Type 2 Diabetes Mellitus

Symptoms: Increased thirst, frequent urination, unexplained weight loss, extreme hunger, blurred vision, slow-healing sores, frequent infections, fatigue, tingling or numbness in the hands or feet.

Causes: Genes or Genetics, Gestational diabetes, Insulin resistance, Overweight, Physical inactivity, Polycystic ovary syndrome, Weight, Diet, Inactivity, Family history, Prediabetes, Race or ethnicity, High triglycerides, and Hormonal conditions.

Risk Factors: Risk factors include heart disease and stroke, high blood pressure, nerve damage (neuropathy), eye problems (retinopathy) that can lead to blindness, kidney disease, skin problems, hearing problems and amputation.

Prevalence: The prevalence of type 2 diabetes is a significant public health concern worldwide, with numbers steadily rising. Here's a key takeaway:

Centre for Disease Control and Prevention Diabetes Surveillance System reported in 2022 a prevalence of diagnosed diabetes of approximately 11.3 per cent of adults (37.3 million people; 28.7 million with diagnosed diabetes, an estimated 8.5 million undiagnosed, and 95 per cent of whom have type 2 diabetes).

Severity: Type 2 diabetes severity can range from mild and manageable to chronic and debilitating.

Which doctor to consult: 

Overview: 

Type 2 diabetes is a chronic condition affecting how your body regulates blood sugar. Insulin, a hormone, helps your body use glucose (sugar) for energy. In type 2 diabetes, your body either resists insulin's effects (insulin resistance) or doesn't produce enough insulin.

While many people experience no symptoms initially, some may have increased thirst, frequent urination, fatigue, or blurred vision. Left untreated, type 2 diabetes can lead to serious health problems like heart disease, nerve damage, and blindness.

Risk factors include family history, weight, inactivity, and unhealthy diet. The prevalence is concerning, with over 90% of diabetes cases being type 2 and affecting hundreds of millions worldwide.

Fortunately, type 2 diabetes is manageable. With proper treatment, which may involve lifestyle changes and medication, you can control blood sugar levels and reduce the risk of complications. Talking to your doctor is crucial. They can diagnose the condition, recommend treatment options, and refer you to a specialist like an endocrinologist or diabetologist if needed.

Types: 

Research on subtyping type 2 diabetes is ongoing, and no universally accepted classification system exists. However, several studies have identified potential clusters or subtypes based on different characteristics.

• Severe Insulin-Deficient Diabetes (SIDD)

• Severe Insulin-Resistant Diabetes (SIRD)

• Mild Obesity-Related Diabetes (MOD)

• Mild Age-Related Diabetes (MARD)

Limitations of subtyping:

• These are proposed categories, and individual cases may not neatly fit into one specific subtype.

• Subtyping often relies on clinical characteristics, not necessarily the underlying cause of the diabetes.

Future implications: Subtyping research holds promise for personalized treatment approaches. By understanding the specific subtype, doctors might be able to tailor treatment plans more effectively.

Symptoms: 

Type 2 diabetes, a chronic condition affecting blood sugar regulation, can often be a silent thief. Symptoms may be subtle or absent altogether, particularly in the early stages. However, being aware of the potential warning signs can empower you to seek diagnosis and treatment early on. Here's a detailed breakdown of the symptoms associated with type 2 diabetes:

Classic Symptoms:

• Increased thirst (polydipsia): When your blood sugar levels are high, your body tries to eliminate excess glucose through urine. This can lead to frequent urination, which in turn can make you feel thirstier. Recognizing these symptoms is crucial as it empowers you to take control of your health.

• Frequent urination (polyuria): As mentioned earlier, the body attempts to expel excess glucose through urine, resulting in frequent trips to the bathroom, especially at night.

• Unexplained weight loss: While weight loss can be positive, unexplained weight loss in people with type 2 diabetes can be a sign that the body is breaking down muscle tissue for energy due to a lack of available glucose.

Other Potential Symptoms:

• Extreme hunger (polyphagia): Due to insulin resistance, your cells may not be able to access glucose effectively even after eating, leading to persistent hunger pangs.

• Blurred vision: High blood sugar can affect the lenses in your eyes, causing them to swell and temporarily blur your vision.

• Slow-healing sores: Elevated blood sugar levels can impair circulation and the immune system's ability to fight infection, leading to slow-healing cuts, scrapes, or ulcers.

• Frequent infections: A weakened immune system due to high blood sugar can make you more susceptible to infections, including skin infections, yeast infections, and bladder infections.

• Fatigue: When your cells can't access enough glucose for energy, you may experience constant tiredness and fatigue.

• Tingling or numbness in the hands or feet: High blood sugar can damage nerves, causing tingling, numbness, or pain in the extremities.

Additional Considerations:

• Age: While type 2 diabetes can develop at any age, the risk increases with age.

• Family history: Having a close relative with type 2 diabetes increases your risk.

• Lifestyle factors: Obesity, physical inactivity, and a diet high in processed foods and sugary drinks are significant risk factors.

Keep in mind: It's important to remember that not everyone experiences all of these symptoms, and the severity can vary greatly. Some people may only have mild symptoms, while others may have several more pronounced ones. Additionally, symptoms can develop gradually over time or appear suddenly.

Causes:

Type 2 diabetes arises from a breakdown in your body's ability to use insulin, a hormone produced by your pancreas effectively. Here's a breakdown of the key culprits:

• Insulin Resistance: This is the main culprit. Usually, insulin acts like a key, unlocking the doors of your cells and allowing glucose (sugar) from your bloodstream to enter for energy. However, in insulin resistance, these "doors" become partially blocked, and glucose builds up in your bloodstream instead of being ushered into your cells.

• Insulin Deficiency: While insulin resistance is a significant player, in some cases, your pancreas may not be producing enough insulin. This further disrupts the delicate balance of blood sugar control.

Several factors contribute to these underlying issues and increase your risk of developing type 2 diabetes:

• Weight: Carrying excess weight, particularly belly fat, is a significant risk factor. Fat tissue can impede insulin sensitivity.

• Inactivity: A sedentary lifestyle reduces your body's ability to use insulin effectively. Aim for regular physical activity for better insulin sensitivity.

• Genetics: A family history of type 2 diabetes increases your risk. Genes play a role in how your body regulates blood sugar.

• Race and ethnicity: Certain racial and ethnic groups are at higher risk for reasons not fully understood, but likely a combination of genetics and environmental factors.

• Diet: A diet high in processed foods, sugary drinks, and unhealthy fats can contribute to weight gain and insulin resistance. Choose a balanced diet rich in fruits, vegetables, and whole grains.

• Polycystic ovary syndrome (PCOS): Women with PCOS may experience hormonal imbalances that increase their risk of type 2 diabetes.

• Gestational diabetes: Having diabetes during pregnancy (gestational diabetes) raises your risk of developing type 2 diabetes later in life.

Risk factors:

There are two main categories of risk factors for type 2 diabetes: Modifiable and Non-Modifiable.

Modifiable risk factors are those you can influence through lifestyle changes. These include:

• Weight: Being overweight or obese is a major risk factor. Losing weight, even a modest amount, can significantly improve your insulin sensitivity and reduce your risk.

• Inactivity: A sedentary lifestyle increases your risk. Aim for regular physical activity, like brisk walking for at least 30 minutes most days of the week.

• Diet: Consuming a healthy diet low in processed foods, sugary drinks, and unhealthy fats can help manage your weight and improve blood sugar control.

• Other health conditions: Having high blood pressure or high cholesterol increases your risk of type 2 diabetes. It's important to manage these conditions effectively.

By focusing on modifiable risk factors, you can significantly reduce your chances of developing type 2 diabetes.

Non-modifiable risk factors are those you can't change, such as:

• Family history: Having a parent or sibling with type 2 diabetes increases your risk.

• Race or ethnicity: Certain races and ethnicities are at higher risk, including African American, Hispanic/Latino, American Indian, Asian American, and Pacific Islander.

• Age: The risk increases as you get older, though type 2 diabetes is becoming more common in young people.

• Prediabetes: If you have prediabetes, a condition with higher than normal blood sugar levels but not high enough for a type 2 diabetes diagnosis, you're at high risk of developing type 2 diabetes.

• Pregnancy-related risks: Having gestational diabetes (diabetes during pregnancy) or giving birth to a baby weighing more than 9 pounds increases your risk.

Possible complications: 

Uncontrolled type 2 diabetes can lead to long-term damage throughout the body, impacting organs and systems like the heart, blood vessels, nerves, kidneys, eyes, etc.

Heart and Blood Vessel Complications:

• Coronary artery disease (CAD): High blood sugar can damage blood vessels and contribute to plaque buildup, narrowing the arteries that supply blood to the heart. This increases the risk of heart attack and angina (chest pain).

• Stroke: When blood flow to the brain is blocked due to a clot or narrowed arteries, a stroke can occur. High blood sugar weakens blood vessels and makes them more susceptible to blockage.

• Peripheral arterial disease (PAD): This condition affects blood flow to the legs and feet. Symptoms can include cramping pain in the legs, especially when walking, numbness, and sores that heal slowly. In severe cases, amputation may be necessary.

Eye Complications:

• Diabetic retinopathy: This is a leading cause of blindness in adults. High blood sugar damages the tiny blood vessels in the retina, the light-sensitive layer at the back of the eye. Early detection and treatment are crucial to prevent vision loss.

• Diabetic macular edema (DME): Fluid leaks from damaged blood vessels in the macula, the part of the retina responsible for sharp central vision, causing blurred vision and distortion.

• Glaucoma: People with diabetes are at higher risk of developing glaucoma, a condition that damages the optic nerve.

Nerve Damage (Neuropathy):

• Peripheral neuropathy: This is the most common type of nerve damage caused by diabetes. It typically affects the feet and hands, causing tingling, numbness, burning pain, and weakness. This can lead to foot problems like ulcers and infections due to decreased sensation.

Kidney Complications:

• Diabetic nephropathy: High blood sugar can damage the delicate filtering system in your kidneys, leading to chronic kidney disease. Eventually, dialysis or a kidney transplant may be needed.

• Autonomic neuropathy: This affects nerves that control involuntary body functions like digestion, bladder control, sexual function, and sweating. Symptoms can include diarrhea, constipation, urinary incontinence, erectile dysfunction, and problems with sweating.

Skin and Foot Problems:

• Slow-healing sores: High blood sugar can impair circulation and the immune system's ability to fight infection, leading to slow-healing cuts, scrapes, or ulcers. These can become serious if not treated promptly.

• Skin infections: People with diabetes are more prone to bacterial and fungal skin infections due to weakened immunity.

• Foot infections: Nerve damage and poor foot circulation can lead to unnoticed injuries and infections that can become serious if not treated promptly. In severe cases, amputation may be necessary.

Other Potential Complications:

• Hearing problems: People with diabetes are more likely to experience hearing loss.

• Sleep apnea: This sleep disorder, characterized by pauses in breathing during sleep, is more common in people with diabetes.

• Mental health problems: Depression and anxiety are more prevalent in people with diabetes, likely due to the challenges of managing the condition.

Prevention: 

Here's a detailed breakdown of preventive and management methods for type 2 diabetes:

Lifestyle Changes:

• Diet: A healthy diet is the cornerstone of managing type 2 diabetes. Focus on whole, unprocessed foods like fruits, vegetables, and whole grains. Choose lean protein sources and limit unhealthy fats, sugary drinks, and processed carbohydrates. This helps maintain healthy blood sugar levels and reduce your risk of weight gain, another risk factor.

• Exercise: Regular physical activity is crucial. Aim for at least 150 minutes of moderate-intensity exercise (like brisk walking) or 75 minutes of vigorous-intensity exercise (like running) spread throughout the week. Physical activity improves insulin sensitivity and helps your body use blood sugar more effectively.

• Weight Management: Losing weight, even a modest amount, can significantly improve blood sugar control. If you're overweight or obese, consult your doctor or a registered dietitian for guidance on healthy weight loss strategies.

• Stress Management: Chronic stress can elevate blood sugar levels. Practice relaxation techniques like yoga, meditation, or deep breathing to manage stress effectively.

Medications:

• Oral Medications: Several types of oral medications can help lower blood sugar levels. These include drugs like metformin, which helps the body use insulin more effectively, and sulfonylureas, which stimulate the pancreas to produce more insulin.

• Injectable Medications: In some cases, injectable medications like insulin may be necessary to manage blood sugar effectively. There are different types of insulin, and your doctor will determine the best type and dosage for you.

Monitoring and Screening:

• Blood Sugar Monitoring: Regularly monitoring your blood sugar levels at home helps you understand how your body responds to food, exercise, and medications. This information is crucial for managing your diabetes effectively.

• Doctor Visits and Screenings: Regular checkups with your doctor are essential. They will monitor your blood sugar control, screen for complications, and adjust your treatment plan as needed. This may include screenings for eye problems, kidney disease, and nerve damage.

Additional Tips:

• Get Enough Sleep: Aim for 7-8 hours of quality sleep each night. Poor sleep can disrupt hormones that regulate blood sugar levels.

• Don't Smoke: Smoking increases your risk of diabetes complications like heart disease and stroke. Quitting smoking is one of the best things you can do for your overall health.

• Brush and Floss Regularly: Good oral hygiene is important for people with diabetes, as they are more prone to gum disease and other oral infections.

• Foot Care: Practice good foot care to prevent foot problems. This includes inspecting your feet daily for cuts, sores, or redness, washing your feet daily with warm water and drying them thoroughly, and wearing comfortable, well-fitting shoes.

Remember: By implementing these preventive and management strategies, you can take control of your type 2 diabetes and significantly reduce your risk of complications. It's crucial to work with your healthcare team to develop a personalized plan that fits your specific needs and preferences.

When to see a doctor? 

You should see a doctor about type 2 diabetes if you experience any of the following:

Classic Symptoms: These are the most common signs and have been around for a while.

Sudden or More Severe Symptoms: These can indicate a more serious situation and require prompt medical attention.

Risk Factors and Prediabetes: Even if you don't have full-blown symptoms, a doctor's visit is recommended if you have: 

• Increased thirst and urination

• Unexplained weight loss

• Fatigue

• Blurred vision

• Slow-healing sores

• Frequent infections

• High blood sugar (above 240 mg/dL) that persists even with medication or following a sick day

• Moderate to large amounts of ketones in your urine (a sign of possible diabetic ketoacidosis)

• Worsening abdominal pain, trouble breathing, or breath with a fruity smell (signs of diabetic ketoacidosis)

• A family history of type 2 diabetes

• Overweight or obesity

• A sedentary lifestyle

• History of gestational diabetes

• Polycystic ovary syndrome (PCOS)

• Age 45 or older (although it can develop at any age)

• Prediabetes (blood sugar levels higher than normal but not high enough for a type 2 diabetes diagnosis).

Don't Wait for Symptoms: Even if you don't experience any symptoms, seeing a doctor is recommended if you have risk factors for type 2 diabetes, such as a family history, being overweight, or having a history of gestational diabetes. Early detection, through tests like a blood sugar test, allows for intervention before symptoms develop and helps prevent complications.

Diagnosis:

Blood tests are the definitive way to diagnose type 2 diabetes. Here are the two main tests used:

• Haemoglobin A1c (HbA1c): This test reflects your average blood sugar control over the past 2-3 months. An HbA1c level of: 

• Fasting Plasma Glucose (FPG): This test measures your blood sugar level after not eating for at least 8 hours (usually overnight). A fasting blood sugar level of: 

• Below 5.7% is considered normal.

• Between 5.7% and 6.4% indicates prediabetes (a warning sign for developing type 2 diabetes).

• 6.5% or higher on two separate tests confirms a type 2 diabetes diagnosis.

• Less than 100 mg/dL (5.6 mmol/L) is considered normal.

• Between 100 and 125 mg/dL (5.6 and 6.9 mmol/L) indicates prediabetes.

• 126 mg/dL (7.0 mmol/L) or higher on two separate tests confirms a type 2 diabetes diagnosis.

Additional Considerations:

• Oral Glucose Tolerance Test (OGTT): This test is less common but may be used in certain situations. It involves drinking a sugary drink and measuring your blood sugar levels at intervals over two hours.

Keynote: Early diagnosis and proper management are crucial for living a healthy life with type 2 diabetes. Don't hesitate to seek medical advice if you have any concerns.

Treatment: 

There's no one-size-fits-all treatment plan for type 2 diabetes. Working closely with your doctor and healthcare team is essential to find the best approach for you and adjust your treatment plan as needed over time. 

Lifestyle Changes:

• Diet: This is the foundation of managing type 2 diabetes. A balanced diet rich in fruits, vegetables, whole grains, and lean protein helps regulate blood sugar levels. You'll need to limit processed foods, sugary drinks, and unhealthy fats.

• Exercise: Regular physical activity is crucial. Aim for at least 30 minutes of moderate-intensity exercise most days of the week. Exercise helps your body use insulin more effectively and lowers blood sugar levels.

• Weight Management: If you're overweight or obese, losing even a modest amount of weight can significantly improve blood sugar control.

While lifestyle changes are foundational for managing type 2 diabetes, medications often play a crucial role when those changes alone aren't enough to control blood sugar levels. Here's a breakdown of some commonly prescribed medications and how they work:

Metformin: The Flagship Drug (First-Line Therapy)

• Mechanism of Action: Metformin works in two ways: 

  • It reduces the amount of glucose produced by the liver.

  • It improves insulin sensitivity in your cells, allowing them to absorb glucose from the bloodstream more effectively.

• Benefits: Metformin is generally well-tolerated with minimal side effects. It's the first-line medication for most people with type 2 diabetes due to its effectiveness, safety profile, and affordability.

• Considerations: Metformin can cause side effects like diarrhoea, gas, and stomach cramps, especially when first starting the medication. These side effects often subside over time. It's important to avoid taking metformin if you have certain kidney or liver problems.

Sulfonylureas: Stimulating Insulin Production

• Mechanism of Action: Sulfonylureas stimulate the pancreas to release more insulin.

• Benefits: Sulfonylureas can be effective in lowering blood sugar levels. They are often a good initial choice alongside lifestyle modifications.

• Considerations: Sulfonylureas can cause side effects like weight gain and low blood sugar (hypoglycemia), especially if you take too much medication or don't eat enough carbohydrates. They may not be suitable for everyone, particularly those with a history of severe hypoglycemia.

Examples: Glibenclamide, Tolbutamide, Glimepiride, Glicazide.

Meglitinides: Faster-Acting Insulin Release

• Mechanism of Action: Similar to sulfonylureas, meglitinides stimulate the pancreas to release insulin. However, they work faster and for a shorter duration, specifically targeting post-meal blood sugar spikes.

• Benefits: Meglitinides may be a good option for people who experience significant blood sugar rises after eating. Their shorter duration of action can help minimize the risk of hypoglycemia compared to sulfonylureas.

• Considerations: Meglitinides can be more expensive than other medications for type 2 diabetes. They may not be as effective as other medications for overall blood sugar control.

Examples: Repaglinide and Nateglinide.

DPP-4 Inhibitors: Preserving Blood Sugar Regulators

• Mechanism of Action: DPP-4 inhibitors work by preventing the breakdown of hormones called incretins. Incretins help regulate blood sugar levels by: 

  • Stimulating insulin release after meals

  • Suppressing glucagon (a hormone that raises blood sugar) production

• Benefits: DPP-4 inhibitors can be a good option for people who also experience problems with emptying their stomach (gastroparesis). They may also have some weight-neutral effects.

• Considerations: DPP-4 inhibitors may not be as effective as some other medications for blood sugar control. They can be more expensive than some other options.

Examples: Sitagliptin, Saxagliptin, Linagliptin, Alogliptin and Vildagliptin.

SGLT2 Inhibitors: Removing Excess Sugar through Urine

• Mechanism of Action: SGLT2 inhibitors work by blocking the reabsorption of glucose by the kidneys. This allows excess sugar to be removed from the body through urine.

• Benefits: SGLT2 inhibitors can be a good option for people with high blood pressure, as some of them also have blood pressure-lowering effects. They may also promote weight loss in some people.

• Considerations: SGLT2 inhibitors can increase the risk of urinary tract infections. They may not be suitable for everyone, particularly those with a history of diabetic ketoacidosis (a serious complication of diabetes).

Examples: Canagliflozin, Dapagliflozin, and Empagliflozin.

Keynotes: Choosing the Right Medication: The best medication for you will depend on several factors, including:

• Your individual blood sugar levels.

• Your overall health and medical history.

• Your lifestyle and preferences.