Erie County Medical Society

March 14th, 2019

Type-2 Diabetes

Type-2 Diabetes and You

Prevalence

In 2015, 30.3 million Americans, or 9.4% of the population, had diabetes, according to the American Diabetes Association (ADA). The Center for Disease Control (CDC) reports that over 90% of these patients had type-2 diabetes. The ADA further reports diabetes as the seventh leading cause of death in the US, being an underlying or contributing cause in over 250,000 deaths in 2015.

The US prevalence has more than doubled in the last three decades, largely because of the increased prevalence of obesity. The increase is most concerning among adolescents and young adults.

Type-2 Diabetes 

Important distinctions exist between type-1 diabetes and the much more prevalent type-2 diabetes.

Type-1 diabetes results from the body’s inability to produce insulin due to the destruction of insulin-secreting beta cells in the pancreas. Patients with type-1 diabetes require lifelong insulin therapy. Although onset frequently occurs in childhood, the disease can also develop in adults.

Type-2 diabetes results from a combination of diminished insulin secretion by the pancreas and “peripheral insulin resistance.” This “peripheral insulin resistance” is a shorthand way of saying that (1) the glucose is impaired from getting into the muscles and tends to stay in the blood, (2) that the liver produces increased glucose, and (3) that there is an increased fat breakdown. Patients with type-2 diabetes may require oral medication or oral medication plus insulin.

Type-2 Symptoms 

Many type-2 diabetes patients exhibit no symptoms; the disease can begin insidiously. By the time of diagnosis, some patients have had the disease for 4-7 years and have already begun sustaining eye, nerve, and kidney damage. Other patients have earlier and more obvious symptoms such as excessive eating, drinking, urination, and weight loss.

Type-2 Risk Factors

Major risk factors for type-2 diabetes are

• Age greater than 45 years

• Weight greater than 120% of desirable

• Type-2 diabetes in a first-degree relative

• Ancestry: Hispanic, Native-American, African-American, Asian-American, or Pacific Islander

• High blood pressure or cholesterol-triglyceride problems

• Diabetes during pregnancy or delivering an infant weighing more than 9 pounds

• Polycystic ovary syndrome

Complications of Type-2 Diabetes 

The death rate among people with diabetes is about twice that of people of the same age without diabetes. Some of the major complications of diabetes, fatal and otherwise, are diabetic retinopathy, end-stage kidney disease, neuropathy/vasculopathy, and cardiovascular disease.

Diabetic retinopathy is a major cause of blindness in adults; it accounts for 12,000-24,000 newly blind persons every year. However, laser surgery and appropriate follow-up care can reduce the risk of blindness from diabetic retinopathy.

About 44% of new cases of end-stage kidney disease in 2008, were among diabetics. That year, over 200,000 people with diabetes were on dialysis or had received a kidney transplant.

Diabetes is the leading cause of lower limb amputations not occasioned by accident. Diabetics have an estimated 15- to 40-fold increase in the risk of lower limb amputation over non-diabetics.

For coronary heart disease, the risk is 2-4 times greater among diabetics than among non-diabetics. Cardiovascular disease is the major source of mortality in patients with type-2 diabetes mellitus.

Prevention of Type-2 Diabetes

For prevention of type-2 diabetes in patients at risk (see “Risk Factors” above), the American College of Clinical Endocrinologists recommends

•      • Weight reduction
•      • Proper nutrition
•      • Regular physical activity
•      • Treatment of high blood pressure
•      • Aggressive management of cholesterol-triglyceride problems

Weight management is especially important. In some overweight patients, a 5% body weight reduction maintained over three years was effective in reducing the diabetes risk by 58%.

While the Mediterranean diet receives most of the good publicity, it seems that any balanced diet, with good calorie management, satisfies the proper nutrition requirement.

A worthwhile recommendation for regular physical activity is 30 minutes of aerobic activity five times weekly.

For the treatment of high blood pressure and the management of cholesterol-triglyceride problems, the primary care physician now has substantial options to balance good control with safety and comfort.

Treatment of Type-2 Diabetes 

The goals of treatment are to reduce the risk of complications affecting the eyes, kidneys, nerves, blood vessels, and heart. The foundations of treatment are lifestyle changes involving diet, exercise, and health education. The risks of complications are further reduced by medications to control blood pressure and cholesterol/triglyceride problems. 

There are now multiple medications to control blood sugar levels. Frequently, oral medications are sufficient. These can work by decreasing the liver’s production of glucose, decreasing intestinal absorption of glucose, improving the body’s sensitivity to insulin, or increasing the secretion of insulin. Some promote glucose excretion by the kidneys.

Injectable medications are also available. These may stimulate insulin release in response to food ingestion and may prolong the life of insulin-secreting cells in the pancreas. These injections may need to be administered anywhere from twice daily to once weekly. They may be used alone or in combination with oral medications or insulin.

Insulin is typically associated with type-1 diabetes, but can also be useful in type-2 diabetes. Varieties include rapid-acting, short-acting, intermediate-acting, long-acting, and ultra-long-acting. These have durations anywhere from 3-5 hours to 24-42 hours. Finally, an inhaled insulin powder now exists that is rapid-acting and is taken just before a meal.

Many options for treatment exist and the physician can design an appropriate one for the individual patient. The goal is to find a treatment that controls the disease, that fits the patient’s life, and that can be continued over a lifetime.

Conclusion

In brief, type-2 diabetes is a widespread problem in the US. It is increasing among adults and young people as the obesity epidemic prevails. Type-2 diabetes has life-shortening and life-curtailing complications. The cornerstone of treatment is a change in lifestyle. Aiding this is a growing list of medication options. The key for patients is to work with their physician to plan a treatment that works, that fits, and that endures.

• Thomas Falasca, DO

References 

Aathira, R., & Jain, V. (2014, October 15). Advances in management of type 1 diabetes mellitus. Retrieved from https://www.wjgnet.com/1948-9358/full/v5/i5/689.htm

Bullard, K. M., Cowie, C., & Lessem, S. (2018, March 29). Morbidity and Mortality Weekly Report (MMWR). Retrieved from https://www.cdc.gov/mmwr/volumes/67/wr/mm6712a2.htm

Khordori, R. (2019, February 26). Type 2 Diabetes Mellitus. Retrieved from https://emedicine.medscape.com/article/117853-overview

Statistics About Diabetes. (n.d.). Retrieved March 1, 2019, from http://www.diabetes.org/diabetes-basics/statistics/