An Endocrinologist’s Guide to Diabetes Treatment and Care

Here are the basics: When you eat and drink, your body breaks down the substances you’re consuming into glucose, which then enters your bloodstream. This triggers your pancreas to release the hormone insulin, which gets to work moving glucose out of the blood and into your cells so your body can convert it into energy. Any extra glucose that your body doesn’t currently need for energy gets stored in your liver and muscles for later use. But when issues with insulin function disrupt this process, leading to excess amounts of sugar in the blood, over time this can result in type 2 diabetes.

Here’s what you need to know:

While there are many different kinds—including gestational diabetes, which occurs during pregnancy, and several rare types influenced by genetics—the most common kinds by far are type 1 and type 2.

Type 1 diabetes

Type 1 diabetes is an autoimmune disease in which the body mistakenly attacks healthy insulin-producing cells in the pancreas, explains Carmella Evans-Molina, M.D., Ph.D., director of Indiana University’s Center for Diabetes and Metabolic Diseases. People with type 1 diabetes make up about 5% to 10% of all cases of the disease, and while there is a slight genetic component, many people who are diagnosed with it have no family history of it. Type 1 diabetes is often thought of as something that kids get (it used to be called juvenile diabetes), but adults can develop it too. In fact, 50% of all new cases of type 1 diabetes are thought to be in adults.

Doctors generally have an easier time diagnosing type 1 diabetes in kids, who present with classic symptoms of excessive thirst, excessive urination, and weight loss. “Children often have a really aggressive course of type 1 diabetes, and develop it quickly,” says Dr. Evans-Molina. In adults, however, the effects of the autoimmune response can manifest more slowly. “This is part of why many adults with type 1 are misdiagnosed and treated with drugs meant for type 2 diabetes,” Dr. Evans-Molina says. (The treatments for type 2 are different.) “It can take a number of years for a clinician to make the correct diagnosis.”

Type 2 diabetes

Type 2 encompasses up to 95% of diabetes cases and occurs when the pancreas doesn’t produce enough insulin to deal with the glucose in the blood or the cells no longer respond well to the insulin the pancreas cranks out (that’s insulin resistance). That means too much sugar remains in the bloodstream, which can lead to problems throughout the body, including nerve damage and kidney disease. Genetics play a role in type 2 diabetes, but there are several modifiable risk factors, including weight, diet, and lifestyle (not getting enough exercise can increase your risk).

Type 2 diabetes is the fastest-growing chronic disease in the world, according to the American Diabetes Association (ADA), affecting children and teens in epidemic numbers. Researchers predict that by 2060, as many as 220,000 people under the age of 20 will have type 2 diabetes. That’s a 700% increase from today. Diabetes is a lifelong diagnosis (though it’s possible to go into remission), so the number of adults with the condition is set to explode.

Then there’s the Ozempic factor. No doubt you’ve heard about it as a weight-loss wonder drug, but it was designed for diabetes. GLP-1 (which stands for “glucagon-like peptide-1”) medications, including Ozempic and Trulicity, have been groundbreaking in treating type 2 diabetes: One study compared four classes of diabetes meds for people at moderate risk of cardiovascular disease (which is associated with diabetes) and found that GLP-1’s outperformed all others, not only controlling blood sugar levels but also reducing the risk of heart-related events, including death. These drugs help the pancreas release more insulin when needed and limit the release of stored sugar.

In short, you’re at greater risk of developing the full-blown disease. “Prediabetes essentially means that your hemoglobin A1c, a measure of your three-month glucose values, is no longer in the normal range,” says Dr. Evans-Molina. An A1c below 5.7% is normal; between 5.7% and 6.4% is prediabetic.

Think of this as a major wake-up call, because you can turn things around: “For people with prediabetes, the development of diabetes can often be delayed or prevented through lifestyle changes, weight loss, and/or increased activity,” says Kevin A. Peterson, M.D., vice president of primary care and quality at the American Diabetes Association. Treat your diagnosis as a chance to be more informed about your health and choices. Even small changes can really help: “Studies show that even very modest weight loss can have a dramatic effect on our risk of developing type 2 diabetes over time,” says Dr. Evans-Molina. One study found that losing just 11 pounds could reduce the risk of diabetes by 55% over the course of three years in people with impaired glucose tolerance, which puts them at high risk.

In many cases, there are no symptoms, especially if blood glucose levels are only moderately elevated. In fact, it’s estimated that one in five people with type 2 diabetes is not aware that they have it, even though undiagnosed diabetes can severely impact quality of life and eventually shorten life span.

But people whose blood glucose is very high may experience:

• Increased thirst
• Increased hunger
• Frequent urination
• Unusual rashes or fungal infections Fatigue
• Blurred vision
• Frequent urinary tract infections

When not properly managed, diabetes can lead to serious health complications. “Over time, the high blood sugar levels damage the walls of blood vessels all over the body,” says Dr. Peterson. “The smallest blood vessels in the body are the first to be affected, including ones in the eyes and kidneys.” This is why some of the potential complications include vision problems (damage to small blood vessels in the retina makes diabetes the leading cause of blindness in the U.S. for those ages 20 to 74), kidney failure, and limb loss. Because of damage to the long nerves that extend to the feet, diabetes is the leading cause of leg and foot amputations.

When it comes to type 1 diabetes, unfortunately, there’s currently no way to completely prevent or reverse it. Once the immune system has destroyed the insulin-producing cells in the pancreas, there’s no getting them back—but with management and support, you can live a full and active life.

Type 2 diabetes may be a different story. “There are people who have mild type 2 diabetes who are able to lose weight and make lifestyle changes, allowing for disease remission,” says Dr. Evans-Molina. Dr. Peterson points out that while the underlying genetic and physiologic conditions that cause diabetes are not reversible and thus blood sugar can rise again, it is sometimes possible to bring the blood sugar balance enough under control that medication is not required. That said, it’s important to make changes as soon as you are diagnosed, as the window of opportunity may close.

Talk to your doctor about adopting a healthy lifestyle and having regular testing done. “Most people over 40 should be screened every three years as part of a routine physical exam,” says Dr. Peterson. Getting ahead of a diagnosis may mean you can stop its progression or better manage it and thereby avoid the potential major complications.

While Ozempic has gotten lots of attention, it’s just one of many meds for type 2 diabetes. “Diabetes management is extremely personalized,” says Deena Adimoolam, M.D., a specialist in endocrinology and obesity medicine and a member of Prevention’s Medical Review Board. When choosing meds, she says, you and your doctor should consider factors such as your age, ability to tolerate injections, risk for hypoglycemia, and other medical issues as well as each drug’s side effects, costs, and potential interactions. No matter which medicine you take, your first line of treatment is making lifestyle changes that will help your blood sugar, such as eating fewer simple carbohydrates and exercising more.

Below are the most popular type 2 diabetes medicines (not including insulin, which some people may require, and is considered necessary for people with type 1 diabetes). Knowing about the options can help you have a fruitful conversation with your doctor.

• Metformin. Some brand names: Glucophage and Glumetza. “Metformin is one of the oldest, most studied, and most researched diabetes medications we have and has been shown to be very safe,” says Dr. Adimoolam. Taken as a tablet or a liquid, metformin helps keep blood glucose levels in check by lowering the amount of glucose released by the liver and making muscles more sensitive to insulin so they use more glucose for energy (thereby taking it out of the bloodstream).
• GLP-1 and GIP Receptor Agonists. Some brand names: Rybelsus and Ozempic (GLP-1 receptor agonists); Mounjaro and Zepbound (dual GLP-1/GIP receptor agonists). These medications are known for helping people lose weight in addition to managing blood glucose. Most are taken through self-injection, though one is available as a pill. GLP-1 and GIP are naturally occurring hormones that lower blood glucose levels. Medicines known as GLP-1 and GIP receptor agonists mimic these hormones in our bodies, and as a result, insulin secretion improves.
• DPP-4 Inhibitors. Some brand names: Januvia and Tradjenta. “These are some of the few oral diabetes medications we can use in people with chronic kidney disease,” says Dr. Adimoolam. The GLP-1 and GIP hormones are broken down quickly by an enzyme called DPP-4. Drugs in this category block DPP-4, giving the hormones extra time to stimulate insulin release and lower blood glucose.
  
• SGLT2 Inhibitors. Some brand names: Jardiance and Farxiga. “These oral medications can help with minor weight loss, lower blood pressure, and prevent kidney disease and cardiovascular disease,” says Dr. Adimoolam. This group of medicines blocks the SGLT2 receptor in the kidney; this receptor helps the body reabsorb glucose, so when it is blocked, excess glucose is excreted in the urine instead.
  
• Sulfonylureas. Some brand names: Amaryl and Glucotrol. Diabetes tablets in this tried-and-true category have been around since 1942. Sulfonylureas stimulate beta cells in the pancreas to release more insulin, lowering blood sugar.
• TZD’s. Some brand names: Avandia and Actos. Short for thiazolidinediones, TZD’s also lower blood glucose. TZD’s reduce the amount of glucose produced by the liver and improve insulin sensitivity in muscles and fat.