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Type II Diabetes
WHAT IS TYPE II DIABETES?
WHAT CAUSES TYPE ll DIABETES?
WHO GETS TYPE ll DIABETES?
DIABETES IN THE PREGNANT WOMAN (Gestational Diabetes)
OTHER MEDICAL CONDITIONS
WHAT ARE THE SYMPTOMS OF TYPE ll DIABETES?
WHAT ARE THE EMERGENCY CONDITIONS ASSOCIATED WITH TYPE ll DIABETES?
DIABETIC KETOACIDOSIS (DKA)
WHAT ARE THE DIAGNOSTIC TESTS FOR TYPE ll DIABETES?
WHAT ARE THE GUIDELINES FOR TREATING TYPE 2 DIABETES?
WHAT ARE THE LIFESTYLE MEASURES FOR TREATING AND PREVENTING TYPE ll DIABETES?
WHAT IS TYPE II DIABETES?
Type ll Diabetes, or Non-Insulin Dependent Diabetes Mellitus (NIDDM), is the most common form of Diabetes. While Type 1 or Insulin-Dependent Diabetes typically becomes evident in childhood and is due to an inborn lack or complete absence of insulin production, Type ll Diabetes typically becomes evident in adulthood and is significantly due to the patient's lifestyle. Of all diabetics, 85% to 90% are Type ll. In many countries, the incidence of Type ll Diabetes has been rising sharply in recent decades, while the average age of onset has been declining. Type ll Diabetes affects more than 17 million people in North America, over 20 million in Latin America and over 150 million worldwide.
The following information is supplied by the American Diabetic Association
TYPE ll DIABETES
The two major forms of diabetes are type 1 (previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes) and type ll (previously called noninsulin-dependent diabetes mellitus (NIDDM) or maturity-onset diabetes).
Both diabetes type 1 and type ll share one central feature: elevated blood sugar ( glucose) levels due to absolute or relative insufficiencies of insulin, a hormone produced by the pancreas. Insulin is a key regulator of the body's metabolism. It normally works in the following way:
During and immediately after a meal the process of digestion breaks carbohydrates down into sugar molecules (of which glucose is one) and proteins into amino acids.
Right after the meal, glucose and amino acids are absorbed directly into the bloodstream, and blood glucose levels rise sharply. (Glucose levels after a meal are called postprandial levels.)
The rise in blood glucose levels signals important cells in the pancreas, called beta cells , to secrete insulin, which pours into the bloodstream. Within ten minutes after a meal insulin rises to its peak level.
Insulin then enables glucose and amino acids to enter cells in the body, particularly muscle and liver cells. Here, insulin and other hormones direct whether these nutrients will be burned for energy or stored for future use. (It should be noted that the brain and nervous system are not dependent on insulin; they regulate their glucose needs through other mechanisms.)
When insulin levels are high, the liver stops producing glucose and stores it in other forms until the body needs it again.
As blood glucose levels reach their peak, the pancreas reduces the production of insulin.
About two to four hours after a meal both blood glucose and insulin are at low levels, with insulin being slightly higher. The blood glucose levels are then referred to as fasting blood glucose concentrations .
TYPE II DIABETES
Type ll diabetes is most common form of diabetes, accounting for 90% of cases. An estimated 17 million Americans have type ll diabetes and half are unaware they have it. The disease mechanisms in type ll diabetes are not wholly known, but some experts suggest that it may involve the following three stages in most patients:
The first stage in type ll diabetes is the condition called insulin resistance; although insulin can attach normally to receptors on liver and muscle cells, certain mechanisms prevent insulin from moving glucose (blood sugar) into these cells where it can be used. Most type ll diabetics produce variable, even normal or high, amounts of insulin, and in the beginning this amount is usually sufficient to overcome such resistance.
Over time, the pancreas becomes unable to produce enough insulin to overcome resistance. In type ll diabetes the initial effect of this stage is usually an abnormal rise in blood sugar right after a meal (called postprandial hyperglycemia ). This effect is now believed to be particularly damaging to the body.
Eventually, the cycle of elevated glucose further impairs and possibly destroys beta cells, thereby stopping insulin production completely and causing full-blown diabetes. This is made evident by fasting hyperglycemia , in which elevated glucose levels are present most of the time.
TYPE I DIABETES
In type 1 diabetes, the disease process is more severe and onset is usually in childhood:
Beta-cells in the pancreas that produce insulin are gradually destroyed. Eventually insulin deficiency is absolute.
Without insulin to move glucose into cells, blood glucose levels become excessively high, a condition known as hyperglycemia.
Because the body cannot utilize the sugar, it spills over into the urine and is lost.
Weakness, weight loss, and excessive hunger and thirst are among the consequences of this "starvation in the midst of plenty."
Patients become dependent on administered insulin for survival.
DIABETES SECONDARY TO OTHER CONDITIONS
Conditions that damage or destroy the pancreas, such as pancreatitis, pancreatic surgery, or certain industrial chemicals can cause diabetes. Polycystic ovaries are highly associated with diabetes. Certain drugs can also cause temporary diabetes, including corticosteroids, beta-blockers, and phenytoin. Rare genetic disorders (Klinefelter's syndrome, Huntington's chorea, Wolfram's syndrome, leprechaunism, Rabson-Mendenhall syndrome, lipoatrophic diabetes, and others) and hormonal disorders (acromegaly, Cushing's syndrome, pheochromocytoma, hyperthyroidism, somatostatinoma, aldosteronoma) are associated with or increase the risk for diabetes.
WHAT CAUSES TYPE ll DIABETES?
Type ll diabetes is caused by a complicated interplay of genes, environment, insulin abnormalities (reduced insulin secretion in the beta cells and insulin resistance in muscle cells), increased glucose production in the liver, increased fat breakdown, and possibly defective hormonal secretions in the intestine. The recent dramatic increase indicates that lifestyle factors (obesity and sedentary lifestyle) may be particularly strong in releasing the genetic elements that cause this type of diabetes.
CAUSES OF INSULIN RESISTANCE
The characteristic feature of diabetes type ll is the body's resistance to the actions of insulin. In many people, before diabetes develops, normal or even excessive levels of insulin compensate for this resistance. Over time however, insulin production often drops and resistance worsens. Researchers are trying to determine why these events occur.
Elevated levels of free fatty acids and the hormones resistin and leptin have been associated with insulin resistance at different phases. Such factors are also present in obesity. It is not known yet if elevated levels are simply a product of obesity or play some causal role in diabetes.
Some researchers suggest that proteins called calpains may play an important role in both insulin secretion and insulin action.
Elevated growth hormone during puberty appears to increase the risk for insulin resistance in overweight adolescents.
Some experts theorize that abnormal regulation of certain important peptides (amylin and CGRP) may occur, thus affecting both the nervous and circulatory systems. One effect is to alter blood flow, which may contribute to insulin resistance. How each of these factors contributes to type ll diabetes is under investigation.
One 2001 study found high levels of interleukin 6 (IL-6) and C-reactive protein (CRP) in people with diabetes. Both of these substances are markers for inflammation and damage caused by an over-active immune response. Some researchers believe such inflammation may contribute to the disease process leading to diabetes.
Genetic factors play an important role in type ll diabetes, but the pattern is complicated, since both impairment of beta-cell function and an abnormal response to insulin are involved. Researchers have identified a number of genetic suspects:
Researchers have identified genes responsible for maturity-onset diabetes in youth (MODY), a rare genetic form of type ll diabetes that develops only in Caucasian teenagers. (It should be noted that this is not the diabetes associated with obesity that is now being seen increasingly in young people.)
Some research is now investigating genes that may be responsible for inherited cases of type 2 diabetes in middle-aged Caucasians.
A defective fatty-acid binding protein 2 (FABP2) gene may result in higher levels of unhealthy fat molecules (particularly triglycerides), which may be critical in the link between obesity and insulin resistance in some people with diabetes type ll.
A defective lipoprotein lipase (LpL) gene may pose a risk for coronary artery disease and type ll diabetes in people who have it.
Variations in a gene that regulates a protein called calpain-10 is proving to affect insulin secretion and action and may play a role in diabetes type ll. There is some disagreement, however, about its significance.
Defective genes that regulate a molecule called peroxisome proliferator-activated receptor (PPAR) gamma may contribute to both type ll diabetes and high blood pressure in some patients.
A defective gene has been detected that reduces activity of a protective substance called beta 3-adrenergic receptor, which is found in visceral fat cells (those occurring around the abdominal region). The result is a slow-down in metabolism and an increase in obesity. The defective gene has been found in Pima Indians and other populations with a very high incidence of type ll diabetes and obesity.
The Thrifty Gene. One theory suggests that some cases of type ll diabetes and obesity are derived from normal genetic actions that were once important for survival. Some experts postulate the existence of a so-called "thrifty" gene, which regulates hormonal fluctuations to accommodate seasonal changes. In certain nomadic populations, hormones are released during seasons when food supplies have traditionally been low, which results in resistance to insulin and efficient fat storage. The process is reversed in seasons when food is readily available. Because modern industrialization has made high-carbohydrate and fatty foods available all year long, the gene no longer serves a useful function and is now harmful because fat, originally stored for famine situations, is not used up. Such a theory could help explain the high incidence of type ll diabetes and obesity found in Pima tribes and other Native American tribes with nomadic histories and Western dietary habits. It is also used to explain the relationship between low birth weight and future diabetes in Pima tribes: poor nutrition in fetuses or infants cause changes that reduce insulin sensitivity so that fat storage increases, leading to later obesity and diabetes.
WHO GETS TYPE ll DIABETES?
Diabetes type ll affects at least 17 million Americans, and the incidence is sharply rising. A major 2000 US study reported that the prevalence of type ll diabetes increased by one-third between 1990 and 1998 and the biggest increase (70%) was among young adults in their 30s. Type ll diabetes typically has developed after the age of 40. In 1999 alone it rose by 6% overall with an increase of 10% in African Americans. The primary reason for this dramatic increase appears to be the parallel increase in obesity. And as more and more cultures adopt Western dietary habits, it is likely that diabetes type ll will reach epidemic proportions throughout the world.
DIABETES IN CHILDREN AND ADOLESCENTS
Until recently, diabetes in children was almost always type 1 (an autoimmune disease). Of major concern, however, are estimates that between 8% and 45% of new diabetes cases in children are type ll. (The significant differences in estimates are due to the difficulties in detecting the disease in children.) It is evident that diabetes is on the increase, not only in the US but also in other nations, including Europe and Japan. Diabetes is usually recognized in children who are in middle to late puberty. It most often occurs in girls and children who are overweight.
LOW BIRTH WEIGHT
Research now indicates that low birth weight is a risk factor for type ll diabetes. Some research indicates that malnutrition in the pregnant woman may be responsible for causing metabolic abnormalities in the developing fetus that eventually lead to diabetes.
In a 2001 study of nearly 85,000 nurses, obesity was the number one risk factor for diabetes type ll. It is estimated that 80% to 95% of the current dramatic increases in type ll diabetes is due to obesity and having excess fat in the abdominal region. Excess body fat appears to play a strong role in insulin resistance, but the way the fat is distributed is also significant. Weight concentrated around the abdomen and in the upper part of the body (apple-shaped) is associated with insulin resistance and diabetes, heart disease, high blood pressure, stroke, and unhealthy cholesterol levels. Fat that settles in a "pear-shape" around the hips and flank appears to have a lower association with these conditions. One study suggested that waist circumferences greater than 35 inches in women and 40 inches in men signify increased risk for heart disease and diabetes.
Of note, however, obesity does not explain all cases of diabetes type ll, which is also common among people in countries where weights tend to be low, such as Asia or India.
Between 25% to 33% of all type ll patients have family members with diabetes. Having a first-degree relative with the disease poses a 40% risk of developing diabetes. One study reported that people with positive family histories have a higher risk for developing the disease at an earlier stage with more severe features.
Because families share many lifestyle features (eating and exercise habits) it is difficult to determine when genetics or environment play the major role. When clusters of diabetes type 1 and ll appear within families, genetic factors should be strongly suspected. Interestingly, one study reported that type ll patients who had relatives with type 1 and type 2 diabetes tended to need insulin therapy but also had lower risks for heart disease than patients with only a type ll family history.
The risk for type ll diabetes varies among population groups. Diabetes also seems to pose higher or lower risks for specific complications among ethnic groups. Genetic, socioeconomic factors, or both seem to be involved in ethnic differences.
African Americans. A 2000 study reported that African American men have one and a half times the risk of developing type ll diabetes and African American women have twice the risk as their Caucasian peers. An earlier 1999 study also found that African Americans with diabetes are also at higher risk for amputations than diabetic Caucasians, which is most likely due to a higher incidence of high blood pressure and smoking as well as poorer health care. Genetic factors also play a role. For example, there is some evidence that African Americans have insulin abnormalities unrelated to dietary or other factors.
Native Americans. The Pima tribe in Arizona has an incidence of type ll diabetes that is 19 times higher than that of the white population. The risk for diabetic complications among young Pima adults is also very high. Other Native American tribes in North America are also at high risk for type ll diabetes. The association between diet and diabetes among this population remains critical, however, in assessing these ethnic differences. In one study, Pimas who lived in Mexico exercised more and ate less fat (but consumed more calories) than Pima tribes in Arizona. The incidence of diabetes in their Arizona Pima relatives was about 50%, while it was only 6% in the Mexican Pima tribes (about the same as their non-Pima neighbors).
Hispanic Americans. The rate of type ll diabetes is also very high among Mexican Americans, approximately double that for Caucasians.
Maturity-Onset Diabetes in Caucasian Youth. Maturity-onset diabetes in youth (MODY) is a rare genetic form of type ll diabetes that develops only in Caucasian teenagers. It accounts for 2% to 5% of type ll cases. (It should be noted that this is not the diabetes associated with obesity that is now being seen increasingly in young people, including Caucasians.)
DIABETES IN THE PREGNANT WOMAN (GESTATIONAL DIABETES)
An estimated 5% of pregnant women develop a form of type ll diabetes, usually temporary, in their third trimester called gestational diabetes.
Gestational diabetes is a diabetic condition (nearly always temporary) that develops during the third trimester. After delivery, blood glucose levels generally return to normal, although between one-third and one-half of these women develop type ll diabetes within 10 years.
Who Gets Gestational Diabetes?
Estimates for the prevalence of gestational diabetes are generally about 4%. Some studies, however, have suggested significantly higher rates. For example in one German study, 13% of pregnant women were diagnosed with this form of diabetes, including many who did not have any risk factors.
Risk factors include the following:
- Even modest weight gain (11 to 22 pounds) during early adulthood.
- Family history of diabetes.
- Belonging to African American, Hispanic, or Asian ethnic groups.
- Gaining weight before getting pregnant.
- Being an older mother.
It should be noted that some studies suggest that women who develop gestational diabetes during pregnancy and take progestin-only contraceptives while breast feeding are at high risk for developing full-blown type ll diabetes.
Who Should be Tested for Gestational Diabetes?
A number of expert groups now recommend that nearly all pregnant women be tested for gestational diabetes between their 24th and 28th week. Pregnant women at high risk for diabetes should be tested earlier. The only women who do not need to be tested are those at very low risk. Generally they have the following characteristics:
- Under 25 years old.
- Normal weight.
- No first-degree relatives with diabetes.
- Not belonging to the following ethnic groups: Native American, Hispanic, Asian or African-American.
How Serious Is Diabetes in the Pregnant Patient?
Because glucose crosses the placenta, a woman with diabetes can pass high levels of blood glucose to the fetus. In response, the fetus secretes high level of insulin. Studies indicate that such conditions may effect the developing fetus as soon as it is conceived, placing the unborn child at risk for the following:
- Birth defects.
- Excessive growth of the fetus.
- Delayed lung development.
- Possibly a higher risk for future diabetes and obesity in the child.
In addition to endangering the fetus, diabetes also presents risks to the pregnant woman.
In one German study, 25% of women with gestational diabetes required a cesarean section. (The non-diabetic rate in the study was also high however, 19.6%.)
The most serious potential complications from diabetes are high blood pressure and preeclampsia, a potentially dangerous condition. In one study blood pressure was abnormally high in 6.5% of women with gestational diabetes compared to 1.7% of pregnant women without diabetes. (It should be noted that one study suggested that mortality rates in the pregnant women with gestational diabetes vary widely, and normal rates have been reported in some countries, suggesting that good prenatal care can be fully protective.)
How Is Gestational Diabetes Managed?
Some suggestions for preventing complications include the following:
In most cases, increases in glucose levels can be managed with diet and exercise. Aerobic exercise before and during pregnancy may lower glucose levels and may be protective for women at risk or who have gestational diabetes. (Any pregnant woman should check with her physician before embarking on a vigorous exercise regimen.)
If a woman with gestational diabetes cannot keep her glucose under control with life-style measures, then she usually is given insulin.
Oral sulfonylureas, which are standard agents in type ll diabetes, have not been routinely prescribed because of a higher risk for birth defects and severe hypoglycemia in the newborn. Studies suggest that newer sulfonylurea agents, such as glyburide, however, may be effective and safe alternatives to insulin.
OTHER MEDICAL CONDITIONS
Sleep Loss. Some interesting research suggests that people who do not sleep enough (six hours or less a night) are at higher risk for obesity and ineffective use of insulin, possibly putting them at risk for diabetes.
Polycystic Ovary Syndrome. Polycystic ovary syndrome (PCO) is a condition that affects about 6% of women and results in the ovarian production of high amounts of androgens (male hormones), particularly testosterone. It appears to be an important cause of many menstrual disorders. Women with PCO are at higher risk for insulin resistance, and about half of PCO patients also have diabetes.
Hepatitis C. Patients with hepatitis C appear to have a higher incidence of diabetes type ll.
Peridontal Disease. Some research has found an association between peridontal disease and diabetes type ll. Bacteria that cause peridontal disease may enter the bloodstream and activate immune cells that produce an inflammatory response. Theoretically, this response could damage cells responsible for insulin production in the pancreas, thereby triggering diabetes type ll. More research is needed.
WHAT ARE THE SYMPTOMS OF TYPE ll DIABETES?
Type ll diabetes usually begins gradually and progresses slowly. Symptoms in adults include the following:
- Excessive thirst.
- Increased urination.
- Blurred vision.
- Weight loss.
- In women, vaginal yeast infections or fungal infections under the breasts or in the groin.
- Severe gum problems.
- Impotence in men.
- Unusual sensations, such as tingling or burning, in the extremities.
Symptoms in children are often different:
- Most children are obese or overweight.
- Increased urination is mild or even absent.
- Many develop a skin problem called acanthosis, which is characterized by velvety, dark colored patches of skin.
WHAT ARE THE EMERGENCY CONDITIONS ASSOCIATED WITH TYPE ll DIABETES?
People with diabetes who need to intensively control glucose levels are at risk for hypoglycemia (also called insulin shock). The condition develops if blood glucose levels fall below normal and may also be caused by insufficient intake of food , excess exercise , or alcohol intake. Usually the condition is manageable, but occasionally, it can be severe or even life threatening, particularly if the patient fails to recognize the symptoms. Mild hypoglycemia is common among people with type ll diabetes, but severe episodes are rare, even among those who are taking insulin. Still, all patients who are intensively controlling glucose levels should be aware of warning symptoms.
Risk Factors for Severe Hypoglycemia. People at highest risk for severe hypoglycemia are those who intensively control blood glucose and also have one or more of the following conditions:
- Long-term diabetes.
- Less education on their condition.
- A previous history of severe hypoglycemia.
- Hypoglycemia unawareness. This is a condition in which people become insensitive to hypoglycemic symptoms. It affects about 25% of those who use insulin, nearly always type 1 diabetics. In such cases, hypoglycemia appears suddenly, without warning, and can escalate to a severe level. Even a single recent episode of hypoglycemia may make it more difficult to detect the next episode. With vigilant monitoring and by rigorously avoiding low blood glucose levels, such patients can often regain the ability to sense the symptoms. It is important to note that even very careful testing may fail to detect a problem, particularly one that occurs during sleep.
Symptoms. Mild symptoms usually occur at moderately low and easily correctable levels of blood glucose. They include the following:
- Rapid heartbeat.
Severely low blood glucose levels can precipitate neurologic symptoms:
- In rare and worst cases, coma, seizure, and death.
Preventive Measures. The following tips may help avoid hypoglycemia or prepare for attacks.
- Patients are at highest risk for hypoglycemia at night. Bedtime snacks may be helpful.
- Patients who intensively control their blood sugar should monitor blood levels as often as possible, four times or more per day. This is particularly important for patients with hypoglycemia unawareness.
- In adults, it is also particularly critical to monitor blood glucose levels before driving, when hypoglycemia can be very hazardous.
- Diabetic patients on therapies that put them at risk for hypoglycemia should always carry hard candy, juice, sugar packets, or commercially available glucose substitutes designed for diabetic individuals.
Family and friends should be aware of the symptoms and be prepared:
- If the patient is helpless (but not unconscious), family or friends should administer three to five pieces of hard candy, two to three packets of sugar, half a cup (four ounces) of fruit juice, or a commercially-available glucose solution for diabetics.
- If there is inadequate response within 15 minutes, additional oral sugar should be provided or the patient should receive emergency medical treatment including the intravenous administration of glucose.
- Family members and friends can learn to inject glucagon, a hormone, which, in contrast to insulin, raises blood glucose.
Diabetic Ketoacidosis (DKA)
Diabetic ketoacidosis (DKA) is a life-threatening complication that is caused by insulin depletion. Until recently, it has been a complication almost exclusively of type 1 diabetes. In such cases, it is nearly always due to noncompliance with insulin treatments. However, DKA is being reported increasingly in type ll diabetes, especially among Hispanic and African Americans. It is not clear, however, what causes total insulin depletion in these patients. Research is needed to find which individuals are at particular risk.
Diabetic ketoacidosis often develop as follows:
- The process is usually triggered in insulin-deficient patients by a stressful event, most often pneumonia or urinary tract infections. Other triggers include alcohol abuse, physical injury, pulmonary embolism, heart attacks, or other illnesses.
- Severely low insulin levels cause excessive amounts of glucose in the bloodstream (hypergycemia).
- Fat breakdown then accelerates and increases the production of fatty acids.
- These fatty acids are converted into chemicals called ketone bodies, which are toxic at high levels.
Symptoms and complications include the following:
- Nausea and vomiting.
- Breathing may be abnormally deep and rapid with frequent sighing.
- The heartbeat may be rapid.
- If the condition persists, coma and, eventually, death, may occur, although over the past 20 years, death from DKA has decreased to about 2% of all cases.
- Other serious complications from DKA include aspiration pneumonia and adult respiratory distress syndrome.
Life-saving treatment employs rapid rehydration using a saline solution followed by low-dose insulin and potassium replacement.
WHAT ARE THE DIAGNOSTIC TESTS FOR TYPE ll DIABETES?
Experts now recommend that everyone over age 45 be tested regularly for diabetes. Younger adults should be tested who have the following conditions:
- A weight that is 20% more than ideal body weight.
- High blood pressure.
- Low HDL cholesterol levels (under 35 mg/dl) and high triglyceride levels (over 250 mg/dl).
- A close relative with diabetes.
- A high-risk ethnic group background.
- Delivered a baby weighing over nine pounds.
- A history of gestational diabetes.
Some experts recommend that any child over 10 should be tested for type ll diabetes (even if they have no symptoms), if they are overweight and have at least two of the above mentioned risk factors. It should be noted that children who have symptoms of diabetes are usually diagnosed with type 1. This is of particular concern given the rise in childhood type 2 diabetes, and some centers report a misdiagnosis in 25% of cases.
Testing for Diabetes
Fasting Plasma Glucose. In order to simplify the diagnosis of diabetes, the American Diabetes Association has recommended the sole use of the fasting plasma glucose (FPG)(Fasting Plasma Glucose) test. It is a simple blood test taken after eight hours of fasting. In general results indicate the following:
- FPG (Fasting Plasma Glucose) levels are considered normal up to 110 mg/dl (or 6.1 mmol/L).
- Levels between 110 and 125 (6.1 to 6.9 mmol/L) are referred to as impaired fasting glucose. They are only slightly above normal but are considered to be risk factors for diabetes type ll and its complications.
- Diabetes is diagnosed when FPG levels are 126 mg/dl (7.0 mmol/L) or higher on two different days.
The FPG (Fasting Plasma Glucose) test is not always reliable and there is considerable controversy about using it as the sole basis for diagnosing diabetes. Arguments against its sole use are the following:
- Some experts argue that the 126 mg/dl cut-off causes many people to be diagnosed with diabetes type ll who are only at very small risk for actual complications.
- On the other hand, the test may show normal results in many people who are still at risk for diabetes. For example, people who take the test in the afternoon and show normal results may have abnormal (and more accurate) levels if they are tested in the morning.
- It is it not as useful as the glucose tolerance test for predicting people at high risk for diabetes, heart disease or death, nor is it as useful as the glycated hemoglobin test for identifying people with diabetes at risk for severe complications.
- Some research indicates that the FPG (Fasting Plasma Glucose) is not as accurate as the glucose tolerance test for detecting diabetes in specific groups (eg, women with a history of gestational diabetes or certain Asian populations.)
At this time, even if a person has normal FPG (Fasting Plasma Glucose) levels but still has symptoms of diabetes and a family history or other risk factors, then diabetes should not be ruled out and a glucose tolerance test should also be performed.
Glucose Tolerance Test. A glucose tolerance test uses the following procedures:
- It first employs an FPG (Fasting Plasma Glucose) test.
- A blood test is then taken two hours later after drinking a special glucose solution.
The following results suggest different conditions:
- In people without diabetes, blood sugar increases modestly after drinking the glucose beverage and decreases after two hours.
- In diabetes, the initial increase is significant and the level remains high, 200 mg/dL (11.1 mmol/L) or more.
- Measurements that fall between 7.8 and below 11.1 mmol/l puts a person at risk for diabetes and are referred to as impaired glucose tolerance . This condition is now strongly associated with a high risk for future diabetes and a higher than average risk for heart disease and poorer survival rates. (Studies suggest it is a much stronger predictor of diabetes than impaired fasting glucose. See Above.)
Test for Glycated Hemoglobin. Another test examines blood levels glycated hemoglobin , also known as hemoglobin A1c (HbA1c). Measuring glycated hemoglobin is not currently used for an initial diagnosis, but it may be useful for determining the severity of diabetes. Some experts think it should be used to help predict complications in people who have FPG levels between 110 and 139, which are above normal but do not indicate full-blown diabetes.
The basis for its use as a diagnostic measurement in diabetes is as follows:
- Hemoglobin is a protein molecule found in red blood cells. When glucose binds to it, the hemoglobin becomes modified, a process called glycosylation.
- Glycosylation affects a number of proteins, and elevated levels of glycolated hemoglobin is strongly associated with complications of diabetes.
- A glycated hemoglobin level of 1% above normal range identifies diabetes in 98% of patients. Normal HbA1c levels do not necessarily rule out diabetes, but if diabetes is present and levels are normal, the risk for complications is low.
The test is not affected by food intake so it can be taken at any time. A home test has been developed that might make it easier to measure HbA1c. In general, measurements suggest the following:
- Normal HbA1c levels should be below 7%.
- Levels of 11% to 12% glycolated hemoglobin indicate poor control of carbohydrates. High levels are also markers for kidney trouble.
- for Insulin Resistance. Investigators hope that some day a simple test for insulin resistance will be available that will be able to identify people at risk for diabetes. Some research suggests that measuring insulin and triglyceride levels during a fasting period may predict a person's sensitivity to insulin.
Screening Tests for Complications
Screening for Heart Disease. All patients should be tested for hypertension and unhealthy cholesterol and lipid levels and given an electrocardiogram. Other tests may be warranted in patients with signs of heart disease.
Screening for Kidney Damage. The earliest manifestation of kidney damage is microalbuminuria, in which tiny amounts (30 to 299 mg per day) of protein called albumin are found in the urine. About 20% of type ll patients show evidence of microalbuminuria upon diagnosis of diabetes. It should be noted, however, that only a small percentage of type ll diabetics eventually develop kidney disease. Microalbuminuria is also a marker for other complications involving blood vessel abnormalities, including heart attack and stroke.
Screening for Thyroid Abnormalities. Thyroid function tests should be administered.
WHAT ARE THE GUIDELINES FOR TREATING TYPE 2 DIABETES?
General Guidelines for Treatments
Treatment for type ll diabetes generally follows certain stages that depend on the amount of residual insulin and ability to control blood glucose levels:
- Healthy lifestyle habits are the cornerstone of diabetes treatment. A healthy diet, weight control, and exercise are essential for any treatment program. Many type ll diabetics can control their condition with diet and exercise alone for years.
- If they cannot, then medication is introduced. Most often a single oral agent that stimulates or preserves any residual insulin is the first choice. (Some physicians are recommending a very aggressive initial approach for newly-diagnosed patients who have type ll diabetes. Knowing that many patients have had diabetes for years prior to diagnosis, these physicians believe that physicians should not wait to initiate treatment with one or more medications.)
- Some patients may be able to control their glucose levels with a single drug. One study reported, however, that after three years, half of the patients needed more than one agent, and at nine years, only 25% could remain on a single drug. In fact, according to a 1999 survey, 90% of diabetes specialists reported that they prescribed three or more medications for their patients.
- Eventually, natural insulin may completely fail; in such cases patients then require insulin replacement. Some people may even need to start off with insulin. Such patients may include those with severe hyperglycemia, those with signs of autoimmune diabetes, and women during pregnancy.
Treatment Goals and Intensive Control of Blood Glucose Levels
Major studies have now reported that, as in type 1 patients, rigorous control of blood glucose levels can help reduce the risk for complications in type ll diabetics, including retinopathy, kidney and nerve damage. Even short-term control of blood glucose may improve their quality of life. (It may also help prevent impotence in men. )
It is not clear, however, if controlling blood glucose has any major benefits on the heart, and heart disease is the most serious complication in type ll diabetes. Studies are mixed on the effects of intensive glucose control, with some even reporting some harm. Of particular concern is weight gain from insulin therapies, a major problem and health risk in most patients with type ll diabetes. Newer insulin-sensitizing medications may pose less of a risk for weight gain, however, and new weight loss drugs are also proving to be helpful in offsetting weight gain from other drugs.
Until more is known, at this time patients should still aim for the following test results:
- Fasting plasma glucose concentrations below 110 mg/dL.
- Glycolated hemoglobin (HbA1c) levels of less than 7%. Type ll diabetics with normal or low HbA1c levels have the lowest risk for complications. According to one 2000 study, a 1% reduction in people with elevated glycolated hemoglobin levels lowers the risk for complications by 21%.
Patients should discuss all options with their physicians.
WHAT ARE THE LIFESTYLE MEASURES FOR TREATING AND PREVENTING TYPE ll DIABETES?
Healthy lifestyle habits are the cornerstone of diabetes treatment. Lifestyle changes are difficult to initiate and sustain, however. Patients should be certain to surround themselves with a solid network of doctors, dietitians, family, and friends who understand both their condition and their needs. At least one study has found that family involvement plays a large role in adhering to lifestyle and medical regimens.
A Diabetic Diet and Weight Loss
The Diabetic Diet. The current state of the diabetic diet is in flux, and at this time, there is no single diet that meets all the needs of everyone with diabetes. Patients should meet with a professional dietitian to plan an individualized diet that takes into consideration all health needs. There are some constants, however:
- Limit fats (particularly saturated fats and trans-fatty acids).
- Limit dietary cholesterol.
- Consume plenty of fiber-rich foods in the form of whole grains and fresh fruits and vegetables.
- Limit protein.
- Reduce salt.
Weight Loss. Being overweight is the number one risk factor for diabetes type ll. A number of studies have suggested that healthy habits might prevent diabetes, but they have had significant flaws. Now, an important well-conducted 2001 study in Finland has added very strong evidence on the value of weight loss and exercise. In the study, individuals at risk for developing type ll diabetes were put on a weight loss and exercise program. Although the average weight loss was relatively small (about 10 pounds), the risk for diabetes in this group was 58% lower than the comparison group who were given no intervention. Health benefits are highest with the first pounds lost, and losing only 10% of body weight can control progression of diabetes.
Unfortunately, not only is weight loss difficult to sustain, but many of the oral medications used in type ll 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 beneficial. In some studies, for example, orlistat not only helped subjects to reduce weight but also improved glucose, cholesterol, and lipid levels. Surgical procedures are proving to be extremely beneficial in selected cases.
Regular exercise, even of moderate intensity (such as brisk walking), improves insulin sensitivity and can even prevent type ll diabetes. In fact, studies of older people who engage in regular to moderate aerobic exercise (eg, brisk walking, biking) lower their risk for diabetes even if they don't lose weight. Exercise also helps lower blood pressure, improve cholesterol levels, and decrease body fat. All in all, even moderate exercise reduces the risk of heart disease in people with type ll diabetes, even if they have no cardiac risk factors other than diabetes. Low-impact aerobic exercise is best. Resistance or high impact exercises can strain weakened blood vessels in the eyes of patients with retinopathy. High-impact exercise may also injure blood vessels in the feet.
In general, experts recommend the following:
- Before starting exercise, individuals over age 40 or anyone under age 40 with heart disease should take a stress test. (Because diabetics may have silent heart disease, they should always check with their physicians before undertaking vigorous exercise.)
- Patients who are taking medications that lower blood glucose, particularly insulin, should take special precautions before embarking on a workout program.
- For best and fastest results, frequent high-intensity (not high-impact) exercises are best for people who are cleared by their physicians.
- For people who have been sedentary or have other medical problems, lower-intensity exercises are recommended using regimens designed with physicians.
Monitoring Blood Glucose
In patients being treated with insulin or insulin-producing or sensitizing drugs, it is important to monitor blood glucose levels carefully to avoid hypoglycemia. Patients should aim for the following measurements:
- Pre-meal glucose levels of between 80 and 140 mg/dL .
- Bedtime levels of between 100 and 160.
Different goals may be required for specific individuals, including pregnant women, very old and very young people, and those with accompanying serious medical conditions.
Blood glucose levels are generally more stable in type ll diabetes than in type 1, so experts usually recommend measuring blood levels only once or twice a day. Usually, a drop of blood obtained by pricking the finger is applied to a chemically treated strip. The glucose level is read on a standard meter or a small, portable digital display device. A noninvasive device called the GlucoWatch, measures glucose by sending tiny electric currents through the skin and is showing promise for detecting hypoglycemia.
Some research suggests that not getting enough sleep may impair insulin use and increase the risk for obesity. More research is needed, but it is always wise to improve sleep habits.
This Information was obtained from the American Diabetes Association
Patients should discuss all options with their physicians !