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TYPE 2 DIABETES
Wednesday 18 June 2008
Type 2 diabetes is sometimes described as a ‘lifestyle disease’ because it is more common in people who do insufficient physical activity and are overweight or obese. It is strongly associated with high blood pressure, high cholesterol and an ‘apple’ body shape, where excess weight is carried around the waist.
Type 2 diabetes is by far the most common form of diabetes. It affects 85 to 90 per cent of all people with diabetes. While it usually affects mature adults, younger people are also now being diagnosed in greater numbers as rates of overweight and obesity increase.Type 2 diabetes used to be called non-insulin dependent diabetes(NIDDM) or mature onset diabetes.
he body uses glucose as its main source of energy. Glucose comes from foods that contain carbohydrates. After food is digested, the glucose is released and absorbed into the bloodstream.
The glucose in the bloodstream needs to move into body tissues so that cells can use it for energy. Excess glucose is also stored in the liver or converted to fat and stored in other body tissues.
Insulin is a hormone made by the pancreas, which is a gland located just below the stomach. Insulin opens the doors (the glucose channels) that let glucose move from the blood into the body cells. This is part of a process known as glucose metabolism.
In diabetes, one of two things occurs.
The pancreas can’t make insulin (type 1 diabetes) or the cells don’t respond to the insulin properly (insulin resistance) and the pancreas produces inadequate insulin for the body’s increased needs (type 2 diabetes).
If the insulin can’t do its job, the glucose channels can’t open properly and glucose builds up in the blood. High blood glucose levels cause the health problems linked to diabetes, often referred to as complications.

Risk Factor of Type 2 Diabetes
Research don't fully understand why some people develop type 2 diabetes and others don;ts.it's clear that certain factors increase the rusk,however,including:
  • Obesity ; being overweight is a primary risk faktor for type 2 diabetes.the more fatty tissue you have,the more resistant your cells beccome to insulin.
  • Gestational Diabetes Millitus (DM during pregnancy) or large baby (over 4kg) ; if you develeop gestatioanl diabets when you are pregnant or if you gave birth to a baby weighing more than 4kg, your risk of developing type 2 diabetes later increase.
  • Family History of diabetes millitus ; if a parents or sibling has type 2 diabetes also the risk you will get type 2 diabetes.
  • Cardiovascular disease and cerebrovascular disease ; any problem in the heart is risk to get diabetes type 2 including hypertension,ischemich heart attack,peripheal vascular disease.
  • Race ; Althuogh it's unclear why,people of certain races-including blacks african-carribbean origin,hispanics and asian are more likely to develop type 2 diabetes.
  • Age ; the risk type 2 diabetes increases as you get older.especially after age 45.often,that's because people tend to exercise ,lose muscle mass and gain weight as they age.but type 2 diabetes increasing dramatically among children,adolescent ang younger adults.
  • Inactivity ; the less active you are,the greater your risk of type 2 diabets.phisical activity helps you control your weight,uses up glucose as energy and makes your cells more sensitive to insulin.
  • Pre diabetes ; when your blood sugar red limit.is mean more than normal but not enough to be idntifiead as type 2 diabetes.left untreated,prediabetes often progresses to type 2 diabetes.
Sign and Symptoms

Type 2 diabetes usually begins gradually and progresses slowly. Symptoms in adults include:

  • Excessive thirst(Polydipsia) As excess sugaf builds up in your blood stream,fluid is pulled from your tissue.this may leave you thirsty
  • Increased urination(polyuria) As a result thirsty,you may drink more.so that urinate more than usual
  • Extreme hunger(Polypagia)Without enough insulin to move sugar into your cells.your muscles and organs become depleted of energy.this triggers intense hunger thay may persisit eveb after eating.
  • Fatigue.if the cells are deprived of sugar,become tired and irritable
  • Blurred vision ig blood sugar level is too high fluid pulled from the tissue- including the lenses of eyes.this make affect ability to focus.
  • Weight loss.despite eatning more tha usual to relieve hunger,may lose weight.without energy the energy sugar supplies,muscles tissue and fat stores may simply shrink.
  • In women, vaginal yeast infections or fungal infections under the breasts or in the groin
  • Severe gum problems
  • Itching
  • Erectile dysfunction in men
  • Slow-healing sores or frequent infections.type 2 diabetes affects abilty to heal and fight infections.
  • Macrovascular complications often present.microvascular comlications may be present

Symptoms in children are often different:

  • Most children are obese or overweight
  • Increased urination is mild or even absent
  • Many children develop a skin problem called acanthosis, characterized by velvety, dark colored patches of skin
Diagnosis and testing
Usually discovered when a patient presents to the physician for some other related symptoms.Various blood tests can be used to screen for diabetes, including:
  • 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 milligrams per deciliter (mg/dL) or higher suggests diabetes.
  • Fasting blood sugar test. A blood sample will be taken after an overnight fast. A fasting blood sugar level between 70 and 100 mg/dL is normal. A fasting blood sugar level from 100 to 125 mg/dL is considered prediabetes, which indicates a high risk of developing diabetes. If it's 126 mg/dL or higher on two separate tests, you'll be diagnosed with diabetes.it is a simple blood test taken after 8 hours of fasting
  • Oral Glucose Tolerance Test(OGTT) is more complex than the FBS and may overdiagnose diabetes in people who do no have it. some expert recommend it as a follow-up after FBS. if the later test result are normal but the patient has symptoms or risk factors of diabetes.GTT prosedure : the patien first has an FBS and take again after 2 hours drinking a special glucose solution.OGTT levels are considered normal up to 140 mg/dl.pre diabetes 140-199 mg/dl and higher 200 mg/dl are diabetes.
  • Post Prandial Blood sugar (PPBS) taken after 2 hours eating
  • Glycostated Hemoglobi(HBA1C) is a form of hemoglobin used primarily to identify the avarege Plasma glucose concentration over prolonged periods of time ( within 3 months ) .HBA1C are not used for an initial diagnosis but they are usefull for determining the severity of diabetes.
Screening Tests for Complications
  • Screening for Heart Disease. All patients with diabetes should be tested for hypertension and unhealthy cholesterol and lipid levels and given an electrocardiogram. For cholesterol, people with diabetes should aim for LDL levels below 100 mg/dL, HDL levels over 50 mg/dL, and triglyceride levels below 150 mg/dL. Blood pressure goals should be 130/80 mm Hg or lower. Other tests may be needed in patients with signs of heart disease.
  • The electrocardiogram (ECG or EKG) is used extensively in the diagnosis of heart disease, from congenital heart disease in infants to myocardial infarction and myocarditis in adults. Several different types of electrocardiogram exist.
  • Screening for Kidney Damage. The earliest manifestation of kidney damage is microalbuminuria, in which tiny amounts (30 - 300 mg per day) of protein called albumin are found in the urine. About 20% of type 2 patients show evidence of microalbuminuria upon diagnosis of diabetes. (However, not all people with type 2 diabetes eventually develop kidney disease.) Microalbuminuria typically shows up in patients with type 2 diabetes who have high blood pressure.people with diabetes receive an annual microalbuminuria urine test. Patients should also have their blood creatinine tested at least once a year. Creatinine is a waste product that is removed from the blood by the kidneys. High levels of creatinine may indicate kidney damage. A doctor uses the results from a creatinine blood test to calculate the glomerular filtration rate (GFR). The GFR is an indicator of kidney function; it estimates how well the kidneys are cleansing the blood.
  • Screening for Retinopathy.patients with type 2 diabetes get an initial comprehensive eye exam by an ophthalmologist or optometrist shortly after they are diagnosed with diabetes, and once a year thereafter. (People at low risk may need follow-up exams only every 2 - 3 years.) The eye exam should include dilation to check for signs of retinal disease (retinopathy).
  • Screening for Neuropathy. All patients should be screened for nerve damage (neuropathy), including a comprehensive foot exam. Patients who lose sensation in their feet should have a foot exam every 3 - 6 months to check for ulcers or infections.
  • Screening for Thyroid Abnormalities. Thyroid function tests( TFT ) should be administered.
Dietary Goals and Exercise

Diet

The treatment goals for a diabetes diet are:
  • Achieve near-normal blood glucose levels. People with type 1 diabetes must coordinate calorie intake with medication or insulin administration, exercise, and other variables to control blood glucose levels. New forms of insulin now allow more flexibility in timing meals.
  • Protect the heart and aim for healthy lipid (cholesterol and triglyceride) levels and control of blood pressure.
  • Achieve reasonable weight. A reasonable weight is usually defined as a weight that is achievable and sustainable, rather than one that is culturally defined as desirable or ideal. Children, pregnant women, and people recovering from illness should be sure to maintain adequate calories for health.
  • Manage or prevent complications of diabetes. People with diabetes, whether type 1 or 2, are at risk for a number of medical complications, including heart and kidney disease. Dietary requirements for diabetes must take these disorders into consideration.
  • Promote overall health.

Overall Guidelines. There is no such thing as a single diabetes diet. Patients should meet with a professional dietitian to plan an individualized diet within the general guidelines that takes into consideration their own health needs.

Healthy eating habits along with good control of blood glucose are the basic goals, and several good dietary methods are available to meet them. General dietary guidelines for diabetes recommend:

  • Carbohydrates should provide 45 - 65% of total daily calories. The type and amount of carbohydrate are both important. Best choices are vegetables, fruits, beans, and whole grains. These foods are also high in fiber. Patients with diabetes should monitor their carbohydrate intake either through carbohydrate counting or meal planning exchange lists.
  • Fats should provide 25 - 35% of daily calories. Monounsaturated (olive, peanut, and canola oils; avocados; nuts) and omega-3 polyunsaturated (fish, flaxseed oil, and walnuts) fats are the best types. Limit saturated fat (red meat, butter) to less than 7% of daily calories. Choose nonfat or low-fat dairy instead of whole milk products. Limit trans-fats (hydrogenated fat found in snack foods, fried foods, commercially baked goods) to less than 1% of total calories.
  • Protein should provide 12 - 20% of daily calories, although this may vary depending on a patient’s individual health requirements. Patients with kidney disease should limit protein intake to less than 10% of calories. Fish, soy, and poultry are better protein choices than red meat.

Weight Management

Being overweight is the number one risk factor for type 2 diabetes. Even modest weight loss can help prevent type 2 diabetes from developing. It can also help control or even stop progression of type 2 diabetes in people with the condition and reduce risk factors for heart disease. Patients should lose weight if their body mass index (BMI) is 25 - 29 (overweight) or higher (obese).

The American Diabetes Association recommends that patients aim for a small but consistent weight loss of ½ - 1 pound per week. Most patients should follow a diet that supplies at least 1,000 - 1,200 kcal/day for women and 1,200 - 1,600 kcal/day for men.

Unfortunately, not only is weight loss difficult to sustain, but many of the oral medications used in type 2 diabetes cause weight gain as a side effect. For obese patients who cannot control weight using dietary measures alone, weight-loss drugs, such as orlistat (Xenical) or sibutramine (Meridia), may be helpful. Orlistat may have specific benefits for people with diabetes. It may not only help achieve weight but also improve glucose, cholesterol, and lipid levels. In 2007, the FDA approved a non-prescription form of orlistat (alli). [For more information, see In-Depth Report #53: Obesity.]

Exercise

Sedentary habits, especially watching TV, are associated with significantly higher risks for obesity and type 2 diabetes. Regular exercise, even of moderate intensity (such as brisk walking), improves insulin sensitivity and may play a significant role in preventing type 2 diabetes -- regardless of weight loss. An important study reported a 58% lower risk for type 2 diabetes in adults who performed moderate exercise for as little as 2.5 hours a week.

Aerobic Exercise. Aerobic exercise has significant and particular benefits for people with diabetes. Regular aerobic exercise, even of moderate intensity, improves insulin sensitivity. People with diabetes are at particular risk for heart disease, so the heart-protective effects of aerobic exercise are especially important. Moderate exercise protects the heart in people with type 2 diabetes, even if they have no risk factors for heart disease other than diabetes itself.

For improving glycemic control, the American Diabetes Association recommends at least 150 minutes per week of moderate-intensity physical activity (50 - 70% of maximum heart rate) or at least 90 minutes per week of vigorous aerobic exercise (more than 70% of maximum heart rate). Exercise at least 3 days a week, and do not go more than 2 consecutive days without physical activity.

Strength Training. Strength training, which increases muscle and reduces fat, is also helpful for people with diabetes who are able to do this type of exercise. The American Diabetes Association recommends performing resistance exercise three times a week. Build up to three sets of 8 - 10 repetitions using weight that you cannot lift more than 8 - 10 times without developing fatigue. Be sure that your strength training targets all of the major muscle groups.

Exercise Precautions. The following are precautions for all people with diabetes, both type 1 and type 2:

  • Because people with diabetes are at higher than average risk for heart disease, they should always check with their doctors before undertaking vigorous exercise. For fastest results, frequent high-intensity (not high-impact) exercises are best for people who are cleared by their doctors. For people who have been sedentary or have other medical problems, lower-intensity exercises are recommended.
  • Strenuous strength training or high-impact exercise is not recommended for people with uncontrolled diabetes. Such exercises can strain weakened blood vessels in the eyes of patients with retinopathy. High-impact exercise may also injure blood vessels in the feet.

Patients who are taking medications that lower blood glucose, particularly insulin, should take special precautions before embarking on a workout program:

  • Monitor glucose levels before, during, and after workouts (glucose levels swing dramatically during exercise).
  • Avoid exercise if glucose levels are above 300 mg/dL or under 100 mg/dL.
  • Inject insulin in sites away from the muscles used during exercise; this can help avoid hypoglycemia.
  • Drink plenty of fluids before and during exercise; avoid alcohol, which increases the risk of hypoglycemia.
  • Insulin-dependent athletes may need to decrease insulin doses or take in more carbohydrates prior to exercise, but may need to take an extra dose of insulin after exercise (stress hormones released during exercise may increase blood glucose levels).
  • Wear good, protective footwear to help avoid injuries and wounds to the feet.
  • Some blood pressure drugs can interfere with exercise capacity. Patients who use blood pressure medication should talk to their doctors about how to balance medications and exercise. Patients with high blood pressure should also aim to breathe as normally as possible during exercise. Holding the breath can increase blood pressure
Treatment

Pre-diabetes precedes the onset of type 2 diabetes. People who have pre-diabetes have fasting blood glucose levels that are 100 - 125 mg/dL -- higher than normal, but not yet high enough to be classified as diabetes. (Pre-diabetes used to be referred to as “impaired glucose tolerance.”) Pre-diabetes greatly increases the risk for diabetes.

Treatment of pre-diabetes is very important. Research shows that lifestyle and medical interventions can help prevent, or at least delay, the progression to diabetes. While doctors sometimes prescribe insulin-regulating drugs such as metformin (Glucophage) and acarbose (Precose), evidence indicates that lifestyle changes can be at least as effective as drug therapy. The most important lifestyle treatment for people with pre-diabetes is to lose weight through diet and regular exercise. Even a modest weight loss of 10 - 15 pounds can significantly reduce the risk of progressing to diabetes.

Because people with pre-diabetes have a higher risk for heart disease and stroke, diet and exercise are also very important for heart health, as is quitting smoking. It is also important to have your doctor check your cholesterol and blood pressure levels on a regular basis. Your doctor should also check your fasting blood glucose levels every 1 - 2 years.

The major treatment goals for people with type 2 diabetes are:

  • Treat all conditions that place patients at risk for heart disease and stroke, the major killers of people with type 2 diabetes.
  • Control blood glucose levels. The goal is to achieve fasting blood glucose levels of less than 110 mg/dL and glycosylated hemoglobin (HbA1c) levels of less than 7%. The objective is to reduce complications in small blood vessels and the nerve damage associated with diabetes.
  • In general, most people with type 2 diabetes should aim for HbA1c levels of less than 7%. However, patients who have heart disease or cardiovascular risk factors should talk to their doctor about individualized treatment goals for intensive blood sugar control.

An intensive multi-pronged approach is critical for reducing complications and improving survival rates in patients with diabetes. Intensive therapy includes:

  • Healthy lifestyle changes: Regular exercise, heart-healthy diet, quitting smoking.
  • Controlling blood sugar levels. Monitor blood sugar and hemoglobin HbA1c levels. Oral anti-hyperglycemic drugs such as metformin are first-line drug treatments. Insulin may eventually be needed.
  • Heart-protective drugs. These medications include various drugs to control high blood pressure (such as ACE inhibitors and diuretics) and cholesterol (statins and fibrates). Controlling high blood pressure is a proven factor in reducing mortality rates. Aspirin helps prevent blood clots and heart attack.
Aim:
  • glycemic control trough a combination of accurate monituring,diet, exercise,oral medicine and or insulin therapy
  • HBA1C less than 7 %
  • Cholesterol less than 4 mmol/L
  • HDL-C more than 1 mmol/L
  • LDL-C less than 2 mmol?L
  • Triglycerides less than 1.5 mmol/L
Medication

Many anti-hyperglycemic drugs are available to help patients with type 2 diabetes control their blood sugar levels. Most of these drugs are aimed at using or increasing sensitivity to the patient's own natural stores of insulin. Metformin is the only drug to date that achieves lower mortality rates.

For the most part older oral hypoglycemic drugs -- such as metformin and sulfonylureas -- are less expensive than, and work as well as, newer diabetes drugs. They are generally recommended as first-line drugs to use. Metformin is a safe and effective drug because it does not cause weight gain or too-low blood sugar. Metformin can also help lower LDL (“bad”) cholesterol.

In general, these drugs will reduce hemoglobin A1c levels by 1 - 2%. Adding a second oral hypoglycemic is generally recommended if inadequate control is not achieved with the first medication. For the most part, doctors should add a second drug rather than trying to push the first drug dosage to the highest levels.






 
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