Can you beat diabetes

Contents

How to Beat Type 2 Diabetes With Diet and Lifestyle Changes

Improve Your Diet to Help You Treat Type 2 Diabetes Naturally

Keeping close tabs on your diet is a major way to help manage type 2 diabetes. A healthy diet for people with type 2 diabetes includes fresh or frozen fruit and vegetables, whole grains, beans, lean meats, and low-fat or fat-free dairy. Focus on eating fruit and non-starchy vegetables, like broccoli, carrots, and lettuce, and having smaller portions of starchy foods, meats, and dairy products. Be especially careful about loading up on foods that are high on the glycemic index (GI) and especially the glycemic load (GL), systems that rank foods according to how they affect glucose levels.

“High glycemic index foods are going to be primarily processed foods,” says Lori Chong, RD, CDE, at The Ohio State University Wexner Medical Center in Columbus. Those processed foods tend to have more white sugar and flour in them, which are higher on the GI, she says. Foods lower on the GI include vegetables, especially non-starchy vegetables, like broccoli, cauliflower, and leafy greens and whole-grain products, such as brown rice (as opposed to white rice), Chong says. She notes that even many fruits are low on the GI, with pineapple and dried fruit being some of the highest (Berries, apples, and pears tend to be fairly low.)

Limit fast food, too, as these eats contain trans fats, refined carbohydrates, and loads of sodium, which can be especially unhealthy for people with type 2 diabetes due to their effect on the heart and body weight.

To help you avoid or limit fast food, Chong recommends planning ahead by packing healthy meals or snacks. Diabetes-friendly snack ideas include a piece of fruit, a handful of nuts, and yogurt. Also, if you absolutely must stop at a fast-food restaurant, steer clear of anything that’s deep-fried — such as french fries, chicken nuggets, and breaded fish or chicken, Chong says.

Lose Weight — Especially Belly Fat — to Help Lower Glucose Levels

Shedding pounds can improve blood sugar levels and help keep type 2 diabetes under control. And you don’t have to lose a lot of weight to make a difference. “If you already have type 2 diabetes, losing just 10 to 15 pounds can lower your glucose levels,” says McLaughlin.

In fact, the CDC notes that losing just 5 to 7 percent of your body weight can help lower your risk of developing type 2 diabetes. So, if you’re 200 pounds, aiming to lose about 10 to 14 pounds might help you prevent prediabetes from progressing to full-blown type 2 diabetes or help halt the advancement of type 2 diabetes if you’ve already been diagnosed.

Where your fat is distributed also affects your diabetes risk and management. People who carry most of their fat in their belly (referred to as having an apple-shaped body) are more prone to type 2 diabetes than those with fat mostly in the thighs, hips, and buttocks (having a pear-shaped body).

“The abdominal fat tends to increase insulin resistance,” Chong explains. “Insulin resistance is really the heart of the problem with type 2 diabetes.”

A woman whose waist measures more than 35 inches and a man with a 40-inch waist need to lose weight for good diabetes management regardless of what their body mass index (BMI) may be, says McLaughlin, adding that a healthy diet and regular aerobic exercise will whittle away weight in the stomach area.

Exercise Regularly as Part of Your Type 2 Diabetes Treatment Plan

Even without losing a pound, you can help keep type 2 diabetes under control with exercise.

“When you do physical activity, such as walking, your muscle contractions push glucose out of your blood into your cells,” explains McLaughlin. The result: better blood sugar levels.

The more intense the exercise, the better. According to the British diabetes association diabetes.co.uk, high-intensity interval training (HIIT) may be better for weight loss and glucose control than continuous aerobic activity like jogging. HIIT involves alternating between short bursts of increased intensity exercise and rest — for instance, running and then walking on and off throughout the workout.

Regular weightlifting sessions can also help keep blood sugar levels steady. McLaughlin recommends using hand weights or resistance bands for 30 minutes two or three times a week. The CDC recommends getting at least 150 minutes a week of brisk walking or a similar activity, which comes out to about 30 minutes a day, five times a week.

Control Sleep Apnea to Help Manage Blood Sugar Spikes and Dips

Many overweight people with type 2 diabetes also have sleep apnea, a condition in which a person stops breathing temporarily while sleeping. In fact, a study published in 2013 in Family Medicine suggests that as many as one in two people with type 2 diabetes may have or be at high risk for sleep apnea, many of whom are undiagnosed.

People with type 2 diabetes and sleep apnea are at higher risk of death from diabetes complications such as heart attack and stroke.

Chong points to previous research in Circulation that describes the underlying mechanisms of sleep apnea. In people with sleep apnea, activation of the sympathetic nervous system — including increased heart rate, increased blood pressure, and constriction of blood vessels — all led to a higher risk of heart attack and stroke, which can be compounded in people who have type 2 diabetes (and thus already have a higher risk of heart disease).

“It’s a whole cascade of events, and no one is really sure what comes first,” Chong says.

Severe cases of sleep apnea may need to be treated with surgery or by wearing a special device while sleeping, but less severe cases can be managed by losing weight. Talk to your doctor if you suspect you may have sleep apnea — loud snoring, a large neck, and being overweight are all risk factors.

If you spot bleeding gums, it could be the first sign you’re at risk of type 2 diabetes. Gum disease and insulin resistance share common origins, let’s explore how to reverse type 2 diabetes

One big mistake that healthcare has made is that it has considered the body’s systems as separate. Gums are treated by the dentist, hearts by the cardiologist, and type 2 diabetes by the endocrinologist.

As a dentist, I see many patients with type 2 diabetes and advanced gum disease. It’s long been know that the two conditions are linked. We must consider the body as a whole if we want to cure type 2 diabetes.

Type 2 diabetes affects over 30 million Americans and is the seventh leading cause of death. What’s more, 7.2 million of that 30 million are unaware they have type 2 diabetes. This disease is on the rise and expected to affect one in three Americans by 2050.

These are staggering numbers, impossible to ignore in my opinion.

Gone are the days where the only piece of nutritional advice you’ll hear from a dentist is “don’t eat candy, it’ll rot your teeth.” As a functional dentist – I care about you and your health much more than that. Your diet and oral health are the gateway to your overall health – a fact that until recently had been largely overlook.

Up until this point, dentists have largely sat on the sidelines of the nutritional and systemic health conversation.

Let’s take a close look at how your teeth provide the secret to help cure type 2 diabetes.

What is the main cause of type 2 diabetes?

First, it’s important to understand what causes 2 diabetes in the first place, and that culprit is insulin resistance.

What does it mean to be insulin resistant? It occurs when your body needs more and more insulin to bring your blood sugar levels down. This happens when someone engages in an activity that raises their blood sugar levels up, over and over again.

What easily raises your blood sugar levels?

You guessed it.

Eating sugar.

Well, sugar and refined carbs are two of the worst for your blood sugar levels. So, not only should you avoid sugar because it “rots your teeth” but also because it’s a major contributor to type 2 diabetes.

A quick side note: Insulin resistance happens in type 1 diabetes but it’s due to an immune system attack on the insulin-producing cells and therefore considered an autoimmune disease – there are different solutions to these two types of illnesses. This article is focusing on type 2 diabetes.

Three key factors in dental diseases that help us understand type 2 diabetes

Decreasing your sugar in your diet is the better known way to reverse type 2 diabetes and cure insulin resistance.

The mouth-body connection gives some more perspective on how to influence type 2 diabetes. These include vitamin D, sleep, and the gut microbiome.

First, the health of your gut is critical to your overall health. This is because your gut is home of trillions of microbes called the gut microbiome. These microbes work in symbiotic and antagonistic relationships within your body. A 2017 study using multiple therapies to manipulate the gut microbiome composition, found they could impact the individual’s health more rapidly. This study also found manipulating the gut microbiome as an effective way to avoid insulin resistance and therefore prevent diabetes.

The plot thickens.

Through choosing which microbes to favor through diet, probiotics, and more – it appears possible support glycemic control and improves treatments for people who are diabetic.

Second, researchers have found vitamin D plays a functional role in maintaining glucose tolerance through improving insulin sensitivity and modulating secretion. One study found vitamin D supplementation may reduce insulin resistance.

I believe vitamin D has health roles all over the body, I wrote a four-part series on it. Make sure you’re getting enough sunshine or supplementing.

Vitamin D, Sleep Apnea, Gut Health, and Diabetes

A consequence of our poor diets is we have crowded teeth and smaller airways. You might be surprised to hear it wasn’t always that way – our ancestors had straight teeth, robust jaws, and never brushed or flossed. As a result 22 million Americans suffer from sleep apnea.

I bring this up because sleep apnea increases a person’s risk for developing type 2 diabetes. Also, sleep-disordered breathing is also related to proper nutrition throughout life. And perhaps most importantly, the first line of defense in catching sleep-disordered breathing in patients early, are dentists. This is another area where dentists must get involved if we want to tackle the issue of pervasive type 2 diabetes with any success.

Dentists can tell early on if children are getting the right nutrition and ensure their airway remains open so they can benefit from quality sleep for the rest of their life. This is essential to preventing not only diabetes, but heart disease, cognitive decline, and more.

Sleep apnea is also linked to vitamin D deficiency and gut microbiome changes. So by addressing these three factors in type 2 diabetes, we provide the foundation to cure type 2 diabetes.

4 Ways Prevent or Reverse Type 2 Diabetes

With the oral-systemic link, we can now provide a better plan to cure type 2 diabetes. Here’s a summary of my suggestions.

1) Reduce the cause of insulin resistance

  • Eliminate sugar
  • Eliminate refined carbohydrates
  • Switch to water from flavored drinks

2) Address vitamin D deficiency

  • If possible get enough vitamin D from the sun
  • Eat a fat-rich diet, high in fat-soluble vitamins A, vitamin D, and vitamin K2 – Walk About Emu Oil is a great source of all three of these nutrients.
  • Make sure you’re getting enough magnesium – here’s a great magnesium to help with energy levels.

3) Improve your sleep and address snoring and sleep apnea

  • Get screened for sleep apnea or upper airway resistance syndrome
  • Start breathing and tongue exercises
  • Get high-quality sleep (make sure you don’t have an undiagnosed sleeping disorder)
  • Incorporate stress reduction techniques

4) Heal your gut microbiome

  • Eat more fiber (shoot for 100g per day)
  • Eat prebiotic vegetables. Here’s a prebiotic supplement to get you started.
  • Eat fermented foods 2-3 times a day
  • Take a quality probiotic and oral probiotic – Here’s a pure, premium probiotic to help heal your digestive system
  • Start intermittent fasting by skipping breakfast once or twice a week
  • Exercise 3-4 times a week
  • Include strength training and HIIT training 1-2 times a week.

Now we want to hear from you. Have you been diagnosed with type-II diabetes?

Resources:

Now we want to hear from you. Please leave your questions in the comments below.

For more information on Dr. Lin’s clinical protocol that highlights the steps parents can take to prevent dental problems in their children: .

Reversing diabetes is a term that usually refers to a significant long-term improvement in insulin sensitivity in people with type 2 diabetes

People with type 2 diabetes that are able to get their HbA1c below 42 mmol/mol (6%) without taking diabetes medication are said to have reversed or resolved their diabetes. This also known as putting diabetes into remission.

Loss of body weight can be particularly beneficial in helping to reverse the progression of diabetes.

With time and dedication, type 2 diabetes can be reversed and the results can be very rewarding, with less tiredness and better all-round health.

If you think you need to come off your diabetes medication, ensure you speak to your healthcare team before doing so.

Understanding how diabetes progresses

The most common cause of type 2 diabetes is obesity-related, which generally follows a vicious cycle pattern:

  • Diet high in calories -particularly if high in refined carbohydrates.
  • Insulin levels in the bloodstream rise to cope with the high- and quick-acting carb intake.
  • Weight is gained around the belly (central or truncal obesity).
  • Consistently high insulin levels lead to the body’s cells becoming resistant to insulin and commonly lead to weight gain.
  • High insulin levels also increase weight gain.
  • Insulin resistance leads to an increase in blood sugar levels, particularly after meals.
  • The pancreas produces more insulin to cope with rising blood sugar levels
  • High sugar levels lead to feelings of lethargy and high insulin levels lead to increased hunger.
  • Hunger often leads to overeating and lethargy, with less physical activity being taken.
  • Overeating, less activity and high insulin levels all lead to further weight gain and more insulin resistance.
  • Consistently high demand on the pancreas to produce extra insulin leads to damage of the pancreas’ insulin-producing beta cells.
  • Beta cell damage results in the body struggling to produce enough insulin, and steeper rises in blood sugar levels leads to more recognisable symptoms of diabetes, symptoms of diabetes, such as thirst and a frequent need to urinate

Breaking the progressive cycle of type 2 diabetes

To reverse diabetes, you need to be able to break this cycle by taking the strain off your insulin-producing cells.

Research indicates that effective ways to reverse diabetes include:

  • Low-carbohydrate diets
  • Very low calorie diets
  • Exercise
  • Bariatric surgery

Low-carbohydrate diets

Low-carbohydrate diets are known for lowering the amount of insulin the body needs to produce, resulting in less insulin resistance.

A study published in 2014 by the Second University of Naples showed that a low-carbohydrate Mediterranean diet was able to achieve significant rates of remission in people with type 2 diabetes. After one year of following the diet, 15% of participants achieved remission and, after six years, 5% had achieved remission on the diet – a stunning achievement.

By comparison, low-fat diets were not as effective in the study. After one year, 4% of participants on a low-fat diet had achieved remission and, after six years, 0% of participants had achieved remission.

Dr David Unwin, a UK GP, has run studies that have demonstrated reversal of diabetes in a number of his patients after following a reduced-carbohydrate diet.

Low-carbohydrate diets and remission in the news:

  • Nov 2016: Low-carb diet outperforms high-carb diet in lowering insulin resistance, study reports
  • Apr 2016: Young man from Edinburgh reverses type 2 diabetes with LCHF diet
  • Apr 2014: Low carb Mediterranean diet outperforms low fat diet over 8 year study

Low-carb success stories from the forum:

Read other people’s success stories and see how others have managed to reverse their type 2 diabetes:

  • Down from 9.9 to 6.7 in 10 weeks
  • Type 2 and normal HbA1c with just diet/exercise
  • Down from 23.5 to 5.9 in 8 weeks
  • Latest HBA1C – stunned!
  • After 9+yrs of Metformin no more meds!
  • Lower carb diet and Fatty Liver Gone
  • Hba1c down from 86(12.3) to 38(5.6) in 3 months diet and exercise only and the love of this forum

Transcript

Reversal of diabetes refers to type 2 diabetes. Type 2 diabetes has traditionally been viewed as a condition which gets progressively worse over time. In more recent years, there has been more evidence showing that people can reduce the severity of diabetes to halt and even reverse its progression.

Type 2 diabetes is characterised by the body struggling to respond to its own insulin. As a result, the body needs to produce more insulin to bring down glucose levels.

Research from the Joslin Diabetes Centre states that if the body struggles to keep blood glucose levels steady, the cells which produce insulin will begin to lose their ability to produce insulin. If too many insulin producing cells lose their ability to function, insulin will need to be injected to keep blood glucose levels stable.

Researchers have been able to show that diabetes can be reversed by Bariatric surgery resulting in significant weight loss and very low calorie diets.

These methods have enabled a significant number of study participants with type 2 diabetes to come off diabetic medication. Researchers have hypothesised that the improvement in blood glucose control, as a result of weight loss, may be related to a loss of fat from around organs such as the liver and pancreas.

If you are obese, you may qualify for weight loss surgery. If weight loss surgery is not an option, your doctor may help you to commence a very low calorie diet.

Very low calorie diets are regarded as extreme diets and these should not be undertaken without the support of your health team.

Download the 30 Day Low Carb Meal Plan

Very low-calorie diets

Very-low-calorie diets (VLCD) have been shown to achieve significant weight loss, reduce insulin resistance and allow people with type 2 diabetes to come off their diabetes medication.

In 2011, a study was published by researchers at Newcastle University showing that an 8-week 800 kcal per day diet was able to achieve remission from diabetes in seven of the 11 participants that took part. The diet included around 600 kcal from meal shakes and around a further 200 kcal from non-starchy vegetables.

The trial used MRI scans and showed that the reversal of diabetes appeared to be correlated with significant reductions in fat storage within the liver and pancreas.

Currently, Newcastle University are running a study involving 32 participants. The participants were put on a similar diet for a similar length of time and then followed a low calorie weight maintenance diet.

The participants will be reviewed for at least two years to see how many of the participants can maintain diabetes remission over this period.

Initial results show that 40% of participants had achieved and maintained remission from type 2 diabetes six months after completing the diet.

A VLCD is regarded as an extreme form of diet and therefore should be undertaken with care. If you are interested in following a VLCD, it is important that you first speak with your doctor to ensure the diet is safe for you to follow.

In addition to the results seen in clinical trials, a number of anecdotal reports from patients show VLCDs to be successful at reversing diabetes to varying degrees. Read more on the low calorie diet forum

VLCDs and reversal of diabetes in the news:

  • Mar 2016: Very low-calorie diet can reverse type 2 diabetes for six months
  • Aug 2013: Case of type 2 diabetes reversed in 11 days through Newcastle Diet
  • Jun 2011: Type 2 diabetes can be reversed by eating 600 calories a day

Low-calorie success stories from the forum:

There are many success stories in the forum:

  • Reversed T2 in 3 months diet only!
  • “Complete diabetic remission!”
  • My hba1c today

Exercise

Commitment to exercise has allowed a number of people to successfully reverse their type 2 diabetes.

Exercise helps the body to become more sensitive to its insulin. In combination with a healthy diet, exercise can reduce the demand for insulin in the body and therefore help reverse diabetes.

There is a phrase that says ‘you can’t outrun a bad diet’ and there is a lot of truth in this. The people that have used exercise to reverse their diabetes have done so by combining exercise with healthy eating.

There have been a number of anecdotal accounts showing exercise to be linked with diabetes remission.

A study published in 2015 showed that 67% of participants were able to achieve partial remission of their type 2 diabetes having taken part in a six-month diet and exercise program. The participants in this study were newly diagnosed with type 2 diabetes.

Exercise and type 2 diabetes remission in the news:

  • Mar 2014: Pensioner sends type 2 diabetes into remission with 12-minute workouts
  • Mar 2014: Cyclist puts type 2 diabetes into reverse following 7 stone weight loss

Bariatric surgery

Bariatric surgery has shown significant results in reversing type 2 diabetes, with gastric bypass surgery, leading to particularly impressive remission rates.

A 2010 study showed that, three years after gastric bypass surgery, 72% of participants with type 2 diabetes had achieved remission. , and a 2013 study reported that 24% of participants with type 2 achieved remission six years after receiving gastric bypass surgery.

Gastric bypass surgery delivers the most impressive long-term remission rates but carries a risk of complications during and following surgery. It is a permanent procedure and necessitates a change to how you eat meals.

During gastric bypass surgery, the stomach is made much smaller, and only small meals can eaten following surgery. Additionally, nutritional supplements will need to be taken for the rest of one’s life.

Bariatric surgery and remission in the news:

  • Mar 2016: Weight loss surgery more effective than lifestyle intervention in type 2 diabetes
  • Oct 2015: Type of weight loss surgery affects chances of type 2 diabetes remission

Is it possible to reverse type 1 diabetes?

At the moment, type 1 diabetes cannot be reversed. Type 1 diabetes is an autoimmune disease, and reversing it would require a method of preventing the body’s immune system from attacking its own insulin-producing cells.

Research is currently trying find a type 1 diabetes vaccine which could help to one day reverse the condition.

Where Do I Begin With Type 2?

Where Do I Begin with Type 2?

Diabetes is a journey. The American Diabetes Association is ready to be with you every step of the way.

Start here

First, take a deep breath.

You have type 2 diabetes. And yes, it’s a big deal. But you know what? It’s also something you can deal with. And the American Diabetes Association is here to help.

Finding out

When people first find out that they have diabetes, it’s sometimes really scary, or sad, or even hard to believe.

After all, you probably don’t feel sick, or any different than you felt before you were told you have diabetes. And yet it is very important to take this disease seriously.

Some people who learn they have diabetes worry that it means their life is over, or that they won’t be able to do everything they used to do. Neither of those things is true.

Your new job

What is true is that you may need to change some things about your daily routine.

It’s not your fault that you got diabetes, but it is your job to take care of yourself.

Luckily, there’s a lot that you can do to keep yourself healthy. This section of diabetes.org will give you the first steps for taking control of your diabetes.

Top 10 Tips for People Newly Diagnosed with Type 2 Diabetes

by Adam Brown

twitter summary: Ten tips for newly diagnosed T2 #diabetes: act NOW for long-term benefits, use healthy eating, exercise, meds + structured blood glucose testing

short summary: This article offers ten tips for people newly diagnosed with type 2 diabetes: 1) Know that developing type 2 diabetes does not represent a personal failing; 2) Start to take care of your diabetes as soon as you’re diagnosed (and even better, before, if you know you have prediabetes); 3) Recognize that type 2 diabetes is a progressive disease; 4) Keep in mind that food has a major impact on blood glucose; work to optimize your mealtime choices; 5) Exercise is a powerful and underutilized tool which can increase insulin sensitivity and improve health – use it as much as possible; 6) Use blood glucose testing to identify patterns; 7) Don’t forget that needing to take insulin doesn’t mean you failed; 8) Keep learning and find support; 9) Seek out the services of a Diabetes Educator; and 10) Review our Patient’s Guide to Individualizing Therapy at www.diaTribe.org/patientguide.

  1. Know that developing type 2 diabetes does not represent a personal failing. It develops through a combination of factors that are still being uncovered and better understood. Lifestyle (food, exercise, stress, sleep) certainly plays a major role, but genetics play a significant role as well. Type 2 diabetes is often described in the media as a result of being overweight, but the relationship is not that simple. Many overweight individuals never get type 2, and some people with type 2 were never overweight. At its core, type 2 involves two physiological issues: resistance to the insulin made by the person’s beta cells and too little insulin production relative to the amount one needs. These problems can lead to high blood sugar, which over time can cause various complications like heart disease and stroke, retinopathy, and neuropathy (you can read more about diabetes complications here). Treatments for type 2 diabetes – a healthy eating plan, regular exercise, and blood glucose lowering drugs – involve addressing both insulin resistance and the relative lack of insulin to control blood glucose levels. The progression from normal glucose levels through prediabetes, and then to type 2, can often take five to 10 years.

  2. Taking care of your diabetes soon after diagnosis (and before) will pay off now and in the long term. Type 2 diabetes is not a death sentence by any stretch, but it is a serious disease that demands your attention immediately. Ignoring it may not seem to have significant short-term consequences (chronic high blood glucose levels are not painful), but over time, the elevated glucose levels can damage your nervous system, blood vessels, eyes, heart, and kidneys. In the landmark Diabetes Prevention Program study, even a small percent of people with prediabetes were found to have evidence of eye disease (retinopathy). Managing your blood glucose levels now, along with other health risk factors (e.g., cholesterol, blood pressure, weight), is necessary for preventing these complications. Losing even a small amount of weight and keeping it off can also improve glucose control as well as have other clinical benefits (read more tips on managing diet and exercise below for more on weight loss). Keep in mind that better diabetes management will also benefit you in the here and now – your mood and energy levels are adversely affected when your glucose levels are high.
    What’s the evidence? In the landmark UKPDS study, 5,102 patients newly diagnosed with type 2 diabetes were followed for an average of 10 years to determine whether intensive use of blood glucose-lowering drugs would result in health benefits. Tighter average glucose control (an A1c of 7.0% vs. an A1c of 7.9%) reduced the rate of microvascular complications (which affect the eyes, kidneys, and nervous system) by 25%. For every percentage point decrease in A1c (e.g., from 9% to 8%), there was a 25% reduction in diabetes-related deaths, a 7% reduction in mortality, and an 18% reduction in combined fatal and nonfatal heart attacks.

  3. Recognize that type 2 diabetes is a progressive disease. When people are diagnosed with type 2 diabetes, they have already lost up to 50% or more of their beta cell function (the cells in the pancreas that make insulin) and are typically also insulin resistant, meaning they can’t use the insulin they make effectively. A few patients can initially manage their diabetes with a healthy eating plan and exercise. But over time, beta cell function decreases, which makes blood glucose harder to manage. To continue achieving blood glucose control, people typically need to add one or more different types of medications. The good news today is that there are many more choices available, and a number of these medications don’t cause as much hypoglycemia, hunger and/or weight gain as in the past (e.g., metformin, pioglitazone, DPP-4 inhibitors, GLP-1 agonists, SGLT-2 inhibitors, and better insulin). The need to use more and different types of medications does not mean that you have failed. Diligent management early on can help preserve remaining beta cell function and slow progression – another reason why acting early and aggressively is so important.

  4. Food has a major impact on blood glucose – optimizing your mealtime choices, especially carbohydrates, can improve your diabetes management and overall health. In my experience, carbohydrates can raise blood sugar much more than protein and fat and thus, require extra monitoring and management with available insulin. Here are a few tips that may help you manage blood sugars, and you can read here for more suggestions:

  • ​I try to reduce the amount of carbohydrates I eat at one time, or I choose carbohydrates lower on the glycemic index – see Adam’s Corner on Why All Carbohydrates are Not Created Equal.

  • Avoid drinks with lots of added sugars and carbohydrates (unless you have low blood sugar, also called hypoglycemia). Staying away from regular soda and large amounts of fruit juice is usually wise.

  • Impose portion control. For instance, use the “½ plate rule” – fill half your plate with veggies or salad. Also, avoid directly eating out of food packages, a convenience trap that encourages overeating. At sit-down restaurants, tell the waiter you don’t want the free bread – sometime the temptation is too hard to resist!

  • As a general rule, I try to eat foods that are as natural and minimally processed as possible – the fewer ingredients on the label, the better. Fruits and vegetables are always a good way to go. By contrast, try to avoid highly processed foods (e.g., chips, candy) that I find can be less filling and raise my blood glucose more substantially.

  • Try substituting almond and coconut flour in recipes – in my experience, these have a significantly smaller impact on my blood glucose, contain lots of healthy fat and fiber, and help make baked goods much more diabetes-friendly.

  1. Exercise is a free drug – use it as much as possible! Regular physical activity done for about 30 minutes most days each week can lower blood glucose, help your body better use the insulin your body continues to make, and improve your cholesterol levels. If you already have an activity you love, keep doing it! If you’re not very active right now, it’s critical not to be intimidated by the thought of getting started. Even something as simple as walking (see here for more details) can lower blood glucose and improve your heart. Here are some simple ways to incorporate more activity into your life:

  • Find some friends or coworkers that share your interests. Accountability to someone else is a huge factor in sticking with something. Check out Insulindependence to connect with others in the active diabetes community.

  • Find ways to include exercise in your daily life – go for a walk during your lunch break, try walking meetings, take the stairs instead of the elevator, or park in the farthest spot in the parking lot.

  • Try an app: Moves, GymPact, Seven Minute Workout, Strava, Sworkit, and so many more out there are great to get you moving.

  • Give an activity tracker a shot – these little devices are incredibly motivational and the data is completely addicting. The most popular option is Fitbit, but there are many others.

  • Set goals and hold yourself accountable – read here for a few pointers.

  1. Use blood glucose testing to identify patterns. When it comes to managing blood sugar, think of your glucose meter as a compass. By testing before and after certain events like meals and exercise, these data can point the way toward factors that affect your blood glucose. I make this fun by approaching it like a scientist: How much does walking lower my blood glucose? How does a dinner of chicken and vegetables compare to a pasta meal?
    To make your glucose results more useful, you can try structured testing, a more strategic approach to checking your blood sugar – Accu-Chek has developed two free tools to help identify blood sugar patterns that you can download here and here. Remember that the purpose of collecting glucose readings is to give you information to optimize your therapy. Are you running consistently high after breakfast? Is your blood sugar dropping low in the middle of the night? Recognizing such patterns in your glucose readings can answer these types of questions and help you and your healthcare provider make changes to your diabetes management.

  2. Needing to take insulin is NOT YOUR failure. Type 2 diabetes is a progressive disease, and your body’s ability to make insulin is likely to decline over time. Indeed, about 30-40% of type 2 patients end up needing to take insulin to manage their blood glucose, particularly those who have had diabetes for a long time. As you start to take insulin, remember that you are not alone! Injections can be a hassle for everyone, but there are now devices designed to ease the burden – insulin pens that are increasingly patient friendly, Valeritas’ V-Go insulin delivery device, Medtronic’s i-Port Advance, and full-featured insulin pumps.

  3. Keep learning and find support! The more you learn about type 2 diabetes – from organizations and other people – the more you will realize how much there is to know. Here are some resources that we enjoy (although there are many more).

  • Websites: American Diabetes Association, CDC, NIH/NIDDK, The Mayo Clinic, The Joslin Diabetes Center

  • Books: Diabetes Burnout by Dr. William H. Polonsky, Diabesity by Dr. Fran Kaufman, Your First Year with Diabetes: What To Do, Month by Month by Theresa Gamero, The First Year: Type 2 Diabetes: An Essential Guide for the Newly Diagnosed by Gretchen Becker, Diabetes Meal Planning Made Easy by Hope S. Warshaw

  • Conferences: TCOYD (for all patients) and Diabetes Sisters (for women)

  • Support: TuDiabetes, Diabetes Daily, Diabetic Connect

  1. Seek out a Diabetes Educator. Diabetes educators are certified health care professionals with specialized knowledge in diabetes self-management and education. They provide real-life guidance, coaching, and support. To receive diabetes education, you can ask for a referral from your primary health care provider. Going to a diabetes educator is covered by Medicare Part B as well as many health insurance plans. You can learn more by using this resource from the American Association of Diabetes Educators.

  2. Review our Patient’s Guide to Individualizing Therapy at www.diaTribe.org/patientguide. This short list of questions is intended to help you and your healthcare provider discuss what therapies and goals are right for you.

Interested in learning more about tips for people with diabetes? Please read our top ten tips for people newly diagnosed with type 1, for parents of children with type 1.

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Type 2 Diabetes: How Is It Treated?

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People with type 2 diabetes need to follow a treatment plan. Also called a diabetes management plan, it helps them manage their diabetes and stay healthy and active. Treatment plans are based on a person’s individual health needs and the suggestions of the diabetes health care team.

Diabetes Treatment Basics

The first thing to understand when it comes to treating diabetes is your blood glucose level, which is just what it sounds like — the amount of glucose in the blood. Glucose is a sugar that comes from the foods we eat and also is formed and stored inside the body. It’s the main source of energy for the cells of the body, and is carried to them through the blood. Glucose gets into the cells with the help of the hormone insulin.

So how do blood glucose levels relate to type 2 diabetes? People with type 2 diabetes don’t respond normally to insulin anymore, so glucose stays in the bloodstream and doesn’t get into the cells. This causes blood glucose levels to go too high.

High blood sugar levels can make teens with type 2 diabetes feel sick, so their treatment plan involves keeping their blood sugar levels within a healthy range while making sure they grow and develop normally. To do that, they need to:

  • eat a healthy, balanced diet and follow a meal plan
  • get regular exercise
  • take medicines as prescribed
  • check blood sugar levels regularly

The good news is that sticking to the plan can help people feel healthy and avoid diabetes problems later.

Eat a Healthy Diet and Follow a Meal Plan

Eating right and exercising more often is good for everyone. But it’s especially important for people with type 2 diabetes. When people put on too much body fat, it’s because they’re eating more calories than they use each day. The body stores that extra energy in fat cells. Over time, gaining pounds of extra fat can lead to obesity and diseases related to obesity, like type 2 diabetes.

Getting to a healthy weight — even losing just a few pounds of extra body fat — goes a long way in helping to keep blood sugar levels under control. How do you do it? Eating healthy foods is one thing people with type 2 diabetes can do. They also have to pay attention to the amount of carbohydrates (or carbs) and calories in the foods they eat.

Eating certain foods will cause blood sugar levels to go up more than others, which can make controlling blood sugar more difficult for people with diabetes unless insulin and other diabetes medicines are taken at the proper times and doses.

The three major nutrients in food are carbs, proteins, and fats. Foods that cause blood sugar levels to go up contain carbohydrates. Foods that contain mostly protein and/or fat don’t affect blood sugar levels as much as foods with carbs. But they still contain calories and can cause people to gain too much body fat if they eat too much of them.

For people with type 2 diabetes (and everyone else, too), it’s best to not eat too many sugary treats or fast foods. They’re not really healthy food choices, and they can make them gain too much body fat and get cavities. They also might need to eat smaller amounts of food.

A balanced, healthy diet doesn’t mean giving up your favorite foods or going on a starvation diet. But you’ll probably have to limit junk food and sweets and eat smaller portions of foods if you’re overweight.

To help you eat right, you and your diabetes health care team will create a written diabetes meal plan. Meal plans usually consist of guidelines for preparing breakfast, lunch, and dinner with scheduled between-meal snacks.

The diabetes meal plan won’t tell you specific foods to eat, but it will guide you in selecting choices from the basic food groups and help you eat nutritious, balanced meals. Each meal and snack in the plan contains a certain amount of carbs, which works with the types and amount of diabetes medicines you take.

Get Regular Exercise

Exercise is good for everyone, including people with diabetes. It’s also an important part of diabetes treatment because exercise can improve your body’s response to insulin, help you lose extra body fat, and get your heart and lungs in good shape.

You might be wondering about how exercise will affect your diabetes, but you shouldn’t use diabetes as an excuse not to get moving. Most types of exercise are great for people with type 2 diabetes — from walking the dog or riding a bike to playing team sports. Make it your goal to exercise every day to get the most benefits.

You can talk to your diabetes health care team about making any necessary meal or medication adjustments when you exercise. They’ll offer specific suggestions to help you get ready for exercise or join a sport and give you written instructions to help you respond to any diabetes problems that may happen during exercise, like hypoglycemia (low blood sugar), or hyperglycemia (high blood sugar).

Take Medicines as Prescribed

Several medicines are available for people with type 2 diabetes. They work in different ways to help the body make or respond to insulin better.

Sometimes pills for diabetes — even when combined with diet and exercise — aren’t enough to keep blood sugar levels under control. Some people with type 2 diabetes also have to take insulin. The only way to get insulin into the body now is by injection with a needle or with an insulin pump. If someone tried to take insulin as a pill, the acids and digestive juices in the stomach and intestines would break down the medicine, and it wouldn’t work.

Getting insulin injections today is nearly painless, thanks to smaller needles. Insulin pumps (which deliver insulin through a small tube placed just under the skin) cut down on the number of injections needed.

Different kinds of insulin are used for different purposes. The types of insulin you use and how you take it each day will depend on what’s best for you and your daily schedule.

If you take an insulin shot but forget to eat, your blood sugar levels can get too low. So try to avoid skipping meals or snacks. If your parents remind you to eat when you take your insulin, it’s probably because they worry about you, not because they’re trying to nag you!

Your diabetes health care team will teach you how and when to give yourself insulin.

Check Blood Sugar Levels

Checking your blood sugar levels is another part of your diabetes treatment plan. It lets you know how well the other parts of your treatment plan are working, and it’s the only way to know how you are doing with your diabetes control on a daily basis.

Your care team may recommend that you use a continuous glucose monitor (CGM). A CGM is a wearable device that can measure blood sugar every few minutes around the clock. It’s measured by a thread-like sensor inserted under the skin and secured in place. The more frequent CGM blood sugar readings can help you and the care team do an even better job of troubleshooting and adjusting your insulin doses and diabetes management plan to improve blood sugar control.

A blood glucose meter or CGM tells you what your blood sugar level is at the moment. Your doctor may also send you for another type of blood sugar test called a hemoglobin A1c test (HbA1c for short). It lets you and your care team know how your blood sugar levels have been for the few months before the test.

Putting It All Together

Treating and managing diabetes can seem complicated at times. But your diabetes health care team is there for you. Your diabetes management plan should be easy to understand, detailed, and written down for you so that you can refer to it whenever you need to.

The good news about type 2 diabetes is that if you do the diabetes treatment steps listed above, your blood sugar levels can return to a healthier range. For some people with type 2 diabetes, that can mean not even needing to take diabetes medicines anymore.

You also might hear about alternative treatments for diabetes, such as herbal remedies and vitamin or mineral supplements. These practices can be risky, especially when people stop following the treatment plan their doctor has given them. So get the facts by talking to your diabetes health care team. They keep track of the latest research developments, and will introduce new products as they become available.

Reviewed by: Shara R. Bialo, MD Date reviewed: August 2018

Your GP will also be responsible for monitoring your health and ensuring you undergo a number of important diabetes health checks each year. These will include your blood glucose control, blood pressure and cholesterol, amongst others.

Diet

When it comes to diet, weight loss is often a primary goal for those with type 2 diabetes. If you are overweight, losing weight can help to improve insulin sensitivity and make diabetes easier to manage.

To achieve weight loss, your diet should be low-calorie, and because type 2 diabetes is a lifetime condition, it is important to have a diet you are happy to commit and stick to.

In the modern world, many of us have become accustomed to eating energy-dense foods, such as bread, rice, pasta and potato-based foods. Whilst these high-energy foods are convenient they’re less good for those who aren’t regularly physically active.

Vegetables (not counting potatoes) are a strong choice because they provide a variety of nutrients whilst having a relatively low calorie count. Because vegetables are a great source of soluble fibre, they also help us to stay full for longer

If you are at a healthy weight, aim to eat a balanced diet which allows you to keep your blood glucose levels under control.

Diabetes.co.uk’s Low Carb Program, an education program which won the Positive Social Impact Award at the Lloyds Bank National Business Awards UK 2016, can help people with type 2 diabetes achieve better blood glucose levels, enable weight loss and reduce dependency on medication.

Physical activity

Physical activity can be particularly effective in controlling blood glucose levels. When our muscles work they take in glucose from the blood, liver and muscles. After the exercise, the body will start replenishing its stores of glucose by steadily taking in available glucose from the blood.

As well as helping to lower blood sugar levels, exercising makes use of the energy we take in from our diet, meaning that if we exercise more and don’t increase calorie intake, we’re then in a better position to lose weight.

Other lifestyle changes

In addition to diet and physical activity, other lifestyle adjustments such as reducing intake of alcohol and quitting smoking will also help your diabetes and general health.

Blood glucose monitoring

Blood glucose monitoring can be a useful tool as it shows how diet and activity impacts on your blood sugar levels.

If you are on insulin you may need to regularly test your blood glucose levels to help prevent blood glucose levels from going too low.

Blood glucose monitoring is highly valued by some people with diabetes and has helped people achieve excellent control.

Medication

The main role of diabetes medication is to help lower blood glucose levels, although more recently developed medications can also aid weight loss.

Each form of medication has side effects and it is important to be aware of which side effects can occur from any medication you are taking. Known side effects will be detailed in the patient information leaflet in every pack of medication

You may be put onto medication as soon you are diagnosed with type 2 diabetes or sometime after if your blood glucose levels become too high.

You can be moved onto stronger medication if your blood glucose levels remain too high, while you can also be moved onto less strong medication if your blood glucose levels improve. Whilst less common, some people may even be able to come off medication, particularly if significant weight loss is achieved.

Diabetes medication needs to be supported with diet changes and regular physical activity to keep you healthy.

Medication for type 2 diabetes includes tablets and/or injectable medication.

Tablets

There are a range of tablets available for type 2 diabetes and many of these work in different ways. For example, metformin helps the body to better respond to insulin, whereas sulphonylureas prompt the pancreas to produce more insulin.

Metformin is often the first tablet prescribed to people with type 2 diabetes and stronger-acting medication may be prescribed in addition to metformin, or in place of it, if blood glucose levels remain too high.

Injectable medication

There are now a number of different injectable medications available for treating diabetes. These fall into two main groups:

  • Insulin
  • Incretin mimetics

Insulin

Insulin is the most well-known type of injectable medication for diabetes. Insulin is the hormone which helps to move sugar out of the blood and into cells to be used as energy or to be stored as fat.

Insulin is a powerful medication for lowering blood glucose but can lead to dangerously low blood sugar levels ( hypoglycemia ) if too much is taken. For this reason it is important for people to be able to recognise the symptoms of low blood sugar levels and know how to treat hypos should they occur.

Incretin mimetics

Incretin mimetics have been used for treating diabetes since 2005. Incretin mimetics are medications which mimic the action of a hormone called glucagon-like-peptide-1. This hormone plays a number of roles in response to digestion such as increasing the amount of insulin released and decreasing the amount of glucagon (a hormone that helps raise blood sugar) released. A group of tablet medications, known as DPP-4 inhibitors, work in a similar way to incretin mimetics.

Compared with insulin, incretin mimetics are a new medication and their long-term effects on the body are still not so well understood. Whilst incretin mimetics have been shown to be effective in reducing blood glucose levels and helping to reduce appetite, the drug has been linked with an increased risk of pancreatitis.

Weight loss surgery

Bariatric surgery, also known as weight loss surgery, is an option that may be considered if weight gain is leading to a high risk of suffering dangerous health conditions, which may include difficulty breathing and loss of mobility.

There are significant health risks involved in surgery, and bariatric surgery is only offered to people who are very overweight and have not had success with less dangerous weight loss methods.

Understanding preferences for type 2 diabetes mellitus self-management support through a patient-centered approach: a 2-phase mixed-methods study

The study was conducted through PatientsLikeMe® (PLM) , an online platform comprising many disease communities where patients with life-changing medical conditions are able to find other patients like themselves, learn more about their condition, and share information about their outcomes. PLM has over 10,000 registered members with T2DM and approximately 8000 reporting T2DM as their primary condition, many of whom also report significant comorbidities. Patients with T2DM joining the website are asked to share information about their disease through custom questionnaires that populate their profile.

Following institutional review-board approval, a mixed-methods research process, including a comprehensive literature review, qualitative one-on-one patient interviews (January 2014), and a quantitative survey (April–July 2014), was used to comprehensively assess patient preferences regarding self-management support and diabetes management programs. Informed consent was obtained from all participants.

An extensive literature review of program support and assistance for patients with T2DM was first conducted to identify areas of evidentiary gaps for further exploration in the qualitative patient interviews. The areas identified included understanding the context in which patients make decisions about support for their diabetes (family structure, sources of assistance available), what the most important symptoms and problems requiring management are, who gives what kind of support, and which support programs patients may have tried in the past. Patients’ descriptions of their own goals, the relative importance of different kinds of support and support sources, and their preferences helped to inform the content of a structured survey, which was subsequently administered to a larger group of patients with T2DM.

Qualitative interview process

A list was generated of PLM website users who reported T2DM in their patient profiles, had multiple log-in sessions including activity in diabetes forums, and were actively participating in discussions. Of the identified individuals, 44 were contacted, mainly by private message (using PLM email), and invited to participate in 1-h qualitative telephone interviews. Once 10 of the invitees had responded positively, no further invitations were sent out.

The respondents, half of whom were female, had a mean age of 57.5 years (range 34–78). Overall, 60.0 % (n = 6) were non-Hispanic white, and educational levels ranged from high-school diplomas to Master’s degrees.

Patients’ experiences with controlling blood glucose levels and managing symptoms and treatment regimens, and types of programs and support systems used were the key topics that guided the interviews. For a full description of the qualitative interview process, please see Additional file 1.

Qualitative interview findings

Respondents reported common comorbidities including hypertension, hypercholesterolemia, depressive disorders, and chronic obstructive pulmonary disease. The majority perceived their blood glucose levels to be under control, although they were concerned about their weight and activity levels. Of the T2DM support systems/programs that respondents reported having participated in, most were one-time programs in which all follow-up was initiated by a nurse, not by the patient themselves.

Respondents reported that much self-education was performed through reading both online and printed materials. Websites commonly consulted included those of the ADA, PLM, insurance companies, and medical-supplies companies, as well as general medical websites. This was in agreement with information given by respondents that they preferred their materials to be from a ‘serious’ source and to be accessible at the patient’s own convenience. A few female respondents strongly favored participation in small groups for encouragement, sharing, and friendship; however, none actually belonged to such a group.

When questioned about their expectations/hopes for management programs, a range of responses were given, including the desire to not have diabetes or to slow or stop disease progression, to decrease or stop medication use, and to avoid complications (e.g., neuropathy, foot ulcers/amputation, heart disease, vision problems, peripheral artery disease). Respondents reported being motivated by wanting to keep learning and to avoid the negative consequences of their disease. They reported being discouraged from participating in programs because of the difficulty in navigating certain health-care systems and from continued participation due to repetition of material.

When asked from whom they received help in the management of their condition and what form that help took, responses included spouse, adult children, other family members (who often also had diabetes themselves), and online friends. Support and encouragement from health-care professionals (HCPs) was mostly related to diet and medication; additional encouragement and praise on dietary decisions and/or weight loss were desired. ‘Being accountable to someone else’ was considered to be a positive thing.

Overall, and importantly, respondents perceived ‘programs’ as consisting of short-term education by HCPs, whereas ‘support’ was regarded as daily interactions with friends and family.

Concepts and themes regarding diabetes management and support strategies that emerged from the patients’ descriptions informed the creation of quantitative survey questions and response options that reflected the patients’ experiences. These themes included, but were not limited to, weight loss as an area of concern and as a goal for T2DM programming; the importance of modes of support, such as printed materials, in T2DM education; sources of support, such as spouses, partners, family, and friends, in effectively managing T2DM; and how personal expectations/hopes for T2DM can align with goals of T2DM support programming.

Quantitative survey process

Survey development

Based on the results from the qualitative interviews and literature review, a survey consisting of a maximum of 90 questions (accounting for branching and variable questions asked only in response to specific answers to prior questions) and including both closed (Likert-scale, multiple-choice, matrix, and numerical) and open (free-form text) response formats was created . Patient-reported interview data were used to frame and develop questions for use in the quantitative survey. For example, descriptions of diabetes support programs obtained in response to questions from Part 3 of the qualitative survey were used to construct the support program types mentioned in Sections IV, V, and VI of the quantitative survey as well as to provide lists of commonly mentioned response options.

In the survey, respondents were asked to confirm the demographic information previously collected from their profiles by completing a basic demographics panel prior to addressing the main survey questions. Demographic data concerning sex, date of birth, ethnicity, race, educational level, and health-insurance type were collected. Location information, such as country and state, were re-collected from respondents at this point as well. In addition to the demographic covariates, the main survey was composed of seven domains which were framed from the patient perspective:

  1. (1)

    Overall quality of life – to understand all areas of health of the patient

  2. (2)

    Diabetes goals – to focus on what patients want from their disease control

  3. (3)

    Current and past programs – to assess program participation and preferences/dislikes

  4. (4)

    Preferences for self-support – to understand the types, sources, and formats of support that patients want when managing their diabetes

  5. (5)

    Support network – to give an insight into who (or what) comprises the patient’s current support network

  6. (6)

    Treatments and complications – to provide data on what patients have experienced

  7. (7)

    Comorbidities – to provide data on patient-identified additional conditions

An appended sub-survey queried patients on the following: their satisfaction with their health-care; difficulties managing symptoms; glycated hemoglobin A1c (A1C), low-density lipoprotein, and blood pressure measurements; use of oral steroids; weight-loss goals; health literacy; and self-reported treatment adherence.

Branching within the survey was incorporated to address program characteristics, information covered, program length, and outcomes for respondents who participated in a program. Approximately 20 of the 90 questions were in free-form text format, which queried survey respondents on what ‘other’ types of programs, information, or diabetes support they participated in, wanted, or preferred.

Study population

The online survey was fielded during April to July 2014 to active PLM participants reporting T2DM as a condition on their profile, who also reported residing in the USA or did not specify their location and who were aged ≥ 18 years. The initial pool of invitations was limited to the most active patients (those who had logged in to the site in the past 90 days). A second pool of invitations was created for participants who had lower activity (at least one log-in during the past year).

Survey fielding

Patients fulfilling study inclusion criteria were emailed an invitation to participate in a custom survey. The survey fielding was conducted in two waves, a pilot survey and a full survey. The pilot survey was fielded to assess the interpretability of questions by a sample of 100 members with T2DM, and remained open for 2 weeks. The full survey was fielded to the larger T2DM population and remained open for a period of approximately 12 weeks. For both the pilot and full surveys, the invitation to participate appeared as a private message when a T2DM patient logged in to the site. The invitation included a link directing the patient to where the survey could be completed online. Users who did not complete surveys within 3 days were sent an email reminder to participate in the survey.

Statistical analyses

The population for the main analysis consisted of all confirmed US-based patient respondents who fulfilled the inclusion criteria. As there were no changes to the survey, responses obtained during the pilot survey were merged with full survey results prior to data analysis. To provide additional context on the PLM T2DM community, survey respondents were compared with nonrespondents with respect to their demographic characteristics, any listed (additional) conditions, and their PLM website participation as a preface to the main analyses. Before analyzing survey results, available profile data (such as location, primary condition, and zip code) were matched to survey responses by a unique user ID number. Zip codes were then grouped according to area type (urban, suburban, rural) using US Census data.

Descriptive statistics were used to describe patient characteristics by demographic covariates of interest, and summary statistics were used to tabulate frequencies and relative percents, such as patient use of different self-management support systems. χ 2 statistics were used for categorical variables, and two-sample t-tests were used to compare groups for continuous covariates. Trend tests were used to test two-category predictor variables on ordinal-ordered outcomes, such as program participation and satisfaction with one’s health-care. Agreement between binary paired variables, such as past and current program participation, was assessed with the kappa statistic. Only P-values of ≤ 0.05 were reported, and all tests were two-tailed. Free-text or ‘other’ text response options were analyzed by summarizing key concepts by ‘theme’ and enumerating the mention of each theme. Quantitative analyses were conducted with SAS, Version 9.4 (Cary, NC, USA).

Ethics, consent, and permissions

This study was approved by the Western Institutional Review Board on December 31, 2013. Materials sent to study participants such as invitation messages, together with the interview guide, research information, and participant consent were reviewed and approved by the Review Board. Using online means, the nature of the study was explained to potential participants prior to participation, and informed consent was obtained for participation in the study via an online informed consent form. Verbal consent was obtained for the audio recording of verbal interviews.

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