Diabetes Type 2

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Diabetes Type 2

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Definition

Type 2 Diabetes is a chronic (lifelong) disease marked by high levels of sugar (glucose) in the blood. Type 2 diabetes is the most common form of diabetes.

See also:

Alternative Names

Noninsulin-dependent diabetes; Diabetes - type 2; Adult-onset diabetes

Causes, incidence, and risk factors

Diabetes is caused by a problem in the way your body makes or uses insulin. Insulin is needed to move blood sugar (glucose) into cells, where it is stored and later used for energy.

When you have type 2 diabetes, the body does not respond correctly to insulin. This is called insulin resistance. Insulin resistance means that fat, liver, and muscle cells do not respond normally to insulin. As a result blood sugar does not get into cells to be stored for energy.

When sugar cannot enter cells, abnormally high levels of sugar build up in the blood. This is called hyperglycemia. High levels of blood sugar often trigger the pancreas to produce more and more insulin, but it is not enough to keep up with the body's demand.

People who are overweight are more likely to have insulin resistance, because fat interferes with the body's ability to use insulin.

Type 2 diabetes usually occurs gradually. Most people with the disease are overweight at the time of diagnosis. However, type 2 diabetes can also develop in those who are thin, especially the elderly.

Family history and genetics play a large role in type 2 diabetes. Low activity level, poor diet, and excess body weight (especially around the waist) significantly increase your risk for type 2 diabetes.

Other risk factors include:

Age greater than 45 years
HDL cholesterol of less than 35 mg/dL or triglyceride level of greater than 250 mg/dL
High blood pressure
History of gestational diabetes
Polycystic ovarian syndrome
Previously identified impaired glucose tolerance by your doctor
Race/ethnicity (African Americans, Hispanic Americans, and Native Americans all have high rates of diabetes)

Symptoms

Often, people with type 2 diabetes have no symptoms at all. If you do have symptoms, they may include:

Blurred vision
Erectile dysfunction
Fatigue
Frequent or slow-healing infections
Increased appetite
Increased thirst
Increased urination

Signs and tests

Type 2 diabetes is diagnosed with the following blood tests:

Fasting blood glucose level -- diabetes is diagnosed if higher than 126 mg/dL on two occasions.
Hemoglobin A1c test -- this test has been used in the past to help patients monitor how well they are controlling their blood glucose levels. In 2010, the American Diabetes Association recommended that the test be used as another option for diagnosing diabetes and identifying pre-diabetes. Levels indicate:
- Normal: Less than 5.7%
- Pre-diabetes: Between 5.7% - 6.4%
- Diabetes: 6.5% or higher
Oral glucose tolerance test -- diabetes is diagnosed if glucose level is higher than 200 mg/dL after 2 hours.
Random (non-fasting) blood glucose level -- diabetes is suspected if higher than 200 mg/dL and accompanied by the classic symptoms of increased thirst, urination, and fatigue (this test must be confirmed with a fasting blood glucose test).

You should see your health care provider every 3 months. At these visits, you can expect your health care provider to:

Check your blood pressure
Check the skin and bones on your feet and legs
Check the sensation in your feet
Examine the back part of the eye with a special lighted instrument called an ophthalmoscope

The following tests will help you and your doctor monitor your diabetes and prevent complications:

Have your blood pressure checked at least every year (blood pressure goals should be 130/80 mm/Hg or lower).
Have your glycosulated hemoglobin (HbA1c) checked every 6 months if your diabetes is well controlled; otherwise every 3 months.
Have your cholesterol and triglyceride levels checked yearly (aim for LDL levels below 70-100 mg/dL).
Get yearly tests to make sure your kidneys are working well (microalbuminuria and serum creatinine).
Visit your ophthalmologist at least once a year, or more often if you have signs of diabetic retinopathy.
See the dentist every 6 months for a thorough dental cleaning and exam. Make sure your dentist and hygienist know that you have diabetes.

Treatment

The immediate goal of treatment is to lower high blood glucose levels. The long-term goals of treatment are to prevent diabetes-related complications.

The primary treatment for type 2 diabetes is exercise and diet.

LEARN THESE SKILLS

You should learn basic diabetes management skills. They will help prevent complications and the need for medical care. These skills include:

How to test and record your blood glucose (See: Blood glucose monitoring)
What to eat and when
How to take medications, if needed
How to recognize and treat low and high blood sugar
How to handle sick days
Where to buy diabetes supplies and how to store them

It may take several months to learn the basic skills. Always continue to educate yourself about the disease and its complications. Learn how to control and live with diabetes. Over time, stay current on new research and treatments.

SELF-TESTING

Self testing refers to being able to check your blood sugar at home yourself. It is also called self-monitoring of blood glucose (SMBG). Regular self-testing of your blood sugar tells you and your health care provider how well your diet, exercise, and diabetes medications are working.

A device called a glucometer can provide an exact blood sugar reading. There are different types of devices. Usually, you prick your finger with a small needle called a lancet. This gives you a tiny drop of blood. You place the blood on a test strip and put the strip into the device. Results are available in 30 - 45 seconds.

A health care provider or diabetes educator will help set up an at-home testing schedule for you. Your doctor will help you set your blood sugar goals.

Most people with type 2 diabetes only need to check their blood sugar once or twice a day.
If your blood sugar levels are under control, you may only need to check them a few times a week.
Tests may be done when you wake up, before meals, and at bedtime.
More frequent testing may be needed when you are sick or under stress.

The results of the test can be used to adjust meals, activity, or medications to keep your blood sugar levels in an appropriate range. Testing can identify high and low blood sugar levels before serious problems develop.

Keeping a record for yourself and your health care provider. This will be a big help if you are having trouble managing your diabetes.

DIET AND WEIGHT CONTROL

People with type 2 diabetes should eat at about the same times each day and try to be consistent with the types of food they choose. This helps to prevent blood sugar from becoming extremely high or low. Meal planning includes choosing healthy foods, eating the right amount of food, and eating meals at the right time. You should work closely with your doctor, nurse, and registered dietitian to learn how much fat, protein, and carbohydrates you need in your diet. Your meal plans should fit your daily lifestyle and habits, and should try to include foods that you like.

Managing your weight and eating a well-balanced diet are important. Some people with type 2 diabetes can stop taking medications after losing weight (although they still have diabetes).

See: Diabetes diet

Bariatric (weight loss) surgery may be considered for very overweight patients who are not well managed with diet and medications.

See:

REGULAR PHYSICAL ACTIVITY

Regular exercise is important for everyone, but especially if you have diabetes. Regular aerobic exercise lowers your blood sugar level without medication and helps burn excess calories and fat so you can manage your weight.

Exercise can help your overall health by improving blood flow and blood pressure. It decreases insulin resistance even without weight loss. Exercise also increases the body's energy level, lowers tension, and improves your ability to handle stress.

Consider the following when starting an exercise routine:

Always check with your health care provider before starting an exercise program.
Ask your health care provider whether you have the right footwear.
Choose an enjoyable physical activity that is appropriate for your current fitness level.
Exercise every day, and at the same time of day, if possible.
Monitor blood glucose levels at home before and after exercise.
Carry food that contains a fast-acting carbohydrate in case blood glucose levels get too low during or after exercise.
Wear a diabetes identification bracelet and carry a cell phone in case of emergency.
Drink extra fluids that do not contain sugar before, during, and after exercise.
You may need to modify your diet or medication if you exercise longer or more intensely, to keep blood glucose levels in the correct range.

MEDICATIONS TO TREAT DIABETES

If diet and exercise do not help maintain normal or near-normal blood glucose levels, your doctor may prescribe medication. Since these drugs help lower your blood sugar levels in different ways, your doctor may have you take more than one. These drugs may also be given along with insulin, if needed.

Some of the most common types of medication are listed below. They are taken by mouth or injection.

Alpha-glucosidase inhibitors (such as acarbose) decrease the absorption of carbohydrates from the digestive tract to lower after-meal glucose levels.
Biguanides (Metformin) tell the liver to produce less glucose and help muscle and fat cells and the liver absorb more glucose from the bloodstream. This lowers blood sugar levels.
Injectible medications (including exenatide, mitiglinide, pramlintide, sitagliptin, and saxagliptin) can lower blood sugar.
Meglitinides (including repaglinide and nateglinide) trigger the pancreas to make more insulin in response to the level of glucose in the blood.
Sulfonylureas (like glimepiride, glyburide, and tolazamide) trigger the pancreas to make more insulin. They are taken by mouth.
Thiazolidinediones (such as rosiglitazone and pioglitazone) help muscle and fat cells and the liver absorb more blood sugar when insulin is present. Rosiglitazone may increase the risk of heart problems. Talk to your doctor.

If you continue to have poor blood glucose control despite lifestyle changes and taking medicines by mouth, your doctor will prescribe insulin. Insulin may also be prescribed if you have had a bad reaction to other medicines. Insulin must be injected under the skin using a syringe or insulin pen device. It cannot be taken by mouth.

Insulin preparations differ in how fast they start to work and how long they work. Your healthcare provider will determine the appropriate type of insulin to use and will tell you what time of day to use it.

More than one type may be mixed together in an injection to achieve the best blood glucose control. Usually injections are needed one to four times a day. Your doctor or diabetes educator will show you how to give yourself an injection.

Some people with type 2 diabetes find they no longer need medication if they lose weight and increase activity. When they reach their ideal weight, their own insulin and a careful diet can control their blood glucose levels.

It is not known whether hypoglycemia medications taken by mouth are safe for use in pregnancy. Women who have type 2 diabetes and take these medications may be switched to insulin during pregnancy and while breastfeeding.

MEDICATIONS TO PREVENT COMPLICATIONS

Since those with diabetes have a much higher chance of developing Heart disease, kidney disease, and other medical problems, they may need to take certain medicines to treat these problems or prevent them from happening.

An ACE inhibitor (or ARB) is often recommended:

As the first choice medicine for treating high blood pressure in persons with diabetes
For those who have signs of early kidney disease

ACE inhibitors include captopril (Capoten), enalapril (Vasotec), quinapril (Accupril), benazepril (Lotensin), ramipril (Altace), perindopril (Aceon), and lisinopril (Prinivil, Zestril).

Statin drugs are usually the first choice to treat an abnormal cholesterol level. Aim for LDL cholesterol level less than 100 mg/dL (less than 70 mg/dL in high-risk patients).

Aspirin to prevent heart disease is most often recommended for persons with diabetes who:

Are 40 or older
Have a history of heart problems
Have a family history of heart disease
Have high blood pressure or high cholesterol
Smoke

FOOT CARE

People with diabetes are more likely to have foot problems. Diabetes can damage nerves, which means you may not feel an injury to the foot until a large sore or infection develops. Diabetes can also damage blood vessels.

In addition, diabetes affects the body's immune system. This decreases the body's ability to fight infection. Small infections can quickly get worse and cause the death of skin and other tissues. Amputation may be needed.

To prevent injury to the feet, check and care for your feet every day.

See also:

Alternative Names

Noninsulin-dependent diabetes; Diabetes - type 2; Adult-onset diabetes

Causes, incidence, and risk factors

Diabetes is caused by a problem in the way your body makes or uses insulin. Insulin is needed to move blood sugar (glucose) into cells, where it is stored and later used for energy.

When you have type 2 diabetes, your fat, liver, and muscle cells do not respond correctly to insulin. This is called insulin resistance. As a result, blood sugar does not get into these cells to be stored for energy.

When sugar cannot enter cells, high levels of sugar build up in the blood. This is called hyperglycemia.

Type 2 diabetes usually occurs slowly over time. Most people with the disease are overweight when they are diagnosed. Increased fat makes it harder for your body to use insulin the correct way.

Type 2 diabetes can also develop in people who are thin. This is more common in the elderly.

Family history and genes play a large role in type 2 diabetes. Low activity level, poor diet, and excess body weight around the waist increase your risk. See also: Type 2 diabetes for a list of risk factors.

Symptoms

Often, people with type 2 diabetes have no symptoms at first. They may not have symptoms for many years.

The early symptoms of diabetes may include:

Bladder, kidney, skin, or other infections that are more frequent or heal slowly
Fatigue
Hunger
Increased thirst
Increased urination

The first symptom may also be:

Blurred vision
Erectile dysfunction
Pain or numbness in the feet or hands

Signs and tests

Your health care provider may suspect that you have diabetes if your blood sugar level is higher than 200 mg/dL. To confirm the diagnosis, one or more of the following tests must be done.

Diabetes blood tests:

Fasting blood glucose level -- diabetes is diagnosed if it is higher than 126 mg/dL two times
Hemoglobin A1c test --
- Normal: Less than 5.7%
- Pre-diabetes: 5.7% - 6.4%
- Diabetes: 6.5% or higher
Oral glucose tolerance test -- diabetes is diagnosed if glucose level is higher than 200 mg/dL after 2 hours

Diabetes screening is recommended for:

Overweight children who have other risk factors for diabetes, starting at age 10 and repeated every 2 years
Overweight adults (BMI greater than 25) who have other risk factors
Adults over age 45 every 3 years

You should see your health care provider every 3 months. At these visits, you can expect your health care provider to:

Check your blood pressure
Check the skin and bones on your feet and legs
Check to see if your feet are becoming numb
Examine the back part of the eye with a special lighted instrument called an ophthalmoscope

The following tests will help you and your doctor monitor your diabetes and prevent problems:

Have your blood pressure checked at least every year (blood pressure goals should be 130/80 mm/Hg or lower).
Have your hemoglobin A1c test (HbA1c) every 6 months if your diabetes is well controlled; otherwise every 3 months.
Have your cholesterol and triglyceride levels checked yearly (aim for LDL levels below 70-100 mg/dL).
Get yearly tests to make sure your kidneys are working well (microalbuminuriaand serum creatinine).
Visit your eye doctor at least once a year, or more often if you have signs of diabetic eye disease.
See the dentist every 6 months for a thorough dental cleaning and exam. Make sure your dentist and hygienist know that you have diabetes.

Treatment

The goal of treatment at first is to lower high blood glucose levels. The long-term goals of treatment are to prevent problems from diabetes.

The main treatment for type 2 diabetes is exercise and diet.

LEARN THESE SKILLS

You should learn basic diabetes management skills. They will help prevent problems and the need for medical care. These skills include:

How to test and record your blood glucose (See: Blood glucose monitoring)
What to eat and when
How to take medications, if needed
How to recognize and treat low and high blood sugar
How to handle sick days
Where to buy diabetes supplies and how to store them

It may take several months to learn the basic skills. Always keep learning about diabetes, its complications, and how to control and live with the disease. Stay up-to-date on new research and treatments.

MANAGING YOUR BLOOD SUGAR

Self testing means that you check your blood sugar at home yourself. Checking your blood sugar levels at home and writing down the results will tell you how well you are managing your diabetes.

A device called a glucometer can give you an exact blood sugar reading. There are different types of devices. Usually, you prick your finger with a small needle called a lancet. This gives you a tiny drop of blood. You place the blood on a test strip and put the strip into the device. Results are given in 30 - 45 seconds.

A health care provider or diabetes educator will help set up an at-home testing schedule for you. Your doctor will help you set your blood sugar goals.

Most people with type 2 diabetes only need to check their blood sugar once or twice a day.
If your blood sugar levels are under control, you may only need to check them a few times a week.
You may test yourself when you wake up, before meals, and at bedtime.
You may need to test more often when you are sick or under stress.

The results of the test can be used to change your meals, activity, or medications to keep your blood sugar levels in the right range. Testing can identify high and low blood sugar levels before you have serious problems.

Keep a record of your blood sugar for yourself and your health care provider. This will help if you are having trouble managing your diabetes.

DIET AND WEIGHT CONTROL

Work closely with your doctor, nurse, and dietitian to learn how much fat, protein, and carbohydrates you need in your diet. Your meal plans should fit your daily lifestyle and habits, and should try to include foods that you like.

Managing your weight and eating a well-balanced diet are important. Some people with type 2 diabetes can stop taking medications after losing weight (although they still have diabetes).

See also:

Very overweight patients whose diabetes is not well managed with diet and medicine may consider bariatric (weight loss) surgery.

See:

REGULAR PHYSICAL ACTIVITY

Regular exercise is important for everyone. It is even more important you have diabetes. Exercise in which your heart beats faster and you breathe faster helps lower your blood sugar level without medication. It also burns extra calories and fat so you can manage your weight.

Exercise can help your health by improving blood flow and blood pressure. Exercise also increases the body's energy level, lowers tension, and improves your ability to handle stress.

Ask your health care provider before starting any exercise program. People with type 2 diabetes must take special steps before, during, and after intense physical activity or exercise. See also: Diabetes and exercise

MEDICATIONS TO TREAT DIABETES

If diet and exercise do not help keep your blood sugar at normal or near-normal levels, your doctor may prescribe medication. Since these drugs help lower your blood sugar levels in different ways, your doctor may have you take more than one drug.

Some of the most common types of medication are listed below. They are taken by mouth or injection.

Alpha-glucosidase inhibitors (such as acarbose)
Biguanides (Metformin)
Injectable medicines (including exenatide, mitiglinide, pramlintide, sitagliptin, and saxagliptin)
Meglitinides (including repaglinide and nateglinide)
Sulfonylureas (like glimepiride, glyburide, and tolazamide)
Thiazolidinediones (such as rosiglitazone and pioglitazone). (Rosiglitazone may increase the risk of heart problems. Talk to your doctor.)

These drugs may be given with insulin, or insulin may be used alone. You may need insulin if you continue to have poor blood glucose control. It must be injected under the skin using a syringe or insulin pen device. It cannot be taken by mouth. See also: Type 1 diabetes

It is not known whether hyperglycemia medications taken by mouth are safe for use in pregnancy. Women who have type 2 diabetes and become pregnant may be switched to insulin during their pregnancy and while breast-feeding.

PREVENTING COMPLICATIONS

Your doctor may prescribe medications or other treatments to reduce your chances of developing eye disease, kidney disease, and other conditions that are more common in people with diabetes.

See also:

FOOT CARE

People with diabetes are more likely to have foot problems. Diabetes can damage nerves, which means you may not feel an injury to the foot until you get a large sore or infection. Diabetes can also damage blood vessels.

Diabetes also decreases the body's ability to fight infection. Small infections can quickly get worse and cause the death of skin and other tissues.

To prevent injury to your feet, check and care for your feet every day. See also: Diabetes foot care

Support Groups

For more information, see diabetes resources.

Expectations (prognosis)

After many years, diabetes can lead to serious problems with your eyes, kidneys, nerves, heart, blood vessels, or other areas in your body.

If you have diabetes, your risk of a heart attack is the same as that of someone who has already had a heart attack. Both women and men with diabetes are at risk. You may not even have the normal signs of a heart attack.

If you control your blood sugar and blood pressure, you can reduce your risk of death, stroke, heart failure, and other diabetes problems.

Some people with type 2 diabetes no longer need medicine if they lose weight and become more active. When they reach their ideal weight, their body's own insulin and a healthy diet can control their blood sugar levels.

Complications

After many years, diabetes can lead to serious problems:

You could have eye problems, including trouble seeing (especially at night), and light sensitivity. You could become blind.
Your feet and skin can develop sores and infections. After a long time, your foot or leg may need to be removed. Infection can also cause pain and itching in other parts of the body.
Diabetes may make it harder to control your blood pressure and cholesterol. This can lead to a heart attack, storke, and other problems. It can become harder for blood to flow to your legs and feet.
Nerves in your body can get damaged, causing pain, tingling, and a loss of feeling.
Because of nerve damage, you could have problems digesting the food you eat. You could feel weakness or have trouble going to the bathroom. Nerve damage can make it harder for men to have an erection.
High blood sugar and other problems can lead to kidney damage. Your kidneys may not work as well, and they may even stop working.

Infections of the skin, female genital tract, and urinary tract are also more common.

To prevent problems from diabetes, visit your health care provider or diabetes educator at least four times a year. Talk about any problems you are having.

Calling your health care provider

Call 911 right away if you have:

Chest pain or pressure
Fainting or unconsciousness
Seizure
Shortness of breath

These symptoms can quickly get worse and become emergency conditions (such as convulsions or hypoglycemic coma).

Call your doctor if you have:

Numbness, tingling, or pain in your feet or legs
Problems with your eyesight
Sores or infections on your feet
Symptoms of high blood sugar (being very thirsty, having blurry vision, having dry skin, feeling weak or tired, needing to urinate a lot)
Symptoms of low blood sugar (feeling weak or tired, trembling, sweating, feeling irritable, having trouble thinking clearly, fast heartbeat, double or blurry vision, feeling uneasy)

Prevention

You can help prevent type 2 diabetes by keeping a healthy body weight and an active lifestyle.

Stay up-to-date with all your vaccinations and get a flu shot every year.

References

American Diabetes Association. Standards of medical care in diabetes--2011. Diabetes Care. 2011;34 Suppl 1:S11-S61.

Eisenbarth GS, Polonsky KS, Buse JB. Type 1 Diabetes Mellitus. In: Kronenberg HM, Melmed S, Polonsky KS, Larsen PR. Kronenberg: Williams Textbook of Endocrinology. 11th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 31.

Pignone M, Alberts MJ, colwell JA, Cushman M, Inzucchi SE, Mukherjee D, et al. Aspirin for primary prevention of cardiovascular events in people with diabetes: a position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation. Circulation. 2010;121:2694-2701.

Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, Bantle JP, Sledge I. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009 Mar;122(3):248-256.e5. Review. PubMed PMID: 19272486.

ACCORD Study Group, Gerstein HC, Miller ME, Genuth S, Ismail-Beigi F, Buse JB, et al. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Engl J Med. 2011;364:818-828.

Alemzadeh R, Ali O. Diabetes Mellitus. In: Kliegman R, ed. 19th ed. Nelson Textbook of Pediatrics. Philadelphia, Pa: Saunders Elsevier; 2011: chap 583.

Reviewed By

Review Date: 06/28/2011

Ari S. Eckman, MD, Chief, Division of Endocrinology, Diabetes and Metabolism, Trinitas Regional Medical Center, Elizabeth, NJ. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

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Diabetes Type 2

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