No matter what type of diabetes a person has, glucose control is key to managing the diabetes. Treating of diabetes should be initiated as soon as diagnosis is established even if the patient is asymptomatic.

Patient education on diabetes management and lifestyle modifications is the cornerstone of effective diabetes control and treatment. The treatment of diabetes should include the following:

1. Non-Drug Treatment and Prevention of Diabetes (Diet and Lifestyle modifications)
2. Drug Treatment and Prevention of Diabetes (Medication/Drug Therapy)

NON-DRUG TREATMENT/PREVENTION OF DIABETES (DIET AND LIFESTYLE MODIFICATIONS)

TYPE 1 AND TYPE 2 DIABETES MELLITUS

Diet and other lifestyle factors form the basis of the treatment of diabetes mellitus. Change in lifestyle behaviours is effective in preventing or delaying the occurrence of diabetes mellitus. Eating a healthy diet, being physically active, avoiding the use of tobacco in any form/avoiding exposure to second-hand smoke, reducing the intake of alcohol amongst heavy drinkers, managing stress, reducing weight among overweight/obese individuals, etc. are lifestyle changes.

Dietary Modifications (Healthy Eating)

One of the first steps in managing diabetes mellitus is diet control. Dietary recommendations should take into account the patient’s eating habits and lifestyle. For example, patients who participate in Ramadan may be at higher risk of acute diabetic complications if they stop their oral hypoglycemic agent or insulin because of fasting. Although these patients eat in the morning and evening and so can be treated with drugs. They should be encouraged to actively monitor their glucose, alter the dosage and timing of their medication, and seek dietary counseling and patient education to counteract any complications. Diet management includes education about how to adjust the timing, size, frequency, and composition of meals to avoid hypoglycemia or postprandial hyperglycemia.

Although there is no such thing as a diabetes diet, the traditional African diet, which is rich in staples consisting of cereals (rice, cornmeal or flour, sorghum, and millet), roots and tubers (yams, potatoes, and cassava), and accompanying meat, fish or vegetables, is ideal for patients with diabetes. This traditional diet, which is mainly high in starch and dietary fiber and low in fat and sugar, is for the most part, similar to the WHO, American Diabetes Association, and Diabetes UK dietary recommendations for people with diabetes.

Also, doctors may recommend eating fewer animal products and refined carbohydrates, such as white bread and sweets, and also take note of the amount of carbohydrates in the foods eaten. Doing so can give the body enough insulin, thus allowing the body to properly use those carbohydrates.

Therefore, diet control management can include:

• A regular schedule for meals and healthy snacks
• Smaller portion sizes
• More high-fiber foods, such as fruits, non-starchy vegetables, and whole grains
• Fewer refined grains, starchy vegetables, and sweets
• Modest servings of low-fat dairy, low-fat meats, and fish
• Healthy cooking oils, such as olive oil
• Fewer calories

Physical Activity

Physical activity such as exercise is important for losing weight or maintaining a healthy weight. Exercise is an important aspect of diabetes management with diabetic patients encouraged to exercise regularly which helps to manage their blood sugar level. They also need to be educated about the effects of exercise on their blood glucose levels. If patients participate in rigorous exercise for more than 30 minutes, they may develop hypoglycemia unless they either decrease the preceding insulin injection by 10-20% or have an extra snack. Patients must also make sure to maintain their hydration status during exercise.

There are two types of physical activity

• Aerobic Exercise:Type 2 patients can choose an aerobic exercise that they enjoy, such as walking, swimming, biking, or running. Adults should aim for 30 minutes or more of moderate aerobic exercise on most days of the week, or at least 150 minutes a week.
• Anaerobic or Resistance Exercise:Resistance exercise increases the strength, balance, and ability to perform activities of daily living more easily. Resistance training includes weightlifting, yoga, and calisthenics. Adults living with type 2 diabetes should aim for 2 to 3 sessions of resistance exercise each week.
• Limit Inactivity:Breaking up long periods of inactivity, such as sitting at the computer, can help control blood sugar levels. Take a few minutes to stand, walk around or do some light activity every 30 minutes.

Weight Loss

Weight loss results in better control of blood sugar levels, cholesterol, triglycerides, and blood pressure. If one is overweight, he/she may begin to see improvements in these factors after losing as little as 5% of the body weight. However, the more weight one loses, the greater the benefit to the health. In some cases, losing up to 15% of body weight may be recommended.

DRUG TREATMENT/PREVENTION OF DIABETES (MEDICATION/DRUG THERAPY)

TYPE 2 DIABETES

Medications – Drug Use

Once a type 2 diabetic patient can't maintain the targeted blood sugar level with diet and exercise, the doctor may prescribe diabetes medications that help lower glucose levels. Most Type 2 diabetes patients are usually initiated on one or more oral anti-diabetic medicines. Medicines for type 2 diabetes include the following:

Biguanides (Metformin): This is generally the first medicine that is usually prescribed for type 2 diabetes mellitus. It helps to lower the glucose the liver produces and also improves the body’s reaction to insulin, so it can utilize the insulin more effectively. Examples of biguanides include metformin (Glucophage). This is taken at 500mg to 100mg twice a day.

Sulfonylureas: These drugs help the body produce more insulin. Examples are glimepiride (Amaryl), and glipizide (Glucotrol, Metaglip). They are given to type 2 diabetic patients. These are patients that have reduced weight and are not controlled by oral hypoglycemia agents: biguanides.

Meglitinides: This help to stimulate the pancreas to secrete more insulin. They're faster-acting than sulfonylureas but their effect on the body is shorter. Examples include repaglinide (Prandin) and nateglinide (Starlix).

Thiazolidinediones: Just like metformin, thiazolidinediones help make the body more sensitive to insulin. But they can raise the risk of heart problems, so they are not usually the first choice for type 2 diabetes mellitus treatment. Examples of this medicine include pioglitazone (Actos) or rosiglitazone (Avandia).

Glucagonlike Peptide–1 (GLP-1) Receptor Agonists: These are injectable medications that help slow digestion and lower blood sugar levels. Their usage is often associated with weight loss; some may reduce the risk of heart attack and stroke. Examples include exenatide (Byetta, Bydureon Bcise), liraglutide (Saxenda, Victoza), and semaglutide (Rybelsus, Ozempic, Wegovy).

GLP-1 and Glucose-Dependent Insulinotropic Polypeptide (GIP) Agonists: With examples such as Tirzepatide (Mounjaro), this class of drugs helps to improve the blood sugar level by activating both the GLP-1 and GIP receptors.

Dipeptidyl Peptidase IV (DPP-4) Inhibitors: These drugs can help reduce blood sugar levels but tend to have a very modest effect such as joint pain and inflammation of the pancreas. Examples include sitagliptin (Januvia), saxagliptin (Onglyza), and linagliptin (Tradjenta).

Selective Sodium-Glucose Transporter–2 (SGLT-2) Inhibitors: This affects the blood-filtering functions in the kidney by filtering out more glucose, blocking the return of glucose to the bloodstream. This would help remove glucose from the urine. These medicines might help to reduce the risk of heart attack and stroke in individuals with a high risk of those conditions. Examples include canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance).

Insulin Therapy

Type 2 diabetic patients can also be advised to take insulin, in combination with oral medicines to help achieve good control of diabetes. This usually happens when the targeted blood sugar levels have not been reached with lifestyle changes and other medicines. Insulin is another form of drug therapy used for diabetic patients. Insulin is given in the form of injections. It may come in a vial and syringe; or a device that looks like a pen which is easier to use and measures the correct dose.

Monitoring Blood Sugar Level

Doctors can advise a diabetic patient on how often to check his/her blood sugar level to make sure one remains within the target range. One may, for example, need to check it once a day usually before breakfast (fasting blood sugar).

Monitoring is usually done with a small, at-home device called a blood glucose meter (glucometer), which measures the amount of sugar in a drop of blood.

TYPE 1 DIABETES

Insulin Therapy

Patients with type 1 diabetes mellitus (DM) require lifelong insulin therapy. Most require 2 or more injections of insulin daily, with doses adjusted based on self-monitoring of blood glucose levels

There are many types of insulin, including:

• Short-Acting Insulin:Sometimes called regular insulin, this type starts working around 30 minutes after injection. It reaches a peak effect at 90 to 120 minutes and lasts about 4 to 6 hours. Examples are Humulin R, Novolin R and Afrezza.
• Rapid-Acting Insulin:This type of insulin starts working within 15 minutes. It reaches a peak effect at 60 minutes and lasts about 4 hours. This type is often used 15 to 20 minutes before meals. Examples are glulisine (Apidra), lispro (Humalog, Admelog, and Lyumjev), and aspart (Novolog and FiAsp).
• Intermediate-acting insulin:Also called NPH insulin, this type of insulin starts working in about 1 to 3 hours. It reaches a peak effect at 6 to 8 hours and lasts 12 to 24 hours. Examples are insulin NPH (Novolin N, Humulin N).
• Long and Ultra-Long-Acting Insulin:This type of insulin may provide coverage for as long as 14 to 40 hours. Examples are glargine (Lantus, Toujeo Solostar, Basaglar), detemir (Levemir), and degludec (Tresiba).

Some patients might probably need several daily injections that include a combination of long-acting insulin and rapid-acting insulin. These injections act more like the body's normal insulin use than older insulin regimens that only required one or two shots a day. A combination of three or more insulin injections a day has been shown to improve blood sugar levels.

Insulin Delivery Options

Insulin can't be taken by mouth to lower blood sugar because stomach enzymes will break down the insulin, preventing it from working. It is given through insulin injections which are given subcutaneously. The amount of insulin required is usually calculated by the doctor.

Blood Sugar Monitoring

Depending on the type of insulin therapy one selects or needs, one may have to check and record the blood sugar level at least four times a day. This is usually when the patient is on admission.

Doctors recommend testing blood sugar levels before meals and snacks, before bed, before exercising or driving, and whenever a patient thinks he/she has low blood sugar. Careful monitoring is the only way to make sure that the blood sugar level remains within the target range. More frequent monitoring can lower A1C levels but is expected to cause the patient to have normal blood sugar and HbA1C.

Continuous Glucose Monitoring

Continuous glucose monitoring (CGM) monitors blood sugar levels. It may be especially helpful for preventing low blood sugar. These devices have been shown to lower A1C.

Continuous glucose monitors attach to the body using a fine needle just under the skin. They check blood glucose levels every few minutes and is useful in patient with a diabetic crisis who is on admission.

Closed-Loop System

A closed-loop system is an implanted device that links a continuous glucose monitor to an insulin pump. The monitor checks blood sugar levels regularly. The device automatically delivers the right amount of insulin when the monitor shows that it's needed. This sophisticated system is not popularly available in Nigeria.

Other Drugs Treatment

Other forms of drugs such as high blood pressure medications, aspirin (to protect the heart), and cholesterol-lowering drugs may also be prescribed for people with type 1 diabetes and type 2 diabetes mellitus.

DIABETES EDUCATION

Knowledge about diabetes is integral to successful management, and diabetes education is the cornerstone of successful diabetes treatment. This is especially true in the continent where diabetes is believed to be caused by supernatural forces and evil spirits. The lack of diabetes educators in most African countries, scarcity of diabetes specialists and multidisciplinary support teams, low patient educational levels, frequent illiteracy, poor treatment adherence, adverse cultural beliefs, and a lack of reliable and affordable supplies of medication and monitoring equipment, all combine to limit the achievement of good diabetes education and diabetic management.