• Type 2 Diabetes

    (Diabetes Mellitus Type 2; Insulin-Resistant Diabetes; Diabetes, Type 2)

    Definition

    Glucose is a type of sugar. It comes from food, and is also created in the liver. Glucose travels through the body in the blood. It moves from the blood to cells with the help of a hormone called insulin. Once glucose is in those cells, it can be used for energy. Insulin also helps glucose to move into the liver for storage if there is too much to use.
    Diabetes is a condition that makes it difficult for the body to use or store glucose. This causes a buildup of glucose in the blood. It also means the body is not getting enough energy. Type 2 diabetes is one type of diabetes. It is the most common type in adults.
    Medication, lifestyle changes, and monitoring can help control blood glucose levels.

    Causes

    Type 2 diabetes is often caused by a combination of factors. The initial factor is that the body becomes resistant to insulin. This means there is insulin in the body, but the body cannot use it effectively. Insulin resistance is often related to excess body fat. A second factor is that the body begins to make less insulin.

    Risk Factors

    Type 2 diabetes is more common in people who are aged 45 years and older, but can develop in children. It is also common in younger people who are obese and belong to at-risk ethnic groups. Other factors that increase the chance of type 2 diabetes include:
    • Prediabetes—impaired glucose tolerance and impaired fasting glucose
    • Metabolic syndrome—a condition marked by elevated cholesterol, blood glucose, blood pressure, and central obesity
    • Excess weight or obesity, especially central obesity
    • Family history of type 2 diabetes
    • History of gestational diabetes, or having a baby that weighs over 9 pounds at birth
    • Being born small or large for gestational age
    • Certain medications, such as glucocorticoids or thiazides
    • Certain ethnic groups, such as African American, Hispanic, Native American, Hispanic American, Asian American, or Pacific Islander
    • Endocrine disorders, such as Cushing’s syndrome, hyperthyroidism, acromegaly, polycystic ovary syndrome, or acute pancreatitis
    • Conditions associated with insulin resistance, such as acanthosis nigricans
    • Lack of exercise
    • Poor diet—high intake of processed meats, fats, sugar-sweetened foods and beverages, and calories
    • High blood pressure
    • History of cardiovascular disease
    • Depression

    Symptoms

    Diabetes may be present for years before symptoms occur.
    Symptoms caused by high blood sugar include:
    • Increased urination
    • Extreme thirst
    • Hunger
    • Fatigue
    • Blurry vision
    • Irritability
    Symptoms caused by chronic hyperglycemia may include
    • Frequent or recurring infections
    • Poor wound healing
    • Numbness or tingling in the hands or feet
    • Problems with gums
    • Itching
    • Problems having an erection
    • Symptoms of heart or kidney disease

    Diagnosis

    You will be asked about your symptoms and medical history. You will also be asked about your family history. A physical exam will be done.
    Diagnosis is based on the results of blood testing. American Diabetes Association (ADA) recommends diagnosis be made if you have one of the following:
    • Symptoms of diabetes and a random blood test with a blood sugar level greater than or equal to 200 mg/dL (11.1 mmol/L)
    • Fasting blood sugar test is done after you have not eaten for 8 or more hours—showing blood sugar levels greater than or equal to 126 mg/dL (7 mmol/L) on two different days
    • Glucose tolerance test measures blood sugar 2 hours after you eat glucose—showing glucose levels greater than or equal to 200 mg/dL (11.1 mmol/L)
    • HbA1c level of 6.5% or higher—indicates poor blood sugar control over the past 2-4 months
    mg/dL = milligrams per deciliter of blood; mmol/L = millimole per liter of blood
    You may also need blood tests to confirm diabetes is type 1 and not type 2. These may include:
    • Insulin level or C-peptide tests—to see how much insulin is being made by the pancreas
    • Tests that look for antibodies that are working against your pancreas
    You may also need other tests, including.
    • Cholesterol levels
    • Urine for glucose, ketones, or albumin
    • Liver and kidney function tests in adults

    Treatment

    Treatment aims to:
    • Maintain blood sugar at levels as close to normal as possible
    • Avoid hypoglycemia
    • Prevent or delay complications
    • Control other conditions, such as high blood pressure and high cholesterol
    Diet, exercise, and weight loss are recommended for all patients. Most patients will also begin medication.

    Diet

    Food and drinks have a direct effect on blood glucose levels. Eating healthy meals can help control blood glucose. It will also promote overall health. Some basic tips include:
    • Follow a balanced meal plan. It should include carbohydrates, proteins, and fats.
    • Be aware of appropriate serving size. Measure food to help understand ideal serving size.
    • Do not skip meals. Plan meals and snacks through the day. Having meals throughout the day can help avoid major changes in glucose levels.
    • Eat plenty of vegetables and fiber.
    • Limit the amount of fat (especially saturated and trans fats) in foods.
    • Eat moderate amounts of protein and low-fat dairy products.
    • Carefully limit foods containing high concentrated sugar.
    • Keep a food intake record. Share the record with the dietitian or doctor. This will help to create an effective meal plan.

    Weight Loss

    In those who are overweight, weight loss will help the body use insulin better. Talk to the doctor about a healthy weight goal. A safe meal plan can be created.
    These options may help with weight loss:

    Exercise

    Physical activity can:
    • Make the body more sensitive to insulin
    • Help to reach and maintain a healthy weight
    • Lower the levels of fat in the blood
    Aerobic exercise is any activity that increases heart rate. Resistance training helps build muscle strength. Both types of exercise help to improve long-term glucose control. Regular exercise can also help reduce the risk of heart disease.
    Aim for ≥ 150 minutes of physical activity each week. Talk to the doctor about an activity plan. Ask about any precautions that may be needed.

    Medication

    Non-insulin Glucose Lowering Medication
    Medications other than insulin are typically used first to manage blood glucose levels.
    Biguanides, usually metformin, are the first choice. They work by reducing the amount of glucose made by the body.
    • Metformin is the only medication approved for use in children.
    • In adults other medications may be added if treatment goals are not met. Medication taken by mouth may include:
      • Sulfonylureas or dipeptidyl peptidase IV (DPP-4) inhibitors to encourage the pancreas to make more insulin
      • Thiazolidinediones which sensitize the body to insulin so it works better at lower amounts
      • Starch blockers to decrease the amount of glucose absorbed into the blood
      • Sodium-glucose co-transporter 2 (SGLT-2) inhibitors to increase glucose excretion in urine
      • Bile acid binders
      Medications given by injection may include:
      • Glucagon-like peptide-1 receptor agonists (incretin-mimetics) stimulate the pancreas to produce insulin and decrease appetite, which can assist with weight loss
      • Amylin analogs replace a protein of the pancreas that is low in people with type 2 diabetes
    Insulin
    Insulin may be needed if:
    • The body does not make enough of its own insulin
    • Blood glucose levels cannot be controlled with lifestyle changes and other medications
    Insulin is given through injections. There is one short-acting inhaled insulin which may be effective for select persons.
    Other medications
    If not controlled by diet and exercise, medications may be used to control blood pressure and cholesterol.
    Vaccinations will be needed. Some may be needed earlier in children with diabetes.

    Blood Glucose Testing

    Check the level of glucose in the blood with a blood glucose meter. Checking blood glucose levels during the day can help with staying on track. It will also help the doctor determine if treatment is working. Keeping track of blood sugar levels is especially important for those taking insulin.
    Regular testing may not be needed if diabetes is under control and insulin is not being taken. Talk with the doctor before stopping blood sugar monitoring.
    An HbA1c test may also be done at the doctor's office. This is a measure of blood glucose control over a long period of time. Doctors advise that most people keep their HbA1c levels below 7%. Individual goals may be different. Keeping HbA1c in the goal range can help lower the chance of complications.

    Counseling

    Depression can undermine recovery and increase the risk of other complications. Feelings of sadness, hopelessness, and loss of interest in activities that last at least 2 weeks require a call to the doctor. Depression is treatable. Counseling can help better manage depression and diabetes.

    Complications

    Over a long period of time, high blood glucose levels can damage vital organs. The risk of complications increases with increasingly poor control

    Common complications

    Diabetes can also increase the risk of heart disease.

    Decreasing Risk of Complications

    Maintaining goal blood glucose and HbA1c levels according to the doctors recommendations is the first step to lowering the risk of these complications. Other steps:
    • Practice good footcare. Be on the lookout for any sores or irritated areas. Keep the feet dry and clean.
    • Get yearly eye exams.
    • Don't smoke. If you do, look for programs or products that can help you quit.
    • Keep track of moods and be alert for persistent depressive symptoms.
    • Plan medical visits as recommended.

    Prevention

    To help reduce your chance of type 2 diabetes:
    • Participate in regular physical activity
    • Maintain a healthy weight
    • Drink alcohol only in moderation (2 drinks per day for a man, and 1 drink per day for a woman)
    • Eat a well-balanced diet:
      • Get enough fiber
      • Avoid fatty foods
      • Limit sugar intake
      • Eat more green, leafy vegetables
      • Eat whole fruits, especially apples, grapes, and blueberries

    RESOURCES

    American Diabetes Association http://www.diabetes.org

    National Diabetes Information Clearinghouse http://diabetes.niddk.nih.gov

    CANADIAN RESOURCES

    Canadian Diabetes Association http://www.diabetes.ca

    Public Health Agency of Canada http://www.phac-aspc.gc.ca

    References

    American Association of Clinical Endocrinologists, American College of Endocrinology. Comprehensive Type 2 Diabetes Management Algorithm 2017. Endocr Pract. 2017 Feb;23(2):207-238.

    American Diabetes Association Classification and Diagnosis of Diabetes of Diabetes Mellitus. Diabetes Care. 2015 Jan;38 Suppl:S8-S16.

    Symptoms & Causes of Diabetes. National Institute of Diabetes and Digestive and Kidney Diseases website. Available at: https://www.niddk.nih.gov/health-information/diabetes/overview/symptoms-causes. Updated November 2016. Accessed August 25, 2017.

    Diabetes. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/diabetes/home/index.html. Updated July 25, 2016. Accessed August 25, 2017.

    Diabetes mellitus type 2 in adults. EBSCO DynaMed Plus website. Available at: http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults. Updated August 25, 2017. Accessed August 25, 2017.

    Diabetes mellitus type 2 in children and adolescents. EBSCO DynaMed Plus website. Available at: http://www.dynamed.com/topics/dmp~AN~T901364/Diabetes-mellitus-type-2-in-children-and-adolescents. Updated July 18, 2017. Accessed August 25, 2017.

    Dietary considerations for patients with type 2 diabetes. EBSCO DynaMed Plus website. Available at: http://www.dynamed.com/topics/dmp~AN~T270045/Dietary-considerations-for-patients-with-type-2-diabetes. Updated February 7, 2017. Accessed August 25, 2017.

    Traina AN, Kane MP. Primer on pramlintide, an amylin analog. Diabetes Educ. 2011;37(3):426-431.

    Type 2. American Diabetes Association website. Available at: http://www.diabetes.org/diabetes-basics/type-2/?loc=HomePage-type2-tdt. Accessed September 19, 2017.

    11/29/2006 DynaMed Plus Systematic Literature Surveillance. http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Lindstrom J, Ilanne-Parikka P, Peltonen M, Aunola S, Eriksson JG, Hemio K, et al. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet. 2006;368:1673-1679.

    9/19/2006 DynaMed Plus Systematic Literature Surveillance. http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Thomas DE, Elliott EJ, Naughton GA. Exercise for type 2 diabetes mellitus. Cochrane Database of Syst Rev. 2006;CD002968.

    6/1/2007 DynaMed Plus Systematic Literature Surveillance. http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007;356(24):2457-2471.

    7/13/2007 DynaMed Plus Systematic Literature Surveillance. http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Farmer A, Wade A, Goyder E, et al. Impact of self-monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial. BMJ. 2007;335(7611):132.

    12/13/2007 DynaMed Plus Systematic Literature Surveillance. http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Milman U, Blum S, Shapira C, et al. Vitamin E supplementation reduces cardiovascular events in a subgroup of middle-aged individuals with both type 2 diabetes mellitus and the haptoglobin 2-2 genotype. A prospective double-blinded clinical trial. Arterioscler Thromb Vasc Biol. 2008;28(2):341-347.

    2/28/2008 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Davies MJ, Heller S, Skinner TC, et al. Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. BMJ. 2008;336(7642):491-495.

    2/28/2008 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Christian JG, Bessesen DH, Byers TE, Christian KK, Goldstein MG, Bock BC. Clinic-based support to help overweight patients with type 2 diabetes increase physical activity and lose weight. Arch Intern Med. 2008;168:141-146.

    6/18/2008 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358:2560-2572.

    2/24/2009 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Liese AD, Weis KE, Schulz M, Tooze JA. Food intake patterns associated with incident type 2 diabetes: the Insulin Resistance Atherosclerosis Study. Diabetes Care. 2009;32:263-268.

    5/11/2009 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Loimaala A, Groundstroem K, Rinne M, et al. Effect of long-term endurance and strength training on metabolic control and arterial elasticity in patients with type 2 diabetes mellitus. Am J Cardiol. 2009;103:972-977.

    8/19/2009 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Li TY, Brennan AM, Wedick NM, Mantzoros C, Rifai N, Hu FB. Regular consumption of nuts is associated with a lower risk of cardiovascular disease in women with type 2 diabetes. J Nutr. 2009;139:1333-1338.

    10/12/2009 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Crandall JP, Polsky S, Howard AA, et al. Alcohol consumption and diabetes risk in the Diabetes Prevention Program. Am J Clin Nutr. 2009;90:595-601.

    11/20/2009 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Lund SS, Tarnow L, Frandsen M, et al. Combining insulin with metformin or an insulin secretagogue in non-obese patients with type 2 diabetes: 12 month, randomised, double blind trial. BMJ. 2009;339:b4324.

    12/21/2009 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Cappuccio FP, D'Elia L, Strazzullo P, Miller MA. Quantity and quality of sleep and incidence of type 2 diabetes: a systematic review and meta-analysis. Diabetes Care. 2010;33(2):414-420.

    2/15/2010 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: American Diabetes Association. Standards of medical care in diabetes—2010. Diabetes Care. 2010;33(suppl 1:S11-61).

    2/15/2010 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010;33(suppl 1:S62-69).

    7/2/2010 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Micha R, Wallace SK, Mozaffarian D. Red and processed meat consumption and risk of incident coronary heart disease, stroke, and diabetes mellitus: a systematic review and meta-analysis. Circulation. 2010;121(21):2271-2283.

    10/5/2010 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Carter P, Gray LJ, Troughton J, Khunti K, Davies MJ. Fruit and vegetable intake and incidence of type 2 diabetes mellitus: systematic review and meta-analysis. BMJ. 2010;341:c4229.

    1/4/2011 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Pan A, Lucas M, Sun Q, et al. Bidirectional association between depression and type 2 diabetes mellitus in women. Arch Intern Med. 2010;170(21):1884-1891.

    5/6/2011 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Muraki I, Imamura F, Manson J, et al. Fruit consumption and risk of type 2 diabetes: results from three prospective longitudinal cohort studies. BMJ. 2013;347:f5001.

    4/14/2014 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Xi B, Li S, et al. Intake of fruit juice and incidence of type 2 diabetes: a systematic review and meta-analysis. PLoS One. 2014;9(3):e93471.

    7/21/2014 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Afshin A, Micha R, et al. Consumption of nuts and legumes and risk of incident ischemic heart disease, stroke, and diabetes: a systematic review and meta-analysis. Am J Clin Nutr. 2014;100(1):278-288.

    9/11/2014 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Tovote KA, Fleer J, Snippe E, et al. Individual mindfulness-based cognitive therapy and cognitive behavior therapy for treating depressive symptoms in patients with diabetes: results of a randomized controlled trial. Diabetes Care. 2014;37(9):2427-2434.

    9/16/2014 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113993/Diabetes-mellitus-type-2-in-adults: Zhou D, Yu H, He F, et al. Nut consumption in relation to cardiovascular disease risk and type 2 diabetes: a systematic review and meta-analysis of prospective studies. Am J Clin Nutr. 2014;100(1):270-277.

    12/14/2016 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T270053/Risk-factors-for-diabetes-mellitus-type-2: Shen HN, Yang CC, Chang YH, Lu CL, Li CY. Risk of diabetes mellitus after first-attack acute pancreatitis: a national population-based study. Am J Gastroenterol. 2015;110(12):1698-1706.

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