Metformin (Glucophage) is a biguanide. Biguanides lower blood glucose levels primarily by decreasing the amount of glucose produced by the liver. Metformin also helps to lower blood glucose levels by making muscle tissue more sensitive to insulin so glucose can be absorbed. It is usually taken two times a day. A side effect of metformin may be diarrhea, but this is improved when the drug is taken with food.

Reversal of type 2 diabetes to normal metabolic control by either bariatric surgery or hypocaloric diet allows for the time sequence of underlying pathophysiologic mechanisms to be observed. In reverse order, the same mechanisms are likely to determine the events leading to the onset of hyperglycemia and permit insight into the etiology of type 2 diabetes. Within 7 days of instituting a substantial negative calorie balance by either dietary intervention or bariatric surgery, fasting plasma glucose levels can normalize. This rapid change relates to a substantial fall in liver fat content and return of normal hepatic insulin sensitivity. Over 8 weeks, first phase and maximal rates of insulin secretion steadily return to normal, and this change is in step with steadily decreasing pancreatic fat content. The difference in time course of these two processes is striking. Recent information on the intracellular effects of excess lipid intermediaries explains the likely biochemical basis, which simplifies both the basic understanding of the condition and the concepts used to determine appropriate management. Recent large, long-duration population studies on time course of plasma glucose and insulin secretion before the diagnosis of diabetes are consistent with this new understanding. Type 2 diabetes has long been regarded as inevitably progressive, requiring increasing numbers of oral hypoglycemic agents and eventually insulin, but it is now certain that the disease process can be halted with restoration of normal carbohydrate and fat metabolism. Type 2 diabetes can be understood as a potentially reversible metabolic state precipitated by the single cause of chronic excess intraorgan fat.
Because the drugs listed above act in different ways to lower blood glucose levels, they may be used together. For example, a biguanide and a sulfonylurea may be used together. Many combinations can be used. Though taking more than one drug can be more costly and can increase the risk of side effects, combining oral medications can improve blood glucose control when taking only a single pill does not have the desired effects. Switching from one single pill to another is not as effective as adding another type of diabetes medicine.
Regular monitoring of clinical trial participants found that HbA1c levels of those receiving BCG had dropped by more than 10 percent at three years after treatment and by more than 18 percent at four years. That reduction was maintained over the next four years, with treated participants having an average HbA1c of 6.65, close to the 6.5 considered the threshold for diabetes diagnosis, and with no reports of severe hypoglycemia. Participants in the placebo group and in a comparison group of patients receiving no treatment experienced consistent HbA1c elevations over the same eight-year time period.

If I could only prescribe one supplement for a diabetes patient, I would prescribe R-alpha-lipoic acid. Alpha-lipoic acid has numerous benefits to the diabetic patient. It is a water- and fat-soluble antioxidant and has been shown to protect patients with fatty liver from liver disease progression. It can help reduce insulin resistance and has been shown to protect people with diabetes from developing complications in their nerves, eyes, and kidneys. R-ALA can prevent glycosylation of proteins, which reduces the A1C level. It is safe, although very rarely it can cause stomach upset. Alpha-lipoic acid is listed either as ALA or R-ALA. When listed as ALA, this means it contains two forms—the S isomer form and the R isomer form, in a 50:50 ratio. The key is to find a product that says it contains “R-ALA” instead of just “ALA.” A good daily working dose of R-ALA is 300 to 1,200 mg a day, which is the equivalent of 600 to 2,400 mg a day of regular ALA, if you buy a regular ALA listed product.

A new class of medications called DPP-4 inhibitors help improve A1C without causing hypoglycemia. They work by by preventing the breakdown of a naturally occurring compound in the body, GLP-1. GLP-1 reduces blood glucose levels in the body, but is broken down very quickly so it does not work well when injected as a drug itself. By interfering in the process that breaks down GLP-1, DPP-4 inhibitors allow it to remain active in the body longer, lowering blood glucose levels only when they are elevated. DPP-4 inhibitors do not tend to cause weight gain and tend to have a neutral or positive effect on cholesterol levels. Alogliptin (Nesina), linagliptin (Tradjenta), saxagliptin (Onglyza), and sitagliptin (Januvia) are the DPP-4 inhibitors currently on the market in the US.

One easy way to increase your fat content and quit snacking is to begin your meal by eating an avocado. I and others I know have used this trick to easily quit snacking. Avocados protect you from one of the reasons some dietary research wrongly claims that high-fat diets are bad for you: the danger of gorging yourself on delicious, fatty foods. With plain avocados, there is little danger of gorging. Another danger is clogging your arteries and giving yourself heart disease. But it’s been amply shown that the blame for that falls squarely on trans fats, like margarine. If you see any product with the words “partially hydrogenated” or “hydrogenated” in the list of ingredients, put it back, it’s a trans fat. On the other hand, any fat that comes directly from an animal or plant is not a trans fat and can be safely consumed.