Each of these organs plays a unique role in keeping your blood sugar levels stable. Find out how your body maintains this delicate balance — and how certain medications work to lower your A1C.

What Causes High Blood Sugar Levels?

Contrary to popular belief, type 2 diabetes — which affects more than 29 million Americans isn't caused by an overload of sugar. In fact, there are many different factors that can increase a person's risk for the disease, including genetics, body weight, fat distribution, physical activity levels, and race.

However, it is true that people with diabetes may have to limit their sugar intake. That's because type 2 diabetes is characterized by an inability to properly use insulin, a hormone that helps usher sugar (in the form of glucose) out of the bloodstream and into the cells, where it's used as energy. Eventually, the body is unable to produce enough insulin to keep your blood sugar levels stable.

Here's how blood sugar is processed in the body:




Is sugar in a doughnut the same as blood sugar? 

Let's clear up the confusion: Sugar can have many different names, with different meanings.

When doctors and scientists talk about sugar in the blood, they often use the word glucose. Glucose is a simple carbohydrate, also known as a monosaccharide (meaning, it's made up of just one molecule). This can also be called blood sugar.

Unlike sucrose (table sugar) or fructose (the sweetener found in honey and fruit), you won't be able to find glucose in the grocery store.

Related Health Problems

Over time, diabetes can harm almost every organ and system in the body. One reason: Chronically high blood sugar levels can cause high blood pressure and high cholesterol; it can also cause nerve damage, which hampers your ability to send and relay messages to different parts of the body.

Here are some of the most common complications of chronically high blood sugar levels and uncontrolled type 2 diabetes.



When talking about high blood sugar, the first place to start is the pancreas. This pear-shaped organ sits inside the upper left part of the abdomen and is part of the digestive system. The pancreas has two main functions: The exocrine function is to manufacture digestive juices (enzymes) responsible for breaking down all kinds of nutrients including fats, proteins, and carbohydrates. But the pancreas may be best known for the endocrine function that is, making insulin and other hormones.

How Insulin Is Produced

When food enters the gut, cells in the intestines produce a peptide called GLP-1, which blocks the release of glucagon in the body and increases insulin secretion. (The reason: You don't need glucagon to draw on your glucose reserves for energy while you're consuming sugar from a meal.) This also kick-starts the production of insulin by B-cells in the pancreas.

Insulin Resistance: Understanding What Happens in Type 2 Diabetes

In type 2 diabetes, the body has become insulin resistant, meaning insulin is no longer able to effectively remove sugar from the blood. As a result, the pancreas ramps up its insulin production to try to keep up with the amount of carbohydrates you're eating a state of overproduction that can lead to B-cell fatigue.

When B-cells become fatigued (or fail), they can no longer make enough insulin to shuttle glucose out of your bloodstream. The end result: hyperglycemia, or high blood sugar.

The Liver: Your Body's Sugar Warehouse


Healthy Liver


Fatty Liver

The liver is a big organ (it weighs about three pounds) with a big job: regulating chemical levels in the blood. Every system in the body depends on the liver for the high-quality fuel it needs to function. In addition to conditioning the blood and helping to remove waste products, the liver is your body's sugar warehouse. When there's too much sugar in the bloodstream, the body stashes the extra supply in the liver, where it's stored for later use.

And when people become resistant to insulin, they can also develop nonalcoholic fatty liver disease. This further complicates type 2 diabetes because the buildup of fat in the liver can exacerbate insulin resistance as well, worsening type 2 diabetes and leading to high blood sugar. From there, the cycle continues.


Sugar travels into the kidney, where it's used as energy, then released into the blood where it’s used as fuel.


The kidneys are two organs that rest on opposite sides of the spine. Think of them as the TSA of your bloodstream: They scan the blood for unwanted acids and excess minerals and usher the waste products out of the body through the urine. But they also play a surprising role in regulating blood sugar levels.

Specifically, the kidneys remove sugar from the blood and use it as their own source of energy, which provides the fuel they need to function.

What's more, in partnership with the liver, the kidneys perform a process called gluconeogenesis, which produces sugar and releases it into the blood for the body to use as fuel.

Finally, kidneys responsibility to filter waste comes into play. The kidneys filters, called glomeruli, remove sugar from urine. Then, sodium-glucose cotransporters often referred to as SGLTs reabsorb the filtered sugar, moving it to the bloodstream. (This process is why one of the first signs of undiagnosed diabetes can be the need to urinate frequently!)

When these filters are forced to work too hard, they can become permanently damaged, leading to the development of diabetic kidney disease and, eventually, kidney failure.

Treating Type 2 Diabetes: Know Your Numbers, Lower Your A1C

1. If your A1C level is less than 5.7%, your blood sugar level falls in a normal range.
2. If your A1C level is between 5.7% and 6.4%, you have prediabetes.
3. If your A1C level is 6.4% and higher, you have type2 diabetes.

Finger prick tests can measure how high your sugar levels are at any specific moment, but an A1C test will help you find out whether your blood sugar is truly under control.

Because the A1C test looks at your blood-sugar levels over a two- to three-month period, the American Diabetes Association likens its reading to a batting average. An A1C reading of 6.5 percent or higher qualifies a diagnosis of diabetes.

You and your doctor will work together to adjust your treatment plan including diet, exercise, and medications to reach your target A1C.

Type 2 diabetes can increase your risk of heart failure. Here's what experts are saying about preventing this underrecognized risk.


High blood sugar can damage arteries, making it harder for the heart to pump blood efficiently.

It's common knowledge that people with diabetes are at an increased risk of heart complications such as heart disease, stroke, and hypertension. But did you know about the link between type 2 diabetes and heart failure?

According to a report published in June 2019 in the journal Circulation, people with type 2 diabetes are two to four times more likely to develop heart failure than those without diabetes. The report also states that having diabetes or heart failure independently increases the risk of getting the other condition, and both conditions often occur together.

There's a misperception that if you prevent a heart attack, you prevent heart failure, so all you need to do is prevent coronary artery disease, says Javed Bulter, MBBS, MPH, a cardiologist and a professor and chairman in the department of medicine at the University of Mississippi in Jackson. While that is true, that's only part of the story.

Heart attack is a risk factor for heart failure, a condition in which the heart fails to efficiently pump oxygen-rich blood through the body. But experts are learning that people with type 2 diabetes develop heart failure through many other mechanisms.

Prevention of heart failure is something we never focused on, says Dr. Butler. There's been a gap in our thinking that we're now trying to bridge.

How High Blood Sugar Causes Damage to Arteries in the Body

The connection between diabetes and heart disease starts with high blood sugar levels. Over time, high blood sugar in the bloodstream can damage the arteries, causing them to become stiff and hard, making it harder for the heart to pump blood efficiently.

Research suggests that people with diabetes develop damage and dysfunction in the heart muscle, says E. Dale Abel, MD, PhD, the chair of the department of internal medicine at the University of Iowa in Iowa City and the director of the Fraternal Order of Eagles Diabetes Research Center. The question is whether this is driven exclusively by high blood sugar it could also be caused by high levels of fatty acids in the blood, increased inflammation, or cellular dysfunction.

The reason for this dysfunction remains unclear, but it's likely caused by a number of factors, he notes.

In a study published in January 2020 in the journal Mayo Clinic Proceedings, researchers followed people with and without diabetes with no known structural heart disease over a 10-year period, and found that participants with diabetes were still at increased risk of developing heart failure. Researchers believe this may be the result of inherent problems in people with diabetes, such as insulin resistance, BMI, and elevated glucose levels.

The results support the hypothesis that having diabetes is itself a risk factor for heart failure, Dr. Abel notes.

A Class of Medication for Diabetes May Provide Some Help While the link between heart failure and diabetes has been known for decades by the medical community, the topic has gained recent interest because of SGLT2 inhibitors, a class of medication used to treat type 2 diabetes. SGLT2 inhibitors work by preventing glucose from being absorbed in the kidneys, which helps keep sugar levels in the blood low.

Several studies, including one published in November 2019 in the New England Journal of Medicine, found that dapagliflozin, an SGLT2 inhibitor, lowered the risk of heart failure among participants who received it, compared with those who received a placebo, whether or not those participants had diabetes.

They are the only class of antidiabetic medications that have been shown in clinical trials to reduce the risk of heart failure, says Abel.

Though current guidelines recommend using SGLT2 inhibitors for people with diabetes and heart failure, or those at high risk for a heart attack, whether it helps prevent heart failure in all people with diabetes has yet to be determined. SGLT2 inhibitors aren't yet recommended for everyone with diabetes, because studies have not yet been done in low-risk patients, particularly those who were recently diagnosed or whose diabetes is mild.

Focus on Prevention to Reduce Risk of Heart Failure

While it may take years for someone with diabetes to develop heart failure, the danger shouldn't be ignored. It's a slow process, says Abel. Some of the damage could be happening in the prediabetes stage.

Prediabetes is when a person has blood sugar levels higher than normal, but not high enough to be diagnosed with type 2 diabetes. By keeping blood sugar levels in a healthy range, you can lower your risk of developing diabetes. One of the biggest risk factors is being overweight or obese, Abel says. Following a healthy diet and exercising can reduce the risk of developing type 2 diabetes by 70 percent.

Another way to prevent or lower the risk of heart failure is to pay attention to symptoms that are consistent with heart failure, like:

• Shortness of breath
• Fatigue
• Swelling in the legs, ankles, and feet
• A rapid heartbeat

These can often be missed because people are too focused on cholesterol and blood sugar, says Abel, adding, there needs to be an increased awareness in both physicians and patients.

Reap the Health Benefits of B Vitamins


Good nutrition is tied to good health, as well as to the prevention and treatment of many conditions. Getting the recommended amounts of vitamins each day is an important part of the nutrition equation, and B vitamins are essential for preventive care. Abundant in green vegetables, whole or enriched grains, dairy, and meats, B vitamins help promote a healthy metabolism and are also linked to a reduced risk of stroke, research shows.

Take vitamin B12, for example. According to the Mayo Clinic, vitamin B12, a water-soluble vitamin, plays a significant role in nerve function, the formation of red blood cells, and the production of DNA. While most people get plenty of vitamin B12 benefits in a varied, balanced diet, if you are on a vegan or vegetarian diet, you are at risk for vitamin B12 deficiency. Also, elderly adults and people with GI disorders lack adequate B12.

Signs of vitamin B12 deficiency include:

• Anemia
• Confusion
• Dementia
• Depression
• Difficulty maintaining balance
• Fatigue
• Intestinal problems
• Mood disturbances
• Muscle weakness
• Numbness and tingling in the hands and feet
• Poor memory
• Soreness of the mouth or tongue

Vitamin B6 (pyridoxine) is vital for normal brain development and for keeping the immune system and nervous system working properly. Most people who eat poultry, fish, potatoes, chickpeas, and bananas have enough vitamin B6. But certain illnesses, such as kidney disease and malabsorption syndromes, can lead to vitamin B6 deficiency. Lack of B6 can result in a reduction of red blood cells, which take oxygen to tissues throughout the body. People with vitamin B6 deficiency may experience symptoms such as:

• Confusion
• Depression
• Weakened immune system

It's been known that some people with B vitamin deficiencies experience depression, anxiety, and mood swings. Folate (vitamin B9) is in the forefront of mood management. Findings show that many people with depression have lower levels of folate in the blood. Folate is found in green leafy vegetables, beans, peas, peanuts, and other legumes, and citrus fruits. The Food and Drug Administration (FDA) began requiring manufacturers to add folic acid to enriched breads, cereals, flours, cornmeal, pasta, rice, and other grain products in 1998.

Additionally, folic acid (the synthetic form of folate in supplements and fortified food) is essential during early pregnancy to prevent serious birth defects of the brain and spine such as spina bifida. Taking a prenatal vitamin with folic acid three months before conception and eating folic-acid fortified foods can help women get plenty of this essential B vitamin.

Your doctor can determine if you are deficient in one of the B vitamins and may prescribe a vitamin B complex supplement. Even if you're taking a supplement, a varied and balanced diet is essential to avoiding a B vitamin deficiency and reaping the health benefits of these important vitamins.

Read on to learn about the daily doses of different B vitamins you need, natural sources to include in your diet, and the health benefits you can expect to reap.

B Vitamins Are Tied to Lower Stroke Risk



In addition to their role in metabolism and in maintaining healthy skin and hair, B vitamins have been linked to a lower incidence of stroke, a condition in which a blood clot blocks blood flow to the brain, or a blood vessel bursts in the brain. A review of randomized clinical trials that lasted six months or longer revealed that vitamin B supplements lowered risk of stroke by 7 percent for a large group of more than 50,000 participants. The study was authored by Xu Yuming and colleagues from Zhengzhou, China, and published in the September 2013 issue of the clinical journal Neurology. But before you begin taking vitamin B complex or any B vitamin supplement, be sure to talk to your healthcare provider.

Vitamin B1 Is Important for Preventing Beriberi



The recommended daily intake of vitamin B1, also called thiamine, is 1.1 milligram (mg) for women over age 18, up to 1.4 mg for those who are pregnant, and 1.5 mg for those who are breast-feeding. For men age 14 and older, 1.2 mg per day is recommended, according to the National Institutes of Health.

Vitamin B1 plays a major role in metabolizing food into energy. B1 is found in whole-grain cereals, yeast, beans, nuts, and meats. Too little vitamin B1 causes beriberi, a disease affecting the heart, digestive system, and the nervous system. Beriberi is found in patients who are malnourished, and in those who are heavy drinkers of alcohol. Symptoms of beriberi include difficulty walking, loss of sensation in the hands and feet, and paralysis of the lower legs and it may even lead to congestive heart failure.

People who consume large amounts of alcohol should take a vitamin B complex supplement to be sure they get enough B1. Also, taking any one of the B vitamins for a long period of time can result in an imbalance of other important B vitamins. For this reason, you may want to take a B-complex vitamin, which includes all the B vitamins.

Riboflavin (Vitamin B2) Boosts the Immune System



A diet rich in vitamin B2, also known as riboflavin, is needed to avoid riboflavin deficiency. Recommended daily allowances of B2 are 1.3 mg a day for men and 1.1 mg a day for women. Pregnant women need 1.4 mg daily, and breast-feeding mothers should have 1.6 mg each day. You can get this B vitamin from natural sources such as nuts, green vegetables, meat, and dairy products.

Riboflavin helps your body break down and use the carbohydrates, fats, and proteins in your diet and helps metabolize food into energy. This type of B vitamin also functions to keep your skin, the lining of your gut, and your blood cells healthy. Getting enough riboflavin may be preventive for migraine headaches and cataracts, according to the National Institutes of Health. Riboflavin may also increase energy levels, boost the immune system, and treat acne, muscle cramps, and carpal tunnel syndrome.

Vitamin B3 (Niacin) Breaks Down Food Into Energy



We need vitamin B3, also called nicotinic acid or niacin, in our diets every day to break down food we eat into energy we can use. Females who are 14 and older need 14 mg a day; males in this age group need 16 mg daily. Legumes, nuts, enriched breads, dairy, fish, and lean meats are all good sources of this type of vitamin B.

Not getting enough niacin in your diet causes the disorder known as pellagra. Symptoms of pellagra include both physical and mental difficulties, diarrhea, inflamed mucus membranes, and dementia. Pellagra can also result when the body is not able to absorb enough niacin because of alcoholism. Health benefits of niacin include its use as a treatment to help control high blood levels of cholesterol. Doses of niacin high enough to lower cholesterol are associated with several side effects and should only be taken with a physician's supervision.

Take Vitamin B5 for Healthy Hormones



All people age 14 and older should get 5 mg of vitamin B5 (pantothenic acid) each day, according to the Food and Nutrition Board of the Institute of Medicine. You can find vitamin B5 in vegetables of the cabbage family, such as broccoli and kale, as well as in avocado.

In addition, whole-grain cereals, potatoes, dairy, and organ meats are good sources. This type of B vitamin is needed for many of the biochemical reactions that go on in our cells each day, including the breakdown of carbohydrates and lipids for energy. Because it's a water-soluble vitamin, you need vitamin B5 in your diet every day. Pantothenic acid is necessary for our bodies to produce hormones, and it's also needed for growth.

Vitamin B6 May Help Reduce Heart Disease Risk



The recommended daily amount of vitamin B6, also called pyridoxine, is 1.3 mg for adults up to the age of 50, according to the National Institutes of Health. Pregnant or breast-feeding teens and women need even more vitamin B6 daily about 2 mg. You can find vitamin B6 in the following foods:

• Bananas
• Beans
• Beef liver
• Bran
• Brown rice
• Carrots
• Cheese
• Chicken
• Fortified ready-to-eat cereal
• Lentils
• Milk
• Salmon
• Shrimp
• Spinach
• Sunflower seeds
• Tuna
• Turkey
• Wheat germ
• Whole-grain flour

Vitamin B6 is important because it's involved in more than 100 enzyme reactions in the body's cells, helping us metabolize amino acids from our food and build new red blood cells. There is intriguing research that B6 may help reduce the risk of heart disease, but this benefit has not yet been definitely established. The health benefits of vitamin B6 uncovered by clinical research include reduction in heart disease risk. Although deficiency in this vitamin is rare in the United States, it can lead to muscle weakness, depression, irritability, short term memory loss, nervousness, and difficulty concentrating.

Avoid Anemia With Vitamin B12



Adults need only 2.4 micrograms (mcg) of vitamin B12, also called cyanocobalamin, each day. Pregnant or breastfeeding teens and women need more: 2.6 to 2.8 mcg daily. Vitamin B12 is not naturally occurring in plant foods, so vegetarians and vegans may not get enough in their diets and may need to take a B supplement. Natural sources rich in vitamin B12 are dairy products, fish, meat, and in particular beef liver and clams. This type of vitamin B can also be found in fortified items like breakfast cereals and nutritional yeast.

Vitamin B12 is essential for building blood cells and maintaining healthy nerve cells in the body. As many as 15 percent of people in the United States have a vitamin B12 deficiency, which can lead to anemia. Symptoms of B12 deficiency include weakness, fatigue, constipation, weight loss, and loss of appetite. Deficiency is also damaging to the nervous system and can cause depression, confusion, and dementia.

Folic Acid Is Essential for a Healthy Baby



Vitamin B9, also called folic acid or folate, is a nutrient that's necessary for the body's growth and development. The National Institutes of Health recommends that adults get 400 micrograms (mcg) daily, while breast-feeding mothers need 500 mcg a day, and pregnant teens and women should get 600 mcg a day. Naturally occurring folate is found in many sources, including dark-green leafy vegetables, asparagus, brussels sprouts, oranges, nuts, beans, and peas. In addition, folic acid is added to many fortified foods such as cereals and breads.

Teens and women who are pregnant or planning to get pregnant may find it difficult to get enough folate, but this B vitamin is vital to a baby's health and development. Getting enough folate prevents neural tube (brain and spine) birth defects in babies and promotes healthy growth.

The Office of Dietary Supplements of the National Institutes of Health recommends talking with your healthcare providers about any dietary supplements you take.

Diabetes linked to greater discomfort regardless of weight status, age, or radiographic severity.

Does having diabetes make knee osteoarthritis hurt more?

New research shows that people with diabetes and knee osteoarthritis (KOA) are more likely to experience more pain as a result of their condition compared with people with diabetes alone. The study, published in February 2020 in Arthritis Care & Research, found that the increased pain was present even after controlling for obesity status, sex, and the severity of the disease according to imaging tests.

These finding are interesting because we tend to think about osteoarthritis as a mechanical problem, says Joshua F. Baker, MD, assistant professor of medicine and rheumatologist at Penn Medicine in Philadelphia. We know that weight is really important in the development of osteoarthritis, and wear and tear can be greater because of that excess weight, but there may be also metabolic changes related to obesity that could influence osteoarthritis. It's reasonable to think that diabetes and other metabolic problems might actually make your arthritis worse and give you more symptoms, says Dr. Baker.

Diabetes and Knee Osteoarthritis Are Becoming More Prevalent.

The number of people with type 2 diabetes continues to climb; according to the Centers for Disease Control and Prevention (CDC), it's estimated that more than 34 million people age 18 and older have diabetes. Knee osteoarthritis is on the rise as well, as shown in a study published August 2017 in the journal PNAS, which found that the prevalence of knee osteoarthritis has more than doubled in prevalence since 1940, rising from 6 to 16 percent; current estimates show that almost 20 percent of people in the United States over age 45 have KOA.

Although the two conditions share key risk factors, such as having a body mass index (BMI) over the healthy range and being older, research published in Diabetes Care showed that having type 2 diabetes increases the risk for developing severe osteoarthritis independent of either of those factors.

Diabetes: An Independent Risk Factor for Pain in Knee Osteoarthritis

Researchers analyzed data from 2,481 patients previously enrolled in the Osteoarthritis Initiative, a nationwide research study sponsored by the National Institutes of Health. Participants were between 45 and 79 years old, and 202 (8 percent) had diabetes.

Subjects were evaluated in the following ways:

• Knee pain was determined using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and numerical rating scale (NRS).
• Physical status was assessed by the Medical Outcomes Short Study Form, a survey that assesses overall health and quality of life.
• Mental health was evaluated with the Center for Epidemiological Studies Depression Scale.

The KOA patients who had diabetes reported worse knee pain, as well as greater physical and mental issues, compared with people without diabetes. The findings remained consistent even when controlling for BMI, sex, age, and the severity of the disease as determined by radiographic severity. KOA is often measured by radiograph using the Kellgren and Lawrence system, which classifies severity of the disease by measuring the space between the joints as well as the presence of osteophytes, a bony outgrowth that is associated with the degeneration of cartilage at joints.

Diabetes Is a Risk Factor for Increased Joint Pain

"Our findings confirm results in a larger cohort that have been shown in previous studies in smaller patient groups," Annett Eitner, PhD, lead author and researcher at Friedrich Schiller University in Jena, Germany, wrote in an email message. Although there is much evidence for a role of metabolic factors in the development of osteoarthritis, its relative importance is still disputed; our data show that diabetes mellitus is an independent risk factor for increased joint pain, she noted.

The main limitation of these findings is that they're based on observational data, says Baker. In an observational study, researchers simply observe the effect of a risk factor without trying to change or control behavior. These subjects in these studies can have characteristics or habits that may impact the results; researchers try to identify them and adjust accordingly, but there can be a lot of unknowns, according to the Institute for Health and Work.

When you're looking at observational data it's very hard to make causal inferences. There is a correlation here between diabetes and symptoms of osteoarthritis, but what we don't know enough to really understand the relationship, says Baker. We don't really know all the differences between people who do have diabetes and who don't have diabetes; they may be different in many different ways besides that their weight is different, he says.

Examples of those differences could be how each person's fat is distributed or if they have other medical conditions, says Baker. Those kinds of factors could influence the outcomes of the study, he adds.

How Could Diabetes Cause More Severe Pain in Knee Osteoarthritis?

It's possible that people with diabetes mellitus may suffer from more knee pain at a comparable stage of osteoarthritis than nondiabetic patients from the increased inflammatory processes in the joint of patients with diabetes mellitus, says Dr. Eitner. The authors also suggested that the increased pain could be a product of diabetic neuropathy, which is a type of nerve damage that can occur for people with diabetes.

Inflammation or neuropathy due to diabetes could be behind the increased pain, but there currently isn't enough evidence to prove either of these theories, says Baker. People with diabetes and metabolic obesity are known to have more systemic inflammation. There's a lot of thought that that inflammation might predispose people to more severe arthritis and even could contribute to inflammation of the joint as a result of arthritis, he says. Theoretically, those factors could make your symptoms worse, although that's not a well-defined relationship and very difficult to prove, he adds.

The other possibility is that the diabetes itself may influence the nerves, says Baker. It's very clear that diabetes causes neuropathy; whether diabetes has an effect on how people with diabetes experience pain in knee osteoarthritis as a result is possible, although there isn't specific data to support that hypothesis, says Baker.

More Research Is Needed to Understand Link Between Arthritis Pain and Diabetes

To prove that either of those mechanisms is behind why people with diabetes experience more osteoarthritis symptoms, more research is needed, says Baker. We need more mechanistic studies really trying to understand how the metabolic part of diabetes or how diabetes itself may specifically lead to changes in the joint or changes in the nerves that would contribute to pain or other manifestations of arthritis symptoms, he says.

There is currently a lot of research around trying to understand the relationship between metabolic obesity and inflammation and osteoarthritis. I think we're learning that osteoarthritis is a probably a combination of mechanical issues in the setting of an inflammatory state, says Baker. If that's true, it's likely that the severity of a person's arthritis is related to metabolic consequences of the obesity, he adds.

The more stable your blood sugar levels are with type 2 diabetes, the healthier you'll be.
Here are some daily tips and tricks to help make that happen.



It's not always easy to manage type 2 diabetes or to keep your blood sugar levels steady, so that damage from highs and lows is kept to a minimum. But it's doable. It just takes some planning and smart management.

The key to steady blood sugar levels around the clock and from year to year, according to Jesse Vander Heide, a certified diabetes educator at Oregon Health and Science University in Portland, is to develop a routine that you're confident you can stick to over time.

Anybody can do something for a week, Heide says. With diabetes, we want to look at the long-term picture. How can you do this for one day and for five years? How can you do this for rest of your life? Until we have some sort of cure for type 2 diabetes, [these are the timeframes] we are looking at.

Heide urges people to think about all aspects of having type 2 diabetes: How you like to take your medication, how you check your blood sugar, how you eat. All of these things should be what you can keep up in the long-term, he says. Routine is vital to success as is understanding your disease.

Here's a morning-to-night routine that can help you successfully manage type 2 diabetes.

In the Morning

Check your blood sugar. If you have type 2 diabetes, you should check your blood sugar level every morning before you eat, says Marjorie Cypress, CDE, a nurse practitioner at ABQ Health Partners in Albuquerque, New Mexico, and past president of health care and education at the American Diabetes Association. This gives you a good baseline idea where you stand and allows you to make adjustments throughout the day.

Take your medication on time. If you're prescribed long-acting basal insulin, which is designed to keep your blood sugar levels steady over the course of the night and between meals, you may want to consider the AM as the time to do it, before the distractions of the day take over. But consistency is what really matters, Heide says. Whether that's morning or night, aim to take your basal insulin at the same time each day. 

We tend to cater [this decision] more towards what the person has an easier time remembering, he explains. If you're prescribed other medications to take in the morning, be sure to take these consistently as well.

Eat breakfast — and also take a look forward in your day. If you skip breakfast, you're already starting your day on the wrong foot. "Many people tend to skip breakfast, and it's one of the most important meals of the day," Cypress says. "You skip breakfast and you get hungrier and hungrier, and that's one of the reasons people tend to overeat later in the day."

In fact, while eating regular meals will help keep your blood sugar levels steady, skipping them and then binging later can cause spikes morning, noon, or night. Sometimes we put people on standard doses of diabetes medications for meals, and as the meals fluctuate, they can be at risk for high blood sugar or low blood sugar, Heide says.

And when a person is on standard doses of rapid acting insulin (bolus), one of the things we try to talk about is consistency of meals (such as eating the same amount of carbohydrates at every meal), Heide says. That requires some awareness of what you're eating, such as the carb and macronutrient composition of the food, he says.

For these and other reasons, when it comes to managing type 2 diabetes, understanding how to fit food and medication into your life is an example of how knowledge is power, says Heide. This means understanding how the insulin or other medications you've been prescribed affect your blood sugar. 

And since diets are hard to maintain, educators and doctors now focus more on eating strategies and plans instead. These involve looking at larger overall patterns that enable you to get nutritious food and also help keep your blood sugar levels steady throughout the day.

Give your feet a once-over. Over time, high blood sugar can cause nerve damage and loss of sensation in your feet. In extreme cases, a person with diabetes can end up needing to have a foot amputated if an unnoticed cut becomes severely infected. Check your feet for any sores or cuts each morning. 

Also check your shoes before putting them on to make sure there's nothing in your shoe that could cause a sore. Check your feet again at bedtime, as well.

In the Afternoon

Take a satisfying lunch break. Don't eat lunch at your desk that's a sure way to rush and feel stressed. Instead, sit down somewhere else and eat, then take a short walk afterward. Plan a healthy lunch ahead of time or you might resort to unhealthy fast food. You get a triple-win against diabetes with a lunch break: The regular meal and the exercise help keep your blood sugar level stable, and you can release some pressure from work.

Have healthy snacks on hand. Afternoon snacking is a good way to set yourself up for healthy eating once you are home. "Most people like to snack in the afternoon, and I think that's important because you don't want to get home and start grabbing anything because you're so hungry," Cypress says. But make it a sensible snack to help keep your blood sugar steady and also avoid being so hungry that you overeat later on.

Get a little extra activity. Physical activity is crucial to blood sugar control. When you're active, your cells burn blood sugar through a process that doesn't rely on insulin. Activity also lets your body use insulin more efficiently. Take the stairs instead of an elevator. Get up from your desk and go talk to co-workers instead of emailing them.

Experts recommend getting 30 minutes of physical activity each day, but it doesn't have to be all at once, says Don Kain, MA, RD, a certified diabetes educator with Oregon Health & Science University in Portland. Every time you get up and move around, you're adding to your 30-minute total. If you're worn out from work, he says, try to fit in a short walk in the late afternoon.

It's a good idea to check your blood sugar before and after exercise to help determine how different activities affect your blood sugar, Heide says. 

If you take insulin as part of your type 2 diabetes management, you may be at risk for hypoglycemia (low blood sugar) if you don't adjust your insulin dose or carbohydrate intake before exercise. Talk to your doctor about how best to balance activity with food and your medication. It's not a one size fits all scenario, says Heide. 

Variables to consider include the type of exercise they are doing, the type of meal they had beforehand, and the type of insulin they are taking. All of those factors make up a puzzle of what we recommend.

In the Evening

Eat a sensible dinner. Don't overeat at dinnertime. Eat a meal that's about the same size as what you ate for breakfast and lunch. Or at least make sure the meal fits into the larger eating strategy or plan that you've developed with your healthcare team. 

The actual amounts of protein, carbohydrates, fruits, and vegetables you should eat will depend on the meal plan that's best for you. 

As with earlier in the day, maintaining a steady intake of food will make you less vulnerable to blood sugar spikes, especially if you're eating healthy foods. And if you've been prescribed a bolus insulin dose or other diabetes medication before a meal, be sure to take that on time.

Keep moving while you watch TV or listen to a book on tape. Position weights — or even a treadmill or other workout unit nearby. The goal is to stay in motion, at least for a portion of the time. Do sit-ups or push-ups during commercials. Even physical activity that's not aerobic can help your body's ability to use insulin efficiently, and keep your blood sugar levels stable.

At Bedtime

Brush and floss your teeth. Brush in the morning and at night, and floss every night. "People with diabetes are at increased risk for periodontal disease and general dental problems," Kain says.

Apply some lotion. Keep your skin moisturized to prevent peeling, cracking, and developing sores that can be symptoms of diabetes. Apply lotion every night before bed.

Finally, do an end-of-day blood sugar check. Here's where you see how your diabetes management routine pays off. "Checking your blood sugar at bedtime gives you a good idea what happened during the day," Cypress says.

In many ways, the healthiest day and year and decade for the person with type 2 diabetes is patched together with common sense and awareness, Heide says. Almost everything that we teach people about diabetes are things that would be useful for someone who doesn't have diabetes!

When it comes to blood sugar and weight management, not all sugar substitutes are created equal. Find out which option is the best fit for your health goals. When it comes to blood sugar and weight management, not all sugar substitutes are created equal. Find out which option is the best fit for your health goals.



Taming a sweet tooth can be a challenge for anyone, but for people with type 2 diabetes, it's necessary to keep how much you consume in carbohydrates, including sugar, under control.

Sugar substitutes offer sweetness while making it easier to control carbohydrate intake and blood glucose (sugar). There are many sugar substitutes to choose from, but they're not all calorie-free, and they vary in terms of their impact on blood sugar.

When you're deciding which sugar substitutes to use, consider that they come in two varieties, noted an article published in the journal Diabetes Spectrum:

Nutritive These provide calories and can affect your blood sugar.

Nonnutritive These provide little to no calories and, per a review published in May 2018 in the European Journal of Clinical Nutrition, will not raise your blood sugar. They can be several hundred to several thousand times sweeter than sucrose (table sugar), according to the aforementioned article in Diabetes Spectrum.

But even if you choose a calorie-free sweetener, enjoy the sweet stuff in moderation. According to a study published in the journal Physiology & Behavior, artificial sweeteners can alter your brain's response to sweetness and affect your ability to feel satisfied when you eat sweet-tasting food or drink, putting you at risk for consuming too much of it. 

In fact, the American Diabetes Association recommends that in the case of beverages, it's best not to rely on zero- or low-calorie options as a replacement for ones that contain sugar beyond the short term; but instead, to consume as little of any type of sweetener as you can, and simply drink more water.
With that in mind, here are nine low- or no-calorie options to consider:

1 Sucralose (Splenda), the Most Popular Sugar Substitute


This sweetener is excellent for people with type 2 diabetes. That's because Splenda is 600 times sweeter than sugar, yet those little yellow packets have no effect on blood sugar, says Keri Glassman, RD, CDN, of Nutritious Life, a nutrition practice based in New York City. In addition, Splenda passes through the body with minimal absorption. 

These attributes have helped it become the most commonly used artificial sweetener worldwide, according to an article published in October 2016 in Physiology & Behavior.

The Food and Drug Administration (FDA), which has approved sucralose, recommends an acceptable daily intake (ADI) of 5 milligrams (mg) or less of sucralose per kilogram (kg) of body weight per day. A 132-pound (lb) individual would need to consume 23 tabletop packets of the artificial sweetener per day to reach that limit.

2. Saccharin (Sweet ‘N Low), the Oldest Artificial Sweetener


Saccharin, the sweetener sold in pink packets under the brand name Sweet 'N Low, is calorie-free and is about 300 to 500 times sweeter than sugar, per the Sweet N Low website. It was the first artificial sweetener, with chemists discovering it as a derivative of coal tar by mistake in 1879, according to Encyclopedia Britannica.

If you've been using artificial sweeteners since the 1970s, you may remember a previous warning label that warned of saccharin increasing the risk for cancer. But rest assured it's safe. The research that prompted the label was done on animals, and further studies by the National Toxicology Program of the National Institutes of Health concluded that saccharin shouldn't be on the list of potential carcinogens. Saccharin is currently FDA-approved.

A 132-lb individual would need to consume 45 tabletop packets of the artificial sweetener per day to reach the ADI of 15 mg of saccharin per kg of body weight per day, according to the FDA.

3. Aspartame, a Low-Calorie Sweetener yet Not Okay for People With PKU


Aspartame, sold in blue packets under the brand names Equal and NutraSweet, is a nonnutritive artificial sweetener that is 200 times sweeter than sugar, according to the FDA. While not zero-calorie like some other artificial sweeteners, aspartame is still very low in calories.

While the FDA has reviewed the scientific research and found aspartame safe to eat, Glassman notes there have also been some conflicting study results on this sweetener's safety. "Although its low-calorie reputation is appealing for most weight-conscious individuals, it has been linked to many negative side effects," Glassman says. 

Some animal research, including a study published in December 2014 in the journal Cytotechnology, has shown linkage to leukemia, lymphoma, and breast cancer. Other research shows a [possible] linkage to migraines."

Yet the American Cancer Society notes that U.S. and European regulatory agencies have, respectively, concluded that aspartame is safe and that research doesn't indicate an increased risk of cancer in humans.

Nevertheless, people with phenylketonuria (PKU), a rare condition in which they are unable to metabolize phenylalanine (a key component of aspartame), should not consume this sugar substitute, notes the NHS. If you don't have PKU, aspartame is safe to consume.

A 132-lb individual would need to consume a whopping 75 tabletop packets of the artificial sweetener per day to reach the ADI of 50 mg of aspartame per kg of body weight per day, notes the FDA.

4. Stevia (Truvia or Pure Via), a Natural Sweetener Option


Steviol glycosides are sweeteners derived from the leaf of the stevia plant, which is native to Central and South America. Truvia and Pure Via, both brands of stevia-based sweetener, are calorie-free, and stevia is often used as a sweetener in foods and beverages. 

According to the 2019 Standards of Medical Care in Diabetes, published in January 2019 in Diabetes Care, nonnutritive sweeteners, including stevia, have little to no impact on blood sugar.

The FDA has approved the use of certain stevia extracts, which it has generally recognized as safe (a term that is applied to food additives that qualified experts deem as safe, and therefore not subject to the usual premarket review and approval process).

Memorial Sloan Kettering Cancer Center notes that people have reported side effects, like gastrointestinal symptoms, after eating high amounts of stevia. But to date, there is no solid scientific research to prove these claims.

The FDA recommends an ADI of 4 mg or less of Truvia per kilogram of body weight per day. A 132-lb individual would need to consume nine tabletop packets of the artificial sweetener per day to reach that limit.

5. Sugar Alcohols, a Low-Calorie Option for Sweetening Your Fare


Sugar alcohols, or polyols, are derived from the natural fibers in fruits and vegetables, according to the Joslin Diabetes Center. Per the International Food Information Council Foundation, commonly used sugar alcohol sweeteners in many so-called sugar-free desserts, candies and gums include:

Xylitol
Sorbitol
Mannitol
Isomalt

Though sugar alcohols are relatively low in calories and more blood sugar friendly than carbohydrates, they may have a laxative effect and cause indigestion, bloating, and diarrhea in some people, the FDA points out. Products containing sorbitol and mannitol must bear a label warning that excess consumption can cause a laxative effect, per the FDA.

The gastrointestinal symptoms arise because sugar alcohols are not completely absorbed in the digestive tract, says Lynn Grieger, RDN, CDE, a medical reviewer for Everyday Health who's based in Prescott, Arizona.

She explains that unabsorbed carbohydrates from these sweeteners pass into the large intestine, where they are fermented by gut bacteria to produce gas. See how you respond to a small amount before incorporating them into your daily diet.

Also, keep in mind that sugar alcohols do contain some carbohydrates and are nutritive sweeteners, so they can affect blood sugar levels.

It's important for people with diabetes to read the nutrition facts label for total carbohydrate content and plan accordingly, says Grieger. 

Remember that the information in a nutrition facts label is based on one serving, and it's easy to eat more than one serving of foods that contain sugar alcohols, which can increase the total carbohydrate consumed. 

If you count carbs to manage diabetes, a common rule of thumb is to subtract half the amount of the sugar alcohol carbs listed on the nutrition label from the total carbs listed, according to the University of California in San Francisco.

6. Erythritol, a Sugar Alcohol With Fewer Side Effects Than Other Options


Erythritol is also a sugar alcohol sweetener, but unlike the others just mentioned, it has less than 1 calorie per gram, notes the International Food Information Council Foundation, and doesn't have a big effect on blood sugar levels, per the American Diabetes Association. 

It's an ingredient in the stevia-derived sweetener Truvia and is marketed under the brand-name Swerve. Swerve measures cup-for-cup like sugar, and you can use it like table sugar, or in cooking and baking recipes that call for sugar.

If other sugar alcohol sweeteners give you tummy trouble, this may be a better option for you. It is less likely to produce the gas, bloating, and diarrhea that happen from fermentation by gut bacteria because only about 10 percent of the erythritol you consume enters the colon, per past research. The rest leaves the body through your urine.

There's no ADI for erythritol, but the FDA hasn't questioned notices submitted by erythritol makers that the sweetener is generally recognized as safe.

7. Monk Fruit Sweetener, Another Natural Option for Sweetening Your Foods


Also known by the names Luo Han Guo fruit extract and Siraitia grosvenorii Swingle fruit extract, this nonnutritive sweetener comes from a plant native to southern China. The extract contains 0 calories per serving, per the International Food Information Council Foundation, and per the FDA, is 150 to 200 times sweeter than sugar.

Popular brands include Monk Fruit in the Raw and Lakanto. The FDA has not questioned notices submitted by monk fruit sweetener makers that the extract is generally recognized as safe. The agency doesn't specify an ADI for monk fruit sweetener.

8. Acesulfame Potassium, a Popular Sugar Substitute in Diet Soda


Also known as Ace-K, this nonnutritive sweetener is FDA-approved and about 200 times sweeter than sugar. Often manufacturers combine it with other sweeteners, though it is also sold for tabletop use under the brand name Sweet One. You will also find it in some of your favorite diet soft drinks, such as Coca-Cola Zero Sugar and Diet Mountain Dew. The FDA recommends an ADI of 15 mg or less of Ace-K per kilogram of body weight per day.

A 132-pound individual would need to consume 23 tabletop packets of the artificial sweetener per day to reach that limit.

9. Allulose (Dolcia Prima), a New Artificial Sweetener That's No Longer Considered an Added Sugar


Allulose (also known as D-allulose or D-psicose, per the U.S. National Library of Medicine) is an extremely low-calorie sweetener that occurs naturally in small amounts in wheat, raisins, dried figs, brown sugar, and molasses, according to the FDA. 

Marketed under the brand name Dolcia Prima (which Tate & Lyle, Splenda's manufacturer, makes), it has 90 percent fewer calories than sucrose, while being 70 percent as sweet.

You can find Dolcia Prima in Magic Spoon Cereal, which is sold online; and expect to see it soon in beverages, desserts, candy, yogurt, and other treats. That's because allulose got a big boost from the FDA in April 2019, when the agency declared it can be excluded from the total and added sugars listed on nutrition labels going forward.

The latest data suggests that allulose is different from other sugars in that it is not metabolized by the human body in the same way as table sugar, says Susan Mayne, PhD, director of FDA's Center for Food Safety and Applied Nutrition. It has fewer calories, produces only negligible increases in blood glucose or insulin levels, and does not promote dental decay.

Under the revised guidance, manufacturers can use a caloric value of 0.4 calories per gram to calculate the total number of calories per serving of allulose, instead of the previous 4 calories per gram. The sweetener still must be included in the total carbohydrates listed, though. 

While allulose isn't on the list of FDA-approved sweeteners, the agency hasn't questioned notices submitted by manufacturers that the sweetener is generally recognized as safe.

But the European Union has yet to approve allulose, according to an article published in April 2019 in Food Manufacture, nor has Canada added it to their list of permitted sweeteners. 

Furthermore, research into its effectiveness for controlling blood sugar is limited to small studies, such as a small randomized, double-blinded trial published in June 2018 in the journal Nutrients, which was funded by Tate & Lyle. 

The authors observed that small doses of allulose (5 or 10 g) did not have a significant effect on blood glucose levels when taken with a standard glucose tolerance test, but they recommended larger sample sizes for future studies.

Using Sugar Substitutes When Managing Type 2 Diabetes

As you can see, there are many artificial sweeteners to help you reach your blood sugar goals. Just remember that maintaining them will be easier if you practice moderation and don't allow sweet-tasting food and beverages to lead you to overconsume them. A major goal should be to reduce all types of sweeteners in your diet, including sugar substitutes, so that you become accustomed to the naturally sweet taste of food, says Grieger. Then trust your body to tell you when enough is enough.