Managing Type 2 Diabetes: Blood Glucose, Medicines and Lifestyle

What is type 2 diabetes?

Type 2 diabetes is a long-term condition where the body does not make enough insulin, or the insulin it makes does not work properly (insulin resistance). This causes blood glucose (sugar) levels to rise. Over time, high glucose levels can damage the blood vessels and nerves, affecting the heart, eyes, kidneys and feet.

Diabetes UK reports that more than 4.4 million people in the UK have been diagnosed with diabetes, around 90% of whom have type 2, and that over a million more may be living with type 2 diabetes without knowing it.

Symptoms to look out for

• Passing more urine than usual, especially at night
• Feeling very thirsty or tired
• Losing weight without trying
• Itching around the genitals or repeated thrush
• Cuts or wounds that heal slowly, or blurred vision

Many people have no symptoms, which is why checks matter if you are at higher risk, for example if you are over 40 (or over 25 if you are of South Asian, Black African or Black Caribbean background), are overweight, or have a close relative with diabetes.

Understanding HbA1c

HbA1c is a blood test that reflects your average blood glucose over the previous two to three months.

HbA1c	What it means
Below 42 mmol/mol (6.0%)	Normal range
42 to 47 mmol/mol (6.0% to 6.4%)	Higher risk of type 2 diabetes (sometimes called prediabetes)
48 mmol/mol (6.5%) or above	Consistent with type 2 diabetes

For most adults managed with lifestyle or a single medicine that does not cause hypoglycaemia, NICE suggests a target of 48 mmol/mol. If you take a medicine that can cause low blood sugar, such as a sulfonylurea or insulin, the target is usually 53 mmol/mol. Your own target should be agreed with your care team.

Medicines

Following NICE guideline NG28, metformin is usually the first medicine offered. Your clinician may add or recommend other medicines depending on your health:

• SGLT2 inhibitors (such as dapagliflozin or empagliflozin), which are also recommended for many people with heart disease, heart failure or chronic kidney disease
• DPP-4 inhibitors (such as sitagliptin)
• GLP-1 receptor agonists (such as semaglutide), usually for people with obesity or high cardiovascular risk
• Sulfonylureas (such as gliclazide) and insulin

If you become unwell with vomiting, diarrhoea or a fever, some diabetes medicines may need to be paused temporarily. Ask your pharmacist or diabetes team for "sick day rules" so you know what to do.

Lifestyle: the foundation of good control

• Diet: focus on vegetables, whole grains, pulses, fish and unsaturated fats, and reduce sugary drinks and refined carbohydrates.
• Activity: aim for 150 minutes of moderate activity a week and break up long periods of sitting.
• Weight: losing weight improves glucose control. In the DiRECT trial, almost half of participants on a structured low-calorie diet programme were in remission after one year.
• Smoking: stopping greatly reduces the risk of heart and circulation problems.

The NHS Type 2 Diabetes Path to Remission Programme offers a supported low-calorie diet to eligible people in England. If your HbA1c is in the higher-risk range, you may be offered the NHS Diabetes Prevention Programme.

Your annual checks

Everyone with diabetes should be offered regular checks, including HbA1c, blood pressure, cholesterol, kidney function, foot checks and annual diabetic eye screening. Do not skip these: they catch problems early, when they are most treatable.

Recognising a hypo

If you take insulin or a sulfonylurea, your blood glucose can drop too low (below 4 mmol/L). Signs include shaking, sweating, hunger, confusion and irritability. Treat with 15 to 20 g of fast-acting sugar, such as a small glass of non-diet fizzy drink or glucose tablets, then recheck after 15 minutes.