Byron Hoogwerf, MD, FACE
Biography

	How long can it take to even out my levels? Why should blood sugar levels not go too low? How long can diet and exercise keep diabetes from progressing? My feet get numb. Should I see a podiatrist? For expert care should I look for a specialist?
	Diabetes Meal Plans

You have diabetes. Now what? How do you begin to get your condition under control? What should your levels be? What's the best way to test? What about diet and exercise? We asked these questions and more on Sept. 21, 2004, when we welcomed The Cleveland Clinic diabetes expert Byron Hoogwerf, MD, as part of the WebMD University course "Diabetes: Get the Advantage."

If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Support for this University course was provided by Medical Mutual.

MODERATOR:
Welcome to "Diabetes: Get the Advantage" Your instructor is The Cleveland Clinic diabetes expert Byron Hoogwerf, MD, FACE. Dr. Hoogwerf, what's the first step toward getting control of diabetes?

HOOGWERF:
First, recognize that diabetes is serious and that management is a lifelong process. Then consider day-to-day management of blood sugars. With newly diagnosed people we generally focus on blood sugar first and that focus includes:

• A review of diet
• A review of exercise
• Decisions about whether medications may be needed to help control blood sugar

MEMBER QUESTION:
I was diagnosed with type 2 diabetes in July, my doctor prescribed 2,000 milligrams of Metformin daily and the past week added 8 milligrams of Avandia. Since the Avandia I have became very nauseated and have had vomiting spells along with dizziness and cold sweats. Is this normal? And as my sugar is running between 180 and 300 daily why has my doctor not prescribed insulin?

HOOGWERF:
There are several approaches to managing blood sugars:

• At onset, some people can be controlled by diet and exercise only. Most physicians start with a single medication; Metformin, or glucophage, is a common choice. It will often lower blood sugar effectively.
• The next steps are to add a second medication if necessary, perhaps a TZD, like Avandia, or Actos, both of which sensitize the body to insulin or make insulin work more efficiently. Another class of agents often added is the sulfonylureas, which stimulate the pancreas to produce insulin.
• In some cases, patients with very high blood sugars, for example, over 200 after starting a single medication, will go to insulin.

The judgment about whether to add oral agents is based on:

• What your blood sugars are doing
• Your personal preferences
• Potential side effects of medication

Nausea is actually more commonly seen with Metformin than it is with Avandia. Common side effects with Avandia are weight gain and some swelling in the legs. Any time patients have side effects it is advisable they review their current medications with their treating physician.

"Adding medication over time is a common practice, and I tell patients, if you have diabetes long enough, you are likely to require insulin."

MEMBER QUESTION:
Will you gain weight on these medicines?

HOOGWERF:
If your blood sugars are running very high and you are spilling sugar in your urine, diabetes may start with weight loss. However, as sugar levels come down, especially if you do not decrease calories, you may gain weight with essentially all of the oral medications or insulin. The weight gain is slightly less with Metformin than other medications.

Weight gain appears to be greatest when insulin is used with the TZDs, like Actos or Avandia. For this reason, instruction in proper diet and review of an exercise regimen is part of the initial and ongoing therapy in everyone with diabetes.

MEMBER QUESTION:
How long can it take to even out blood sugar levels?

HOOGWERF:
I don't want this to sound "flip" but consider that it takes a lifetime. Having said that, in patients who have new onset diabetes, it usually takes a matter of several months to bring sugars from values in the range of 200-plus to the more normal range of under 120 or under 130.

The nature of type 2 diabetes is one where there is progressive loss of insulin production over time. Consequently, there is a tendency for sugars to increase over time. That means medication which may control your diabetes now may be insufficient in a few years. So adding medication over time is a common practice, and I tell patients, if you have diabetes long enough, you are likely to require insulin.

Usually diabetes can be controlled early in a few months, but truly it really takes a lifetime of adjusting diet, exercise, and medication to maintain blood sugar.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician.