Diabetes

Type 2 diabetes mellitus occurs when the pancreas, an organ in the abdomen, produces insufficient amounts of the hormone insulin and/or the body's tissues become resistant to normal or even high levels of insulin. This causes high blood glucose levels, which can lead to a number of complications if untreated.

Causes of Diabetes:

Type 2 diabetes is caused by a complex interaction of environmental factors and predisposing genetic factors.

The lifetime risk that a first-degree relative, will develop diabetes is five to ten times higher than that of a person with no family history of diabetes. Environmental factors such as diet and activity levels interact with genetic causes to influence the development of type 2 diabetes.

The incidence of type 2 diabetes has increased dramatically in the United States over the last 20 years as the percentage of people who are obese increases. About 3 to 5 percent of pregnant women develop gestational diabetes, usually after 24 to 28 weeks of pregnancy. Other, less common causes of diabetes include endocrine conditions that indirectly change the production and action of insulin and lead to diabetes. These include Cushing's syndrome, acromegaly, pheochromocytoma, hyperthyroidism and polycystic ovarian syndrome (PCOS).

Diagnosis:

The diagnosis of diabetes is based upon a person's symptoms and the results of laboratory tests.

Symptoms:

Before being diagnosed with diabetes, some people have symptoms of high blood sugar, including frequent urination, excessive thirst, and blurred vision.

Laboratory Tests:

• Random blood sugar test — For a random blood sugar test, blood can be drawn at any time throughout the day, regardless of when the person last ate. A random blood sugar level of 200 mg/dL or higher in persons who have symptoms of high blood sugar suggests a diagnosis of diabetes.
• Fasting blood sugar test — Fasting blood sugar testing involves measuring blood sugar after not eating or drinking for 8 to 12 hours. A normal fasting blood sugar level is less than 100 mg/dL. A fasting blood sugar of 126 mg/dL or higher indicates diabetes. The test is done by taking a small sample of blood from a vein or fingertip. It must be repeated on another day to confirm that it remains abnormally high.
• Hemoglobin A1C test (A1C) — The A1C blood test measures the average blood sugar level during the past two to three months. It is used to monitor blood sugar control in people with known diabetes. Normal values for A1C are 4 to 6 percent. The test is done by taking a small sample of blood from a vein or fingertip.
• Oral glucose tolerance test — Oral glucose tolerance testing (OGTT) can be used to diagnose diabetes and pre-diabetes.  The standard OGTT includes a fasting blood sugar test. The person then drinks a 75 gram liquid glucose solution. Two hours later, a second blood sugar level is measured.

Diabetes Type II Treatment:

The goal of treatment in type 2 diabetes is to keep blood sugar levels at normal or near-normal levels. Careful control of blood sugars can help prevent the long-term effects of poorly controlled blood sugar (diabetic complications of the eye, kidney, and cardiovascular system).

Home blood sugar testing:

In people with type 2 diabetes, home blood sugar testing is often recommended at least once per day, before the first meal of the day.

Lifestyle Modifications:

Changes in diet can improve many aspects of type 2 diabetes, including obesity, high blood pressure, and the body's ability to produce and respond to insulin. Regular exercise can benefit people with type 2 diabetes, even if weight is not lost. Exercise improves blood sugar control because it improves the body's response to insulin. The most common long-term complication of type 2 diabetes is cardiovascular (heart) disease, which can cause myocardial infarction (heart attack), angina (chest pain), stroke, and even death. The risk of heart disease is estimated to be at least twice that of persons without diabetes. However, people with type 2 diabetes can substantially lower the risk of cardiovascular disease by quitting smoking, taking a low-dose aspirin every day, and by managing high blood pressure and hyperlipidemia (high cholesterol) with diet, exercise, and medications.

Medications:

• Biguanides, such as Metformin, is first line treatment for patients who are newly diagnosed with type 2 diabetes.Metformin improves the body's response to insulin to reduce high blood sugar levels.
• Sulfonylureas, such as glipizide and glyburide, are the most commonly recommended second line medication. They work by increasing insulin production, and can lower blood sugar levels by approximately 20 percent.
• Thiazolidinedione, such as Actos and Avandia, are an alternative to sulfonylureas, but only for people who are not at increased risk of heart failure or bone fracture. They work to lower blood sugar levels by increasing the body's sensitivity to insulin.
• GLP-agonist, such as Byetta, is an option for patients who are overweight and who want to avoid developing low blood sugar. It is not a first-line medication, but may be considered for people whose blood sugar is not controlled on the highest dose of one or two oral medications.
• Meglitinide, such as Prandin or Starlix, are an option for people who are allergic to sulfa-based drugs. They work to lower blood sugar levels, similar to the sulfonylureas. These medications are not generally used as a first-line treatment because they are more expensive than sulfonylureas and are short-acting, so they must be taken with each meal.
• Alpha-glucosidase, such as Precose and Glyset, work by interfering with the absorption of carbohydrates in the intestines. . This results in lower blood sugar levels, though are not as effective as metformin or the sulfonylureas.
• Insulin: Oral agents become less effective as beta cell function declines. The therapeutic options for patients who fail initial therapy with lifestyle intervention and metformin are to add a second oral or injectable agent, including insulin, or to switch to insulin. There is no consensus about which option is most effective. However, insulin is the preferred second-line medication for patients with A1C >8.5 percent or with symptoms of hyperglycemia despite metformin titration. Thus, many patients with type 2 diabetes will ultimately require treatment with insulin. Initial insulin therapy begins with a bedtime intermediate-acting insulin or a bedtime or morning long-acting insulin.

Types of Insulin:

• Rapid-acting-insulin lispro (Humalog), Insulin aspart (Novolog), insulin glulisine (Apidra)
• Short-acting-insulin regular
• Intermediate-acting-insulin NPH
• Long-acting-insulin glargine (Lantus), insulin detemir (Levemir)

Diabetes Type II Complications:

Diabetes mellitus is a chronic condition that can lead to complications over time. These complications can include:

• Coronary heart disease, which can lead to a heart attack
• Cerebrovascular disease, which can lead to stroke
• Retinopathy (disease of the eye), which can lead to blindness
• Nephropathy (disease of the kidney), which can lead to kidney failure and the need for dialysis
• Neuropathy (disease of the nerves), which can lead to, among other things, ulceration of the foot requiring amputation