Diabetes - Type 2

 

 

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credits: Sourced from the website Patient UK, authored by Dr Colin Tidy (see below). Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

 

Overview

There are two main types of diabetes mellitus, which are called type 1 diabetes and type 2 diabetes. Type 1 diabetes is the type of diabetes that typically develops in children and in young adults. In type 1 diabetes the body stops making insulin and the blood sugar (glucose) level goes very high. Type 2 diabetes occurs mostly in people aged over 40 years. However, an increasing number of younger people, even children, are being diagnosed with type 2 diabetes.

The first-line treatment is diet, weight control and physical activity. If the blood sugar (glucose) level remains high despite these measures, then tablets to reduce the blood glucose level are usually advised. Insulin injections are needed in some cases. Other treatments include reducing blood pressure if it is high, lowering high cholesterol levels and also using other measures to reduce the risk of complications.

What is type 2 diabetes?

Type 2 diabetes tends to develop gradually (over weeks or months). This is because in type 2 diabetes you still make insulin (unlike in type 1 diabetes).

However, you develop diabetes because:

• You do not make enough insulin for your body's needs; or
• The cells in your body do not use insulin properly. This is called insulin resistance. The cells in your body become resistant to normal levels of insulin. This means that you need more insulin than you normally make to keep the blood sugar (glucose) level down; or
• A combination of the above two reasons.

Type 2 diabetes is much more common than type 1 diabetes.

Who develops type 2 diabetes?

• Type 2 diabetes develops mainly in people older than the age of 40 (but can also occur in younger people).
• Type 2 diabetes is now becoming more common in children and in young people.
• 9 out of every 10 people with diabetes have type 2 diabetes.

 

Risk Factors

Other risk factors for type 2 diabetes include:

• Having a first-degree relative with type 2 diabetes. (A first-degree relative is a parent, brother, sister, or child.)
• Being overweight or obese.
• Having a waist measuring more than 80 cm if you are a woman or more than 94 cm if you are a man.
• Having pre-diabetes (impaired glucose tolerance). Impaired glucose tolerance means that your blood sugar (glucose) levels are higher than normal but not high enough to have diabetes. People with impaired glucose tolerance have a high risk of developing diabetes and so impaired glucose tolerance is often called pre-diabetes.
• Having diabetes or pre-diabetes when you were pregnant. 

 

Symptoms

What are the symptoms of type 2 diabetes?

As already mentioned, type 2 diabetes symptoms often come on gradually and can be quite vague at first. Many people have diabetes for a long period of time before their diagnosis is made. The most common symptoms are:

• Being thirsty a lot of the time.
• Passing large amounts of urine.
• Tiredness.
• Weight loss.

 

The reason why you make a lot of urine and become thirsty is because blood sugar (glucose) leaks into your urine, which pulls out extra water through the kidneys.

As the symptoms may develop gradually, you can become used to being thirsty and tired and you may not recognise that you are ill for some time. Some people also develop blurred vision and frequent infections, such as recurring thrush. However, some people with type 2 diabetes do not have any symptoms if the glucose level is not too high. But, even if you do not have symptoms, you should still have treatment to reduce the risk of developing complications.

 

Diagnosis

How is type 2 diabetes diagnosed?

A simple dipstick test may detect sugar (glucose) in a sample of urine. However, this is not sufficient to make a definite diagnosis of diabetes. Therefore, a blood test is needed to make the diagnosis. The blood test detects the level of glucose in your blood. If the glucose level is high, then it will confirm that you have diabetes. Some people have to have two samples of blood taken and may be asked to fast. (Fasting means having nothing to eat or drink, other than water, from midnight before the blood test is performed.)

It is now recommended that the blood test for HbA1c can also be used as a test to diagnose type 2 diabetes. An HbA1c value of 48 mmol/mol (6.5%) or above is recommended as the blood level for diagnosing diabetes.

In many cases type 2 diabetes is diagnosed during a routine medical or when tests are done for an unrelated medical condition.

 

Complications

What are the possible complications of diabetes?

Short-term complication

A very high glucose level

This is not common with type 2 diabetes. It is more common in untreated type 1 diabetes when a very high level of blood sugar (glucose) can develop quickly. However, a very high glucose level develops in some people with untreated type 2 diabetes. A very high blood level of glucose can cause lack of fluid in the body (dehydration), drowsiness and serious illness which can be life-threatening.

Long-term complications

If your blood glucose level is higher than normal over a long period of time, it can gradually damage your blood vessels. This can occur even if the glucose level is not very high above the normal level.

This may lead to some of the following complications (often years after you first develop diabetes):

• Furring or 'hardening' of the arteries (atheroma): This can cause problems such as angina, heart attacks, stroke and poor circulation.
• Kidney damage which sometimes develops into chronic kidney disease.
• Eye problems which can affect vision (due to damage to the small arteries of the retina at the back of the eye).
• Nerve damage.
• Foot problems (due to poor circulation and nerve damage).
• Impotence (again due to poor circulation and nerve damage).
  
  

Other rare problems

The type and severity of long-term complications vary from case to case. You may not develop any at all. In general, the nearer your blood glucose level is to normal, the less your risk of developing complications. Your risk of developing complications is also reduced if you deal with any other risk factors that you may have, such as high blood pressure.

 

Treatment

Complications of treatment

Hypoglycaemia (which is often called a 'hypo') occurs when the level of glucose becomes too low, usually under 4 mmol/L. People with diabetes who take insulin and/or certain diabetes tablets are at risk of having a hypo. Not all tablet medicines used for diabetes can cause a hypo.

A hypo may occur if you have too much diabetes medication, have delayed or missed a meal or snack, or have taken part in unplanned exercise or physical activity. To treat hypoglycaemia, you should take a sugary drink or some sweets. Then eat a starchy snack such as a sandwich.

Monitoring to detect and treat any complications promptly

Doctors, nurses, dieticians, specialists in foot care (podiatrists - previously called chiropodists), specialists in eye health (optometrists) and other healthcare workers all play a role in giving advice and checking on progress.

Regular checks may include:

• Checking levels of blood sugar (glucose), HbA1c, cholesterol and blood pressure.
• Ongoing advice on diet and lifestyle.
• Checking for early signs of complications - for example:
  • Eye checks: to detect problems with the retina (a possible complication of diabetes), which can often be prevented from becoming worse. Increased pressure in the eye (glaucoma) is also more common in people with diabetes and can usually be treated. Eye checks usually include taking photographs of the back of your eye (retinal photography) to see whether there are any problems.
  • Urine tests: which include testing for protein in the urine, which may indicate early kidney problems.
  • Foot checks: to help prevent foot ulcers.
  • Other blood tests: these include checks on kidney function and other general tests.

 

It is important to have regular checks, as some complications, particularly if detected early, can be treated or prevented from becoming worse.

 

Immunisation

You should be immunised against flu (each autumn) and also against pneumococcal germs (bacteria) (just given once). These infections can be particularly unpleasant if you have diabetes.

Type 2 Diabetes Treatment

Although diabetes cannot be cured, it can be treated successfully. If a high blood sugar level is brought down to a normal level, your symptoms will ease.

You still have some risk of complications in the long term if your blood glucose level remains even mildly high - even if you have no symptoms in the short term. However, studies have shown that people who have better glucose control have fewer complications (such as heart disease or eye problems) compared with those people who have poorer control of their glucose level.

Therefore, the main aims of treatment are:

• To keep your blood glucose level as near normal as possible.
• To reduce any other risk factors that may increase your risk of developing complications. In particular, to lower your blood pressure if it is high and to keep your blood lipids (cholesterol) low.
• To detect any complications as early as possible. Treatment can prevent or delay some complications from becoming worse.

 

Type 2 diabetes is usually initially treated by following a healthy diet, losing weight if you are overweight, and having regular physical activity. If lifestyle advice does not control your blood sugar (glucose) levels, then medicines are used to help lower your blood glucose levels. One medicine (usually metformin) is used first but two or even three medicines may be needed.

Most of the medicines for type 2 diabetes are given in tablet form. However, some people with type 2 diabetes need insulin injections to help control blood glucose levels. Some people gain a great deal of benefit from insulin injections and these are sometimes used fairly soon after the diagnosis of type 2 diabetes has been made. Insulin injections can be used in combination with other medicines to further improve glucose control.

Lifestyle - diet, weight control and physical activity

You can usually improve your blood sugar (glucose) control if you:

Eat a healthy balanced diet: Your practice nurse and/or a dietician will give details on how to eat a healthy diet. The diet is the same as recommended for everyone. The idea that you need special foods if you have diabetes is a myth. Basically, you should aim to eat a diet low in fat, high in fibre and with plenty of fruit and vegetables. Getting to a perfect weight is unrealistic for many people. However, if you are obese or overweight then losing some weight will help to reduce your blood glucose level (and have other health benefits too).

Do some physical activity regularly: If you are able, a minimum of 30 minutes' brisk walking at least five times a week is advised. Anything more vigorous and more often is even better - for example, swimming, cycling, jogging, dancing. Ideally you should do an activity that gets you at least mildly out of breath and mildly sweaty. You can spread the activity over the day - for example, two 15-minute spells per day of brisk walking, cycling, dancing, etc. Regular physical activity also reduces your risk of having a heart attack or a stroke.

Many people with type 2 diabetes can reduce their blood glucose (and HbA1c) to a target level by the above measures. However, if the level remains too high after a trial of these measures for a few months then medication is usually advised.

Medication is used in addition to, and not instead of, the above lifestyle measures.

Medication

Medication to reduce the blood glucose level:

Metformin:

Metformin is a biguanide medicine. It lowers blood sugar (glucose) mainly by decreasing the amount of glucose that your liver releases into the bloodstream. It also increases the sensitivity of your body's cells to insulin (so more glucose is taken into cells with the same amount of insulin in the bloodstream). Metformin has also been shown in studies to lower your risk of other complications of diabetes (such as heart attack and stroke).

Metformin is commonly the first tablet advised if your blood glucose level is not controlled by lifestyle measures alone. It is particularly useful if you are overweight, as it is less likely than some other glucose-lowering tablets to cause weight gain. Another advantage of metformin is that it generally does not cause a low blood glucose level (hypoglycaemia) which is a possible problem with some other glucose-lowering tablets. You can also take metformin in addition to other glucose-lowering tablets if one tablet does not control blood glucose well enough on its own.


Possible problems with metformin:

When metformin is first started, some people feel sick (nausea) or have mildly runny stools (diarrhoea). These are less likely to occur if you start with a low dose and gradually build up to the usual dose over a few weeks. If these side-effects do occur, they tend to ease off in time. Other side-effects are uncommon.

Sulfonylurea medicines:

There are several types of sulfonylurea medicines. These include glibenclamide, gliclazide, glimepiride, glipizide and tolbutamide. They work by increasing the amount of insulin that your pancreas makes. (If you have type 2 diabetes, you still make insulin in your pancreas. However, you do not make enough to keep your blood glucose level normal.)

A sulfonylurea tends to be used if you cannot take metformin (perhaps because of side-effects or other reasons), or if you are not overweight. Usually a low dose is started. The dose can be increased if necessary every few weeks until there is good control of the blood glucose level. You can take a sulfonylurea in addition to other glucose-lowering tablets if one tablet does not control blood glucose well enough on its own.

Possible problems with sulfonylureas:
As sulfonylureas boost your level of insulin, low blood sugar (hypoglycaemia) is a possible complication. However, this is an uncommon problem. 

Some weight gain is a common side-effect. Other side-effects are uncommon and are usually mild. They include feeling sick, mild diarrhoea and constipation.

DPP-4 inhibitors (Dipeptidyl peptidase-4 inhibitors):

Also known as incretin enhancers, this group includes saxagliptin, sitagliptin, vildagliptin, alogliptin and linagliptin. Dipeptidyl peptidase 4 (DPP-4) is a chemical (an enzyme) which breaks down hormones called incretins. Incretins are chemicals which are produced by the gut (intestine) in response to food.

These medicines work by reducing your blood glucose level by enhancing the effects of incretins as they prevent DPP-4 from working. One of these may be advised in addition to metformin or a sulfonylurea, or even to both of these if your HbA1c level is still high.

Side-effects are uncommon and are usually mild. They may include feeling sick or having wind (flatulence). If you take vildagliptin then there is a slight risk of liver damage. Therefore, you should have a blood test to check on your liver function before starting it and then at regular intervals.

Pioglitazone:

Pioglitazone is a thiazolidinedione (sometimes called a glitazone). Pioglitazone lowers blood glucose by increasing the sensitivity of your body's cells to insulin (so more glucose is taken into cells for the same amount of insulin in the bloodstream).

They are not usually used alone but are an option to take in addition to metformin or a sulfonylurea.You should not take these medicines if you have heart failure, as this can worsen. There is also a slight risk of liver damage. Therefore, you should have a blood test to check on your liver function before starting these medicines. The blood test is then repeated at regular intervals. Some weight gain is a common side-effect, probably due to fluid retention. Hypoglycaemia is an uncommon side-effect. Other possible side-effects are uncommon.

(SGLT-2) inhibitors (Sodium-glucose co-transporter-2 inhibitors):

Dapagliflozin, canagliflozin, and empagliflozin are sodium-glucose co-transporter-2 (SGLT-2) inhibitors which increase the amount of glucose in your urine and so reduce blood glucose levels. These medicines can be used on their own or with other medicines to help control blood glucose for people with type 2 diabetes.

Possible side effects include: yeast infections of the genitals, urinary tract infections, changes in urination (including urgent need to urinate more often, discomfort when urinating, urinating in larger amounts, or at night) and nausea.

Acarbose:

Acarbose works by delaying the absorption of carbohydrates (which are broken down into glucose) from the gut. Therefore, it can reduce the peaks of blood glucose which may occur after meals. It is an option if you are unable to use other tablets to keep your blood glucose level down. It can also be used in addition to other glucose-lowering tablets.

However, many people develop gut-related side-effects when taking acarbose, such as bloating, wind and diarrhoea. Therefore, it is not used very often.

Insulin:

Insulin injections lower blood glucose. Only some people with type 2 diabetes need insulin. It may be advised if your blood glucose level is not well controlled by tablets. The dose and type of insulin used varies from person to person. Sometimes insulin is used alone. However, sometimes it is used in addition to your tablets (such as metformin or a sulfonylurea). If you are advised to use insulin, your doctor or practice nurse will give detailed advice on how and when to use it.

Possible problems with insulin: some weight gain is a common side-effect. Weight gain may be less of a problem if you use insulin in combination with a glucose-lowering tablet such as metformin. Hypoglycaemia is a possible complication.

GLP-1 mimetics (glucagon-like peptide-1):

Exenatide, albiglutide, dulaglutide, liraglutide and lixisenatide - are glucagon-like peptide-1 (GLP-1) mimetics which are treatments given as an injection. They work in a similar way to the action of the naturally occurring hormone glucagon-like peptide 1. These actions include stimulating insulin secretion in response to glucose and preventing glucagon release after meals. Glucagon is a hormone which raises blood sugar.

Exenatide and liraglutide are usually used as an add-on treatment to improve glucose control when insulin treatment is not acceptable.

Side-effects may include hypoglycaemia, feeling sick and headaches. People receiving this treatment usually lose weight.

 

How is the blood glucose level monitored?

Your treatment should be monitored regularly. You may need to step up treatment from time to time. For example, your blood sugar (glucose) may be well controlled by lifestyle measures alone for a number of years. However, in time, you may need to add in one tablet. And then at a later time you may need to add in another tablet to keep your blood glucose level down.

The blood test that is mainly used to keep a check on your blood sugar (glucose) level is called the HbA1c test. This test is commonly done every 2-6 months by your doctor or nurse.

The HbA1c test measures a part of the red blood cells. Glucose in the blood attaches to part of the red blood cells. This part can be measured and gives a good indication of your average blood glucose level over the previous 1-3 months.

Treatment aims to lower your HbA1c to below a target level which is usually agreed between you and your doctor. The ideal target for many people is to maintain your HbA1c to less than 48 mmol/mol (6.5%) but higher target levels - for example, 53 mmol/mol (7.0%) - may be more appropriate.

Higher target levels are usually advised for people who are at particular risk if the blood sugar goes too low (this is called hypoglycaemia, or a 'hypo'). Examples include people who are prone to falls, people who are unwell due to other illnesses, or people who use heavy machinery at work.

 

Other treatments

To help prevent heart disease, stroke and poor circulation:

• If you have high blood pressure (hypertension) then it should be treated.
• You should not smoke.
• You will usually be advised to take tablets to lower your blood cholesterol level.
• To help prevent some serious infections, you are usually advised to be immunised against flu each year, and also given an immunisation against pneumococcal infection.
• Other treatments may be advised if you develop complications from diabetes.

 

Diabetes burnout

Caring for diabetes is extremely demanding. Diabetes burnout occurs when you feel overwhelmed by diabetes. This can lead to feeling angry, frustrated, defeated and also worried about not taking care of diabetes well enough.

Try not to be a perfectionist don't be too hard on yourself. Keep a balance in your life so that diabetes doesn't take over completely. Talk to your doctor or nurse to tell them how you're feeling. Just talking about how you feel can help. Burnout can also respond well to talking therapies such as cognitive behavioural therapy (CBT).

 

 

About the author

Dr Colin Tidy

MBBS, MRCGP, MRCP, DCH

Dr Colin Tidy qualified as a doctor in 1983 and he has been writing for Patient since 2004. Dr Tidy has 25 years’ experience as a General Practitioner. He now works as a GP in Oxfordshire, with a special interest in teaching doctors and nurses, as well as medical students.  In addition to writing many leaflets and articles for Patient, Dr Tidy has also contributed to medical journals and written a number of educational articles for General Practitioner magazines.

 

Recommended websites

For further reading go to:

• Type 2 Diabetes Diet
• Diabetes and Pregnancy
• Diabetes and High Blood Pressure

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