Dr. Subodh Banzal

MD (Med), DM (Endo),
MRCP (UK), FRCP (Glasgow), MAMS

Type II Diabetes

Overview

Type 2 diabetes is also known as adult-onset or noninsulin-dependent diabetes. It is a chronic condition that affects the way your body metabolizes sugar (glucose), which is body's main source of fuel. In type 2 diabetes, body becomes resistant to the effects of insulin ( a hormone that enables the movement of sugar into cells) — or even may not produce enough insulin to sustain a normal glucose level. Type 2 diabetes if left untreated can be life-threatening.

Type 2 diabetes is common in adults but can affect children when childhood obesity increases. Type 2 diabetes is non curable but by eating well, exercising and maintaining a healthy weight we can manage the disease. If blood sugar is not controlled by diet and exercises, one may require diabetes medications or insulin therapy

Causes

When our body becomes resistant to the effect of insulin or when enough insulin is not produced by pancreas, one can develop type 2 diabetes. Why this happens is exactly not known, although obesity and physical inactivity seem to be causal factors.

The role of insulin

Insulin is one of the hormone that is secreted from the islets cells of pancreas, a gland to be found behind and below the stomach. When the islet cells are destroyed, there will be little or no insulin.

  • Insulin is secreted from pancreas into the bloodstream.
  • The circulating insulin helps sugar enter into cells
  • Amount of sugar in ones bloodstream is lowered by insulin.
  • Whenever blood sugar level drops, the secretion of insulin from pancreas also reduces.
The role of glucose

Glucose is a sugar which is one of the main source of energy for the body cells that build up muscles and other tissues.

  • Food and our liver are two main sources of glucose.
  • Sugar from bloodstream, enters in the cells with the help of insulin.
  • Glucose is stored as glycogen in our liver.Whenever insulin levels drops, the stored glycogen is converted into glucose by liver to keep the glucose level within a normal range.

This process works inappropriately in type 2 diabetes. Instead of sugar moving into the cells, it builds up in the bloodstream.

Symptoms

Type 2 diabetes' symptoms develop slowly. Sometimes patient with have type 2 diabetes for years and not know it. Various symptoms are:

  • Increased thirst and recurrent urination. Excess sugar building up in your bloodstream causes fluid to be pulled from the tissues. This may leave you thirsty. As a result, you may drink — and urinate — more than usual.
  • Increased hunger. Without enough insulin to move sugar into your cells, your muscles and organs become depleted of energy. This triggers intense hunger.
  • Weight loss. Despite eating more than usual to relieve hunger, you may lose weight. Without the ability to metabolize glucose, the body uses alternative fuels stored in muscle and fat. Calories are lost as excess glucose is released in the urine.
  • Fatigue. If your cells are deprived of sugar, you may become tired and irritable.
  • Blurred vision. If your blood sugar is too high, fluid may be pulled from the lenses of your eyes. This may affect your ability to focus clearly.
  • Slow-healing sores or frequent infections. Type 2 diabetes affects your ability to heal and resist infections.
  • Areas of darkened skin. Some people with type 2 diabetes have patches of dark, velvety skin in the folds and creases of their bodies — usually in the armpits and neck. This condition, called acanthosis nigricans, may be a sign of insulin resistance.
Risk Factors

Certain factors which increase the risk of developing type 2 diabetes include:

  • Obesity. Obesity is a major risk factor for type 2 diabetes. The more body fat you have, the more resistant body cells become to insulin.
  • Distribution of fat. If one have fat primarily in abdominal area, chances of type 2 diabetes is greater than when body stores fat elsewhere.
  • Inactivity. The risk of type 2 diabetes is more in physically inactive persons. Physical activity helps in using up glucose as energy and makes cells more sensitive to insulin.
  • Family history. Chances of type2diabetes are more in those whose parent or sibling has type 2 diabetes.
  • Race. People of certain races — including blacks, Hispanics, American Indians and Asian-Americans — are more prone to develop type 2 diabetes than whites are.
  • Age. The risk of type 2 diabetes is greater, especially after age 45. Type 2 diabetes is also increasing considerably among children, adolescents and younger adults.
  • Prediabetes. Prediabetes is a condition where your blood sugar levels are higher than normal, but not high enough to be labeled as diabetes. Prediabetes if ignored often progresses to type 2 diabetes.
  • Gestational diabetes. Females developing gestational diabetes during pregnancy are at risk of developing type 2 diabetes.

Diagnosis

In June 2009, an international committee of experts from the American Diabetes Association, the European Association for the Study of Diabetes and the International Diabetes Federation recommended that type 2 diabetes testing include the:

  • Glycated hemoglobin (A1C) test. This blood test indicates your average blood sugar level for the past two to three months. It works by measuring the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level of 6.5 percent or higher on two separate tests indicates you have diabetes.If the A1C test isn't available, or if you have certain conditions that can make the A1C test inaccurate — such as if you're pregnant or have an uncommon form of hemoglobin (known as a hemoglobin variant) — your doctor may use the following tests to diagnose diabetes:
  • Random blood sugar test. A blood sample will be taken at a random time. Regardless of when you last ate, a random blood sugar level of 200 mg/dL (11.1 mmol/L) or higher suggests diabetes, especially when coupled with any of the signs and symptoms of diabetes, such as frequent urination and extreme thirst.
  • Fasting blood sugar test. A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, you have diabetes.
  • Oral glucose tolerance test. This test is now rarely used, in this patient fast overnight, and the fasting blood sugar level is measured. Pt is then given sugary liquid and blood sugar levels are tested repeatedly for the next two hours. A blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal. Blood sugar level more than 200 mg/dL (11.1 mmol/L) after two hours indicates diabetes and reading between 140 and 199 mg/dL (7.8 mmol/L and 11.0 mmol/L) indicates prediabetes.Routine screening for type 2 diabetes beginning at age 45, especially if one is overweight has been recommended by the American Diabetes Association. If the results are normal, repeat the test every three years. If the results are borderline, consult doctor when to come back for another test. Screening is also advised for people who are under 45 and overweight and having other medical history. Doctor will advice for other tests to distinguish between type 1 and type 2 diabetes — which often require different treatments.

Complications

Type 2 diabetes damages many major organs like heart, blood vessels, nerves, eyes and kidneys. These complications can be prevented by controlling blood sugar levels.

Since long-term complications of diabetes develop slowly but they can eventually be disabling or even life-threatening. Various complications of diabetes include:

  • Cardiovascular disorder. Diabetes significantly increases the chances of various cardiovascular problems, including coronary artery disease with chest pain, heart attack, stroke, narrowing of arteries (atherosclerosis) and high blood pressure.
  • Neuropathy-nerve damage. Type 2 diabetes can injure the walls of the tiny blood vessels (capillaries), especially in the legs. It results in tingling, lack of sensation, burning or pain that usually begins at the tips of the toes or fingers and slowly spreads upward. Uncontrolled blood sugar can result in complete loss of sensations in the affected limbs Damage to gastrointestinal tract nerves cause problems like sickness, vomiting, diarrhea or constipation. Erectile dysfunction can occur in males.
  • Damage to kidneys (nephropathy). Diabetes can damage filtering system of kidneys. Extensive injury can lead to kidney failure or irreversible end-stage kidney disease, which may lead to need for dialysis or a kidney transplant.
  • Eye damage. Diabetes harm the blood vessels of the retina (diabetic retinopathy), leading to blindness. Diabetes can also result in other serious conditions, such as cataracts and glaucoma.
  • Foot damage. Foot complications occur due to nerve damage in the feet or poor blood flow to the feet Cuts and blisters in foot if left untreated can become serious infections. Sometimes toe, foot or even leg amputation may be required in severe damage..
  • Skin and mouth conditions. Patients with diabetes become prone to skin problems, including bacterial and fungal infections. Poor dental hygiene may lead to gum infections
  • Osteoporosis. Diabetes results in osteoporosis by lowering bone mineral density.
  • Alzheimer's disease. The risk of Alzheimer's disease and vascular dementia is increased in type 2 diabetes.
  • Hearing problems. Hearing impairment can occur in type 2 diabetes

Treatment

For effective management of type 2 diabetes it requires a lifelong assurance to :

  • Blood sugar monitoring
  • Healthy eating
  • Regular exercise
  • Blood sugar monitoring
  • Diabetes medication or insulin therapy

These steps will help keep your blood sugar level closer to normal.

Diabetes medications

Newly diagnosed patients will be prescribed metformin, a diabetes medication that improves your body tissues' sensitivity to insulin and lowers glucose production in the liver. Your doctor will also recommend lifestyle changes, such as losing weight and becoming more active.

After some time, metformin is not enough to control your glucose level. It is the time to add other oral or injected medications. Medications lower glucose in different ways. Some diabetes medications stimulate your pancreas to produce and release more insulin. They include glipizide, glyburide and glimepiride. Still others block the action of enzymes that break down carbohydrates in the intestine, such as acarbose, or make your tissues more sensitive to insulin, such as metformin or pioglitazone.

Some newer oral drugs are :

  • Sitagliptin
  • Saxagliptin
  • Repaglinide
  • Nateglinide

Recently approved drugs given by injection are :

  • Exenatide
  • Liraglutide

Additionally, the doctor might prescribe low-dose aspirin therapy as well as blood pressure and cholesterol-lowering medications to help prevent heart and blood vessel disease.

Insulin therapy

Some type 2 diabetics may need insulin therapy as well. Because normal digestion interferes with insulin taken by mouth, insulin must be injected. Insulin injections involve using a fine needle and syringe or an insulin pen injector — a device that looks like an ink pen, except the cartridge is filled with insulin.

Bariatric surgery

In obese diabetics, weight-loss surgery (bariatric surgery) is advised to reduce body fat. Blood sugar levels return to normal in 55 to 95 percent of people with diabetes, depending on the procedure performed.

Pregnancy

During pregnancy, women with type 2 diabetes will likely need to alter their treatment. During pregnancy, you'll likely be switched to insulin therapy. Also, many blood pressure and cholesterol-lowering medications can't be used during pregnancy.

Signs of trouble

Problems can arise because so many factors can affect your blood sugar.

  • High blood sugar (hyperglycemia).
  • Increased ketones in your urine (diabetic ketoacidosis).
  • Hyperglycemic hyperosmolar nonketotic syndrome (HHNS).
  • Low blood sugar (hypoglycemia).

Blood sugar levels should be checked regularly, and patients should watch for signs and symptoms of low blood sugar — sweating, shakiness, weakness, hunger, dizziness, headache, blurred vision, heart palpitations, slurred speech, drowsiness, confusion and seizures.

Prevention

Diabetes can be prevented by healthy lifestyle choices

  • Eat healthy foods.
  • Get physical.
  • Lose excess weight.
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