Diabetes is one of the most common conditions we manage in primary care — and one of the most manageable when caught early and handled proactively. Here's a plain-English guide to what it is, how to spot it, and how it's treated.
If you've just been told your A1c is high, here's the most important thing to know first: diabetes care in 2026 looks nothing like it did ten years ago. We no longer just chase a blood-sugar number — we protect your heart, kidneys, and weight at the same time, often with medications that didn't exist a decade ago. Managed well, most people with type 2 diabetes live full, unrestricted lives.
Every cell in your body runs on glucose, and insulin is the key that lets glucose out of the bloodstream and into the cell. In diabetes, that system fails in one of two ways: the pancreas stops making insulin (type 1), or the body stops responding to it — insulin resistance — and the pancreas eventually can't compensate (type 2). The result is the same: glucose piles up in the blood, and over years that excess sugar silently damages the small and large blood vessels feeding your eyes, kidneys, nerves, and heart.
This is why diabetes is really a vascular disease wearing a metabolic mask — and why modern treatment is aimed at protecting those organs, not just lowering a lab value.
Diagnosis rests on three tests: HbA1c ≥ 6.5% (a 3-month glucose average; 5.7–6.4% is prediabetes), fasting glucose ≥ 126 mg/dL, or a 2-hour glucose ≥ 200 mg/dL on a tolerance test. One abnormal result is typically confirmed with a repeat.
But here's where good care gets nuanced: the "right" A1c goal is not the same for everyone. A general target is under 7%, and tighter (≤ 6.5%) can be reasonable for a young, otherwise-healthy patient who can reach it safely. For an older patient — or anyone at risk of dangerous low blood sugars — pushing too hard causes more harm than the number prevents, and a target of 7.5–8% is often smarter. Chasing a textbook A1c at the cost of hypoglycemia is one of the most common mistakes in diabetes care.
In practice, the target is something we set together rather than a number I hand down. A forty-five-year-old with no other health problems can usually aim tight and get there safely. For someone in their late seventies already taking several medications, chasing that same number invites dangerous lows — and a slightly higher, steadier A1c is the smarter goal. The best target is the one you can hold without your blood sugar crashing.
Type 2 is often silent for years, which is why screening matters more than symptoms. When symptoms appear, watch for increased thirst, frequent urination (especially overnight), unexplained weight loss, persistent fatigue, blurred vision, slow-healing cuts or frequent infections, and tingling or numbness in the hands and feet. Prediabetes usually has no symptoms at all — and it's the window where the disease is most reversible.
Until recently, treatment was a simple staircase built around lowering glucose. Today, the biggest shift in diabetes medicine is this: we choose medications based on what else they protect — the heart, the kidneys, and body weight — not glucose alone. Two entire drug classes drove that change.
Inexpensive, safe, weight-neutral, and effective. It lowers the liver's glucose output and improves insulin sensitivity. For many patients it remains step one — but it's no longer where the story ends, and for some patients we now start a second agent early.
These mimic a gut hormone that boosts insulin only when glucose is high (so low risk of hypoglycemia), slows digestion, and reduces appetite. They lower A1c meaningfully and drive significant weight loss, and several have proven cardiovascular benefit. This class includes semaglutide (Ozempic; Rybelsus is the oral form; Wegovy is the weight-loss branding) and dulaglutide (Trulicity).
Tirzepatide (Mounjaro for diabetes; Zepbound for weight) hits two gut-hormone receptors at once and has produced the largest A1c and weight reductions we've seen from a non-insulin medication. For many patients with diabetes and obesity, this class has genuinely changed what's possible.
Empagliflozin (Jardiance), dapagliflozin (Farxiga), and others make the kidneys excrete excess glucose in the urine. Their glucose-lowering is modest — but their protection of the heart and kidneys is profound, with proven benefit in heart failure and chronic kidney disease even in people without diabetes. This is often my choice when a patient also has heart or kidney disease.
Insulin remains essential for type 1 and for many with advanced type 2, and modern basal insulins are far smoother than older ones. Sulfonylureas and others still have a place — usually where cost is the deciding factor.
The first question I ask isn't "which drug lowers sugar the most." It's "what else does this person need protected?" If there's heart disease, heart failure, or chronic kidney disease, an SGLT2 inhibitor often picks itself. If weight is the central problem, a GLP-1 or tirzepatide does two jobs at once. The A1c usually falls into place once the right target and the right drug are chosen — it's rarely the first thing I optimize.
No class of medicine has drawn more attention — or more confusion — than the GLP-1s, and the questions I hear most are about weight and money. Both deserve a straight answer.
On weight: the appetite-lowering effect is real and often significant, which is why the same molecule shows up under different names for different purposes. Semaglutide is Ozempic for diabetes and Wegovy for weight; tirzepatide is Mounjaro for diabetes and Zepbound for weight. For someone who has both type 2 diabetes and excess weight, that overlap is a genuine two-for-one — a single medication that steadies blood sugar and drives meaningful weight loss at the same time.
On cost, here's the practical reality most people eventually meet. Paid out of pocket, these drugs can run well over a thousand dollars a month. But when they're prescribed for diabetes, insurance coverage is far more common than when the identical drug is prescribed purely for weight loss — where plans are often stingy or decline outright. A diabetes diagnosis, in other words, frequently unlocks affordable access to a medication that also happens to treat weight. Most plans still want a prior authorization, and some ask you to try metformin first, but the path is usually navigable — and knowing how to walk a patient through it has quietly become part of good diabetes care.
Perhaps the most empowering advance for patients isn't a drug — it's the continuous glucose monitor (CGM). A small sensor (Dexcom, FreeStyle Libre) reads glucose every few minutes and streams it to your phone. Instead of a few finger-stick snapshots, you see how specific meals, walks, stress, and sleep move your sugar — and we shift the goal from a single A1c to "time in range." Once reserved for type 1, CGM is now widely used in type 2, and the behavior change it drives is often as powerful as medication.
Here's the hopeful part the old blogs missed: for type 2, substantial weight loss can drive the disease into remission — normal blood sugars off medication. Landmark trials showed that significant weight reduction (through intensive lifestyle change, GLP-1 medications, or bariatric surgery) put a meaningful share of patients into remission, especially earlier in the disease. Diabetes is not always a one-way street.
Because diabetes is vascular, good care always looks beyond glucose: blood pressure and cholesterol control, kidney monitoring, annual eye and foot exams, and vaccines. For many patients these do as much to prevent heart attacks, strokes, and kidney failure as the sugar control itself.
See a physician if you have warning signs, a family history, or extra weight and haven't been screened recently. If you already have diabetes and your numbers are drifting up — or you're getting frequent lows — it's time to reassess, because the tools to fix it have never been better.
Dr. Sharma treats diabetes as the whole-body condition it is — setting your A1c target with you rather than for you, and choosing medication around your entire cardiovascular, kidney, and metabolic picture rather than the sugar alone. That often means GLP-1 or SGLT2 therapy and, when it helps, a continuous glucose monitor so you can see what actually moves your numbers. Getting the regimen right is rarely instant; it is something we adjust together over time until your numbers hold steady in a plan you can genuinely live with. Care is available in person at our San Jose and Campbell offices or by telemedicine anywhere in California.
Diabetes care is individualized — targets and medications vary from person to person. Symptoms of very high or very low blood sugar deserve prompt medical attention.
Screening is quick, and catching diabetes early changes everything. Book a visit with Dr. Sharma — in person or by video.