Patients newly diagnosed with type 2 diabetes often opt for modest lifestyle changes before easing into a medication regimen.

Big mistake, says a diabetes expert at Jefferson Medical College, Philadelphia.

Dr. Barry Goldstein, director of the Division of Endocrinology, said delays in treatment allow the disease to progress more rapidly, hastening complications and forcing a patient into insulin therapy sooner than necessary.

To prevent these results, Dr. Goldstein recommends two or more oral drugs -- so-called "combination therapy" -- immediately after diagnosis to drop blood-sugar levels into the normal range or near normal, along with dietary changes and exercise.

"It's good rationale to keep glucose in normal levels from the beginning and not let them deteriorate," he said.

It sounds practical, but doctors typically ease patients into lifestyle changes then slowly add medications to avoid overwhelming them. But the advantages of more aggressive treatment are emerging.

Dr. Goldstein said there's growing evidence that quick control of blood sugar helps preserve one's beta cells, which produce insulin in the pancreas. Normal sugar levels keep the cells functioning longer, delaying or preventing the need for insulin therapy in type 2.

An autoimmune response that damages or destroys the beta cells causes type 1 diabetes. Dr. Goldstein said it's becoming apparent that obesity and high blood-sugar levels may cause the same to occur in type 2.

Oral medications for type 2 generally increase the body's ability to use one's own insulin. So it's important that patients preserve their insulin production so these medications continue working. Once beta cells cease producing insulin, the patient must begin insulin injections.

Even modest increases in blood glucose can be damaging, Dr. Goldstein said.

Type 2 tends to worsen over time, forcing people to use a combination of medications with 40 to 50 percent requiring insulin therapy.

"We don't understand why beta cells don't function in type 2," Dr. Goldstein said. "Diabetes gets worse and worse and most need combination [therapy]. So why not start earlier?"

Dr. Swarna Varma, an endocrinologist specializing in diabetes in Bridgeville and other offices throughout the Pittsburgh area, said she agrees with Dr. Goldstein's premise, but the challenge can be easier said than done.

"Treatment is individualized for the patient's needs and the patient has to be an equal partner with the doctor and agree with the treatment," she said.

The doctor also determines whether the patient has heart disease, renal failure, weight problems and other factors before prescribing a treatment protocol. Dr. Varma said any regimen must reflect the core problems, including insulin deficiency, insulin insensitivity and excess amounts of glucagon, an anti-insulin hormone, that must be reduced in some patients.

The doctor might opt to put the patient on a battery of medications including insulin, but the patient might not be able to afford the cost. In that case, the doctor must come up with an alternative strategy to reduce glucose as much as possible.

The process of finding the right medications and getting the patient acclimated to the routine takes eight weeks at a minimum, but often three to four months.

"It's a real balancing act that takes a lot of individualization," Dr. Varma said. "It takes time, energy, effort and homework along with establishing a rapport with the patient.

"But the rationale is correct," she said. "Anything we can do to preserve beta-cell function is worth a jolly good try."

Dr. Goldstein agreed that people sometimes are reluctant to take more pills at a greater cost. But drug combinations now are available in one pill.

"There's a lot of denial out there," Dr. Goldstein said. "We don't want to alarm a patient, but they need to diet and exercise and start on medications."