The Triple Threat: Meals, Monitoring, and Medications

A Healthier You

The Triple Threat: Meals, Monitoring, and Medications

Diana IsaacsContributor: Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES

Changes in Nutrition: As the weather becomes warmer, many people come out of winter hibernation and decide to adopt healthier eating to prepare for the summer months or get ready for swimsuit season.

This is great because we know that healthy eating has tremendous benefits for diabetes management. We usually expect blood sugars to decrease, which generally makes it easier to reach individual blood sugar targets. Many times, there is also weight loss.

Healthy eating can mean many things, and the American Diabetes Association (ADA) guidelines state that there are multiple eating plans that can be effective for diabetes management. People with diabetes are encouraged to work with a registered dietitian to come up with a plan that will be effective for their individual needs.

But what about medications? As nutrition changes, medications often need to be adjusted. For many people, this can mean decreasing the number of medications or the doses of certain medicines. But how do you and your health care team decide how to adjust your medications?

Glucose Monitoring: The best way to know if medications need to be adjusted is by monitoring glucose levels. Monitoring your blood sugar can be done in many ways. The hemoglobin A1C is a measure of the average glucose over the past 2 to 3 months. For many people, the target is to be under 7%. A 7% A1C is equal to an average glucose of 154mg/dL.

Since A1C is just an average and it's typically only collected every three months, it's helpful to monitor glucose levels on a more regular basis, either with a blood glucose meter or with a continuous glucose monitor (CGM). The data can be shared with your diabetes team to determine if you need medication adjustments as your eating patterns change. When monitoring glucose, you are trying to maximize the time spent in the target range you've set with your healthcare team. As you make healthy changes, it is possible that you may experience low glucose levels (under 70mg/dL), especially if you take certain medications like insulin, sulfonylureas (examples are glipizide, glimepiride, glyburide), or meglitinides (examples are nateglinide, repaglinide).

Medication Adjustments: The good news is that many non-insulin medications do not cause glucose to go low. However, any time diabetes medications are combined with insulin, sulfonylureas, or meglitinides, you are at greater risk. Incorporating new eating patterns means these drugs should be monitored closely and often will need to be decreased. Low carbohydrate eating plans can cause quick drops in glucose levels. If you take meal-time insulin, this may be the first medication to be reduced. If you begin a very low carbohydrate or ketogenic eating plan, your meal-time insulin may be stopped altogether. Long-acting insulin must be continued for type 1 diabetes, although it is often reduced. In people with type 2 diabetes, both the long-acting and meal-time insulin may be reduced or stopped.

Some people with type 2 diabetes experience what’s considered diabetes remission by coming off of their medications. For example, the Virta Health study, which combined remote coaching with very low carbohydrate eating plans, showed that 55% of the participants with type 2 diabetes reached diabetes remission at two years. There is a debate about true diabetes remission. In this trial, it was considered an A1C level under 6.5% without any diabetes medications except for metformin.

Medications to Continue: I hear many people say that it’s their goal to come off their medications. It is important to remember that type 2 diabetes is a progressive condition, and many people require more medications as the years go by. Those with type 1 diabetes will always need insulin (at least until we find a cure), so they should expect to continue. There are some other important facts to know as well. The latest diabetes guidelines recommend certain medications even when A1C is at target for people with cardiovascular disease or high cardiovascular disease risk. This is because some of the newer medications have been found to have tremendous benefits in reducing heart attacks, strokes and death regardless of glucose levels. Medications such as statins for cholesterol and aspirin for anyone who had a previous heart attack or stroke may be recommended even if you reach all of your weight loss and glucose goals because of their other benefits.

The Triple Threat: Meals, monitoring, and medications all go together, forming a triangle with you at the center. Monitoring helps your diabetes team decide how to adjust your medications. And it’s also a valuable tool to show you how different foods, activities, and stressors affect your blood sugar levels. It can inspire change, especially if you have the opportunity to wear a CGM and see your glucose levels updated every 5 minutes in real-time. Be sure to reach out to your healthcare team if you see multiple levels below 70mg/dL. In addition to low glucose levels being a safety concern, they can also make it more challenging to lose weight, especially if you feel like you have to eat to prevent hypoglycemia or low glucose.

I wish you all the best of success this season in reaching your health goals. Please know that you are not alone. Reach out to your friendly dietitian, pharmacist, and diabetes care and education specialist to help you incorporate healthy eating, monitoring, and medication management.

Diana Isaacs, PharmD, BCPS, BC-ADM, BCACP, CDCES is a Clinical Pharmacist and CGM Program Coordinator at the Cleveland Clinic Diabetes Center. Dr. Isaacs earned her Bachelor’s Degree in Chemistry from the University of Illinois at Chicago ans Doctor of Pharmacy Degree from Southern Illinois University Edwardsville. Dr. Isaacs holds board certifications in pharmacotherapy, ambulatory care, and advanced diabetes management. She is the Communications Director for the American Diabetes Association (ADA) Pregnancy and Reproductive Health Interest Group and serves on the 2020-2021 ADA Professional Practice Committee, the committee that updates the ADA Standards of Care. She presents on diabetes related topics nationally and internationally. Dr. Isaacs was awarded the Ohio Pharmacists Association Under 40 Award in 2019 and ADCES Diabetes Care and Education Specialist of the Year in 2020.