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Joslin’s Diabetes Deskbook, Updated 2nd Ed., Excerpt #10: Your Tools for Treatment

Jul 9, 2012

By Richard S. Beaser, M.D., and Richard Jackson, MD




The changes that have occurred in the treatment of diabetes since the first general use of insulin in 1922 have constituted one of the most exciting chapters in the history of medicine.


Within just a few years, the outlook for people with diabetes changed from one of facing near starvation and near survival to a life in which survival is taken for granted and the horizons are almost unlimited. Increasing numbers of people have lived for longer than 50 years following the diagnosis of diabetes — 50 useful and productive years.

Elliott Joslin used to say that the treatment of diabetes is more like a marathon than a sprint. Patients must adapt their lifestyles and self-care routines for the long haul. This is true, as the backbone of all diabetes treatments is non-pharmacologic — education, medical nutritional therapy, exercise, and self-monitoring. If these are not sufficient, then oral or injected antidiabetes medications and/or insulin may be needed.

  • Education. Education has been a vital part of diabetes management for decades. The DCCT and other recent studies have established it as crucial to the success of many, if not most, therapies. Yet there are no landmark studies that unequivocally document the direct benefit of education as a single component. This is probably because successful diabetes management and achievement of desired outcomes are often multifactorial. Many components of treatment contribute to successful outcomes, and education is clearly important to the efficacy of these components (see Chapter 12).
  • Activity. Exercise is one of the original ways of controlling diabetes, used even before the introduction of pharmacologic interventions. Exercise alone is rarely enough to control diabetes, but it can improve the efficacy of other treatment components when used in combination with them. Exercise is beneficial because it improves general health and also reduces insulin resistance. When designing a diabetes treatment plan, it is important to know the required level of activity of the individual. Exercise, to the extent that it is appropriate for the particular individual, can have multiple benefits.
  • Medical Nutritional Therapy. Regulation of nutritional intake is still crucial to the treatment of diabetes. As many people with type 2 diabetes retain some insulin secretary capacity, a properly designed nutrition program makes it easier for their insulin to be effective. The eating plan for people with type 1 diabetes is often less restrictive than that for a patient with type 2 diabetes, but it still will provide guidelines for more intelligent food choices and will coordinate nutrition with insulin and activity.
  • Oral and Injected Antidiabetes Medications. The spectrum of oral antidiabetes medications has widened considerably in the last decade. Previously there was one class of medications available in the United States, the sulfonylureas. This class, typically referred to as “oral hypoglycemic agents,” works by sensitizing the beta-cells to more effectively secrete increased amounts of insulin in response to rising glucose levels. When they were the only available class, they were used with a “one size fits all” approach, regardless of whether or not the underlying pathophysiology in a given patient represented significant insulin secretory insufficiency. Now, newer classes of medications can target specific pathophysiologic defects. Most are given by mouth, but injected medication is also being used for this purpose as well. Medications are available that increase insulin sensitivity, including the biguanides and the thiazolidinediones, which are very effective when either endogenous and/or exogenous insulin is available. Medications in the class of alphaglucosidase inhibitors can slow the gastrointestinal absorption of carbohydrate so that it is entering the circulation at the time that endogenous insulin secretion, lacking at the early “first-phase” release, is present. Colesevelam, a bile acid sequestrant, has been shown to be effective in lowering A1C in patients with diabetes, and is now approved for this use, in addition to its use in lowering LDL cholesterol. The familiar group of medications that stimulate insulin secretion, the sulfonylureas, has been joined by other medication groups that have similar effects, only focused primarily on the postprandial time frame. These medications include one from the meglitinide class and a member of the phenylalanine derivative class. A new group of medications restores incretin function. Incretins are hormones secreted by the gastrointestinal tract that communicate with the pancreas about incoming food, resulting in insulin secretion that is “glucose-dependent” (i.e., stimulated by the rising glucose levels rather than occurring independent of the insulin level), and suppression of glucagon secretion. One such type of medications, the GLP-1 agonists, are injected medications. Others, the DPP-IV inhibitors, are given by mouth.
  • Insulin. If the patient has either absolute or relative insulinopenia, then insulin therapy may be needed. Newer developments in available insulin include the development of synthetic human insulin and more recently the development of insulin analogs, including both rapid-acting insulin to cover incoming meals, and basal insulins to provide background insulin over a 24 hour period. These insulins, given alone or in combination, provide powerful options for controlling A1C in patients with type 1 and type 2 diabetes.
Using the tools described above, the essence of diabetes treatment is to develop a system of balances. The triad of variables — medication, food, and activity — can all be adjusted by the treatment team, as well as manipulated as needed by a well-trained and skillful patient. Yet, there are also other factors — the “intangibles” that affect any treatment program. These intangibles are often imperceptible — daily variations in various factors such as stress, timing, food absorption, insulin absorption (from injections or inhalations), etc., that can also affect the diabetes. They are all factors that remind us that humans are not machines and do not live each day as if it were a carbon copy of the previous. However, the more attention that is paid to these variables, and the more we learn from them and about them, the more effective diabetes treatment can and will be.
Suggested Reading 

Standards of Medical Care in Diabetes–2007, American Diabetes Association Diabetes Care 2007 30: S4-41 (Updated annually — seek newest version)

Diagnosis and Classification of Diabetes Mellitus, American Diabetes Association Diabetes Care 2007 30: S42-47 (Updated annually — seek newest version)

Diabetes Epidemiology: Collaborative Analysis of Diagnostic Criteria in Europe (DECODE). Lancet 1999; 354:617–621.

Tominaga M, et al. The Funagata Diabetes Study. Diabetes Care 1999; 22:920–924.

The DECODE study group. Glucose tolerance and mortality: comparison of WHO and American Diabetes Association diagnostic criteria. Lancet 1999; 254: 617–621.

Copyright © 2010 by Joslin Diabetes Center. All rights reserved. Reprinted with permission. Neither this book nor any part thereof may be reproduced or distributed in any form or by any means without permission in writing from Joslin. Note: Joslin does not endorse products or services.

For Excerpt #1 from the Joslin Diabetes Deskbook, 2nd Ed, in this series, just click here.

For Excerpt #2 from the Joslin Diabetes Deskbook, 2nd Ed, in this series, just click here.

For Excerpt #3 from the Joslin Diabetes Deskbook, 2nd Ed, in this series, just click here.

For Excerpt #4 from the Joslin Diabetes Deskbook, 2nd Ed, in this series, just click here. 

For Excerpt #5 from the Joslin Diabetes Deskbook, 2nd Ed, in this series, just click here. 

For Excerpt #6 from the Joslin Diabetes Deskbook, 2nd Ed, in this series, just click here. 

For Excerpt #7 from the Joslin Diabetes Deskbook, 2nd Ed, in this series, just click here. 

For Excerpt #8 from the Joslin Diabetes Deskbook, 2nd Ed, in this series, just click here. 

For Excerpt #9 from the Joslin Diabetes Deskbook, 2nd Ed, in this series, just click here. 

You can purchase the updated 2nd Edition of JOSLIN’S DIABETES DESKBOOK at:


Please Note: Reasonable measures have been taken to ensure the accuracy of the information presented herein. However, drug information may change at any time and without notice and all readers are cautioned to consult the manufacturer’s packaging inserts before prescribing medication. Joslin Diabetes Center cannot ensure the safety or efficacy of any product described in this book.

Professionals must use their own professional medical judgment, training and experience and should not rely solely on the information provided in this book to make recommendations to patients with regard to nutrition or exercise or to prescribe medications.

This book is not intended to encourage the treatment of illness, disease or any other medical problem by the layperson. Any application of the recommendations set forth in the following pages is at the reader’s discretion and sole risk. Laypersons are strongly advised to consult a physician or other healthcare professional before altering or undertaking any exercise or nutritional program or before taking any medication referred to in this book.