in the intervention group (versus 4 percent in the control group).
• Nicotine restriction (refraining from tobacco use) – participation in a smoking cessation program, if appropriate.
• Limited alcohol consumption (men: max. 25 g alcohol per day; women: max. 12 g alcohol per day), because alcohol can lead to hypoglycemia (hypoglycemia).
• Regular physical activity, at least 30 min. (↑ glucose uptake into the muscles).
• Regular examinations of the feet and footwear (foot care).
• Review of permanent medication due topossible effect on the existing disease or secondary diseases:
  • No use of nonsteroidal anti-inflammatory drugs (drugs that suppress inflammation and are not glucocorticoids (steroid hormones)): Nonsteroidal anti-inflammatory drugs should not be used regularly in patients with hypertension or chronic kidney disease (CKD; chronic renal failure) of any etiology, including diabetes mellitus.
• Avoidance of psychosocial conflict situations:
  • Bullying
  • Mental conflicts
  • Stress
• Avoidance of environmental stress:
  • Nitrosamines (carcinogenic substances).
• Travel recommendations:
  • Before starting a trip participation in a travel medical consultation!
  • Checking the metabolic situation: for seniors with long-standing diabetes mellitus type 2, an HbA1c value of about 7% is sufficient.
  • Most common metabolic derailment during a trip is hypoglycemia (hypoglycemia); as far as there is evidence in the anamnesis (medical history), the therapy must be adjusted.
  • During the flight, blood glucose should be measured every three hours, furthermore on the first day of travel before going to bed, because the risk of hypoglycemia is highest during the first night; at low values, a late meal is required.
  • Adjust insulin dose (see below Travel medicine/Checklists/Flight travel/Taking medication when traveling across multiple time zones).
  • Note that during sporting activity, there is a lower insulin requirement; always take a meter, insulin and glucose with you during sports.
• Diabetes and road traffic: well adjusted diabetics can drive vehicles of groups 1 (motorcycles and cars) and 2 (professional buses, trucks or cabs) without concern; For more see below the eponymous guideline.

Medical aid

• Continuous glucose monitoring (CGM), i.e., measurement of tissue glucose concentration (interstitial measurement) in subcutaneous adipose tissue.The CGM devices with real-time measurement display (so-called real-time function, rtCGM) continuously display the current glucose concentration during the recording phase and thus allow patients to adjust the therapy themselves.Indication: difficult to control blood glucose levels in patients with insulin-dependent diabetes mellitus.

Bariatric surgery/Bariatic surgery

In severely obese patients, gastric bypass (artificially reduced stomach) may be indicated in terms of metabolic surgery. According to a study by Schauer et al, 42 percent of diabetic patients have a normal HbA1c (laboratory parameter for determining blood glucose over the past days or weeks/HbA1c is the “blood glucose long-term memory,” so to speak) after surgery. In another study by Mingrone, as many as 75% of patients achieved remission of diabetes mellitus.

Vaccinations

The following vaccinations are advised, as infection can often lead to worsening of the presenting disease:

• Pneumococcal vaccination
  • The 13-valent polysaccharide vaccine (PCV13) covers fewer serotypes than the 23-valent polysaccharide vaccine (PPSV23), but has a better protective effect in immunosuppression (here: diabetes mellitus).
  • PPSV23 should be given no earlier than 2 months after PCV13; interval of 6-12 months seems to be more immunologically favorable.
• Influenza vaccination
• Herpes zoster vaccination

Regular checkups

• Regular medical check-ups including screenings:
  • Screening for diabetic neuropathy/peripheral nerve disease (once a year).
  • Screening for foot lesions (patients with type 2 diabetes without clinical findings of sensorimotor neuropathy should be screened for foot lesions at least annually; if clinical findings of sensorimotor neuropathy are already present, regular screening for foot lesions should occur every three to six months)
  • Screening for nephropathy/renal disease (once-yearly screening for albuminuria in patients who have poorly controlled plasma glucose or hypertension, if necessary for the latter, are not yet receiving an ACE inhibitor (or AT1 receptor antagonist), and who are also willing to improve therapy)
  • Screening for retinal complications (once a year).
  • Assessment of overall macrovascular and microvascular (large and small vessel disease) risk (at least every one to two years)
  • Screening for depressive disorder (if there are appropriate suspicions).
• Ophthalmologic examination (determination of visual acuity; examination of the anterior segments of the eye; examination of the retina (retinal) for mydriasis (dilated pupil):
  • Initial examination immediately after the diagnosis of diabetes mellitus has been made.
  • Regular check-ups of the eyes:
    • No damage to the retina (diabetic retinopathy; maculopathy), low risk: every 2 years.
    • No damage to the retina, high risk: annually.
    • Damage to the retina present: annually or at shorter intervals.
• Dental examination: participation in an annual dental examination Note: Patients with diabetes mellitus are at increased risk for increased periodontal breakdown and periodontal abscesses, possibly due to deficient neutrophil function.Periodontal treatment improves HbA1c by 0.6 percentage point (95% confidence interval 0.3 to 0.9)

Nutritional Medicine

Nowadays, the diet for a person suffering from diabetes is not as strict as it was a few years ago. It is also allowed to eat sugary foods.

• Individualized nutritional counseling based on a nutritional analysis.
• The goal of the dietary change must be weight reduction to normal weight!
• Observance of the following nutritional medical recommendations:
  • Regular intake of breakfast, lunch and dinner! Notice:
    • Skipping breakfast leads to postprandial hyperglycemia (elevated glucose levels) after the other two main meals.
  • Meals should contain 15-20% protein (upper limit is 21% – if there is no evidence of nephropathy), <30% fats, and 45-60% carbohydrates.
    • Avoidance or reduction of monosaccharides (single sugars) and disaccharides (double sugars).
    • Limit consumption of animal fats, that is, saturated fatty acids (<10% of daily energy); increase consumption of foods high in the monounsaturated oleic acid (10-15% of daily energy); increase consumption of foods high in polyunsaturated fatty acids (<10% of daily energy); that is:
      • Prefer: vegetable spreads (e.g., sunflower margarine), cold-pressed vegetable oils, vegetable spreads, nuts (Brazil nuts, walnuts, macadamia nuts, hazelnuts, pecans), lean meat, poultry, poultry sausage, fatty marine fish.
      • Avoid: Sausage and cold cuts, fried and breaded foods, convenience foods.
      • Replacing saturated fatty acids with polyunsaturated fatty acids reduces the risk of heart attack in diabetics.
  • Diet rich in fruits and vegetables
  • An excess of acid-forming foods is a risk factor for type 2 diabetes mellitus. Especially animal protein with a high content of the amino acids methionine and cysteine is considered acid-forming.
  • Slow eaters protect themselves from obesity and its sequelae.
• Low carb diet with form diet preparations (here: protein shakes) in type 2 diabetics: one week only protein shakes, then slowly increasingly combined with “low-carb” diet (controlled with blood glucose self-measurements); after 52 weeks of therapy, HbA1c was reduced on average by 0, 81 percentage points, weight reduced by 9 kg and blood pressure reduced from 134/80 to 128/77 mmHg.
• Type 2 diabetics who find a daily restriction diet too strenuous can instead fast 2 days a week (called interval fasting). Fasting on these days means limiting intake to less than 500 kilocalories, or one-quarter of what is needed. Comparison of a group on restriction diet with a group that did interval fasting showed the following result:
  • Restriction diet: HbA1c decreased by 0.5 percentage points (significant benefit with 95% confidence interval of 0.2 to 0.8 percentage points)
  • Intermittent fasting: HbA1c decreased by 0.3 percentage points (0.08-0.6)

  CONCLUSION: Intermittent fasting is an effective alternative to restriction diets.

• See also under “Therapy with micronutrients (vital substances)” – if necessary, taking a suitable dietary supplement.
• Detailed information on nutritional medicine you will receive from us.

Sports Medicine

• Endurance training (cardio; ↑ glucose uptake into muscle) and strength training (muscle; ↓ visceral fat and systolic blood pressure) to improve cardiovascular risk profiles
• Aerobic endurance training:
  • Frequency: at least three days a week (break between training sessions no longer than two consecutive days).
  • Intensity: at least moderate intensity (i.e., 40 to 60% of maximum endurance capacity (VO2max).
  • Duration: at least 150 minutes per week

  Aerobic endurance training leads to improvement in glucose metabolism, measured as HbA1c (endurance training -0.7%, strength training -0.6% HbA1c).

• Suitable endurance exercises are: Nordic walking, fast walking, running (jogging), swimming, cycling or even mountain or ski hiking.
• Strength training:
  • Frequency: at least 2 to 3 times per week (as part of physical activity and in addition to regular aerobic endurance training).
  • Intensity: at least from moderate (50% 1-RM, = one-repetition maximum) to vigorous (75 to 80% 1-RM) intensity to achieve optimal gains in muscle strength and insulin activity
  • Scope: consisting of at least 5 to 10 exercises, which include all major muscle groups (upper and lower body and trunk), each to be repeated 10 to 15 times.

  Strength training leads to improvement in glucose metabolism, measured as HbA1c (endurance training -0.7%, strength training -0.6% HbA1c).A possible contraindication (contraindication) that may limit and prohibit strength training in patients with type 2 diabetes mellitus is insufficiently well controlled hypertension.

• Exercise lowers blood glucose levels and improves insulin sensitivity. Suitable for this is an intense interval training, eg.For example, six one-minute exercise phases on the treadmill at 90% of the maximum heart rate, with one-minute breaks in between while walking slowly. This activity should be completed half an hour before meals.Since the diabetic, however, during and after exercise blood sugar fluctuations can occur, a blood glucose measurement before and after exercise is important.
• Patients in the second half of life should exercise dexterity, responsiveness, coordination, flexibility and agility
• Preparation of a fitness or training plan with appropriate sports disciplines based on a medical check (health check or athlete check).
• Detailed information on sports medicine you will receive from us.

Psychotherapy

• Stress management – Participants in an eight-week anti-stress group therapy with weekly exercise program were less depressed and more physically fit after one year; they had lower blood pressure, for example. Their protein excretion was unchanged – it had deteriorated further in the untreated control group.
• Detailed information on psychosomatics (including stress management) is available from us.

Training

Patient education is an integral part of the DMP diabetes mellitus type 2:

• In a diabetic training course, those affected are shown above all the correct use of insulin, the importance of blood glucose self-monitoring and the adapted diet. Furthermore, in such groups, a mutual exchange of experience can take place.
• Topics of patient education are diabetes and hypertension training.