Diabetes Type 2

1. Introduction

  • Definition: Type 2 Diabetes Mellitus (T2DM) is a chronic metabolic disorder characterised by insulin resistance and a progressive decline in pancreatic beta-cell function, leading to hyperglycaemia.
  • Epidemiology: T2DM accounts for 90–95% of all diabetes cases, with rising prevalence worldwide due to increased obesity, sedentary lifestyles, and ageing populations.
  • Significance: A major cause of morbidity and mortality due to its complications, including cardiovascular disease, kidney disease, and neuropathy.

2. Causes and Risk Factors

  • Causes:
    • Insulin resistance in peripheral tissues, combined with insufficient compensatory insulin secretion by beta cells.
  • Risk Factors:
    • Modifiable: Obesity (especially central adiposity), physical inactivity, poor diet, and smoking.
    • Non-modifiable: Family history of diabetes, advancing age, ethnicity (higher risk in South Asians, African-Caribbeans, and Native Americans).
    • Gestational diabetes or polycystic ovary syndrome (PCOS).

3. Pathophysiology

  • Chronic hyperglycaemia results from insulin resistance in skeletal muscle, adipose tissue, and the liver, combined with beta-cell dysfunction. This leads to impaired glucose uptake, increased hepatic glucose production, and lipotoxicity, exacerbating metabolic disturbances.

4. Symptoms and Features

  • Early Symptoms:
    • Increased thirst (polydipsia) and frequent urination (polyuria).
    • Fatigue and unexplained weight loss.
    • Blurred vision and recurrent infections (e.g., urinary tract infections or thrush).
  • Advanced Features:
    • Poor wound healing and numbness or tingling in extremities (neuropathy).
    • Symptoms of complications like chest pain (cardiovascular disease) or swelling in the feet (nephropathy).

5. Complications

  • Acute:
    • Hyperosmolar Hyperglycaemic State (HHS): Life-threatening severe hyperglycaemia without significant ketosis.
  • Chronic:
    • Microvascular: Retinopathy, nephropathy, neuropathy.
    • Macrovascular: Cardiovascular disease, stroke, peripheral vascular disease.

6. Diagnosis

  • Diagnostic Criteria (any one of the following):
    • Fasting plasma glucose ≥7.0 mmol/L (126 mg/dL).
    • Random plasma glucose ≥11.1 mmol/L (200 mg/dL) with classic symptoms.
    • HbA1c ≥6.5%.
    • 2-hour plasma glucose ≥11.1 mmol/L (200 mg/dL) during an oral glucose tolerance test (OGTT).
  • Additional Tests:
    • Lipid profile, liver function tests, urine albumin-to-creatinine ratio (ACR).

7. Management Overview

  • Goals: Achieve and maintain optimal glycaemic control (HbA1c <7%), reduce cardiovascular risk, and prevent complications.
  • Approach: Lifestyle modifications, pharmacological therapy, and routine monitoring of blood glucose and complications.

8. Treatment Options with Cost (USD)

  • Lifestyle Modifications:
    • Healthy diet and exercise: Minimal cost.
    • Weight management programs: ~$50–$150/month.
  • Oral Medications:
    • Metformin: ~$10–$30 per month.
    • Sulfonylureas (e.g., glimepiride): ~$10–$50 per month.
    • DPP-4 inhibitors (e.g., sitagliptin): ~$200–$300 per month.
  • Injectable Therapies:
    • GLP-1 receptor agonists (e.g., semaglutide): ~$800–$1,200 per month.
    • Insulin (for advanced cases): ~$150–$300 per vial.

9. Advanced Treatment Options with Cost (USD)

  • SGLT2 Inhibitors (e.g., empagliflozin): ~$300–$400 per month.
  • Insulin Pumps (if required): Device cost ~$4,000–$7,000, with ~$100–$300/month for supplies.
  • Bariatric Surgery (for obesity and diabetes remission): ~$15,000–$25,000.

10. Pharmacological Treatment

  • First-line: Metformin, combined with lifestyle changes.
  • Second-line: Sulfonylureas, SGLT2 inhibitors, or DPP-4 inhibitors, depending on patient-specific factors like cardiovascular risk or weight.
  • Third-line: Insulin therapy or GLP-1 receptor agonists in advanced cases or when glycaemic targets are not met.

11. Medication Tables

Table 1: Doses and Side Effects

DrugIndicationDoseCommon Side Effects
MetforminFirst-line therapy500–2,000 mg dailyGI upset, lactic acidosis (rare)
GlimepirideSulfonylurea1–4 mg dailyHypoglycaemia, weight gain
SitagliptinDPP-4 inhibitor100 mg dailyHeadache, nasopharyngitis
EmpagliflozinSGLT2 inhibitor10–25 mg dailyUTIs, dehydration
SemaglutideGLP-1 receptor agonist0.25–1 mg weekly (injection)Nausea, weight loss

Table 2: Brand Names and Approximate Costs (USD)

DrugBrand NamesApprox. Cost
MetforminGlucophage$10–$30 per month
GlimepirideAmaryl$10–$50 per month
SitagliptinJanuvia$200–$300 per month
EmpagliflozinJardiance$300–$400 per month
SemaglutideOzempic$800–$1,200 per month

12. Lifestyle Interventions

  • Adopt a balanced, low-glycaemic index (GI) diet rich in whole grains, lean proteins, fruits, and vegetables.
  • Engage in regular aerobic exercise (150 minutes/week) and resistance training.
  • Limit alcohol intake and avoid smoking.
  • Set realistic weight loss goals (5–10% reduction in body weight).

13. Monitoring Parameters

  • Regular blood glucose self-monitoring or continuous glucose monitoring (CGM).
  • HbA1c every 3–6 months to assess long-term glycaemic control.
  • Annual screening for complications:
    • Retinopathy: Eye exams.
    • Nephropathy: Urine albumin-to-creatinine ratio (ACR).
    • Neuropathy: Foot exams.
  • Lipid profile and blood pressure monitoring to manage cardiovascular risk.

14. Patient Counseling Points

  • Educate about the chronic nature of diabetes and the importance of adherence to medications and lifestyle changes.
  • Discuss signs and management of hypoglycaemia (e.g., sweating, shakiness, confusion).
  • Encourage routine follow-ups to monitor for complications.
  • Emphasise the benefits of regular physical activity and healthy eating for long-term diabetes management.

15. Special Populations

  • In Elderly: Individualise glycaemic targets to minimise hypoglycaemia risks.
  • In Pregnancy: Switch to insulin therapy as oral agents are typically avoided.
  • In Obese Patients: Focus on weight loss therapies like GLP-1 receptor agonists or bariatric surgery.

16. Prevention

  • Maintain a healthy diet and regular exercise routine to prevent or delay T2DM onset in high-risk individuals.
  • Monitor blood glucose levels in overweight or prediabetic individuals.
  • Manage comorbidities like hypertension and hyperlipidaemia to reduce overall risk.

17. FAQs

  1. What is Type 2 Diabetes?
    Answer: A chronic condition where the body becomes resistant to insulin or does not produce enough insulin.
  2. What causes Type 2 Diabetes?
    Answer: A combination of genetic predisposition and lifestyle factors like obesity and inactivity.
  3. How is Type 2 Diabetes treated?
    Answer: With lifestyle changes, oral medications, and, in some cases, insulin therapy.
  4. Can Type 2 Diabetes be reversed?
    Answer: In some cases, weight loss and lifestyle changes can lead to remission.
  5. What foods should I avoid with Type 2 Diabetes?
    Answer: Sugary drinks, processed foods, and refined carbohydrates.
  6. How often should I check my blood sugar?
    Answer: This depends on your treatment plan; many patients monitor it daily or several times a week.
  7. What is HbA1c?
    Answer: A measure of average blood glucose levels over the past 2–3 months.
  8. Can Type 2 Diabetes cause complications?
    Answer: Yes, it can lead to complications like heart disease, kidney damage, and vision problems.
  9. What is the role of exercise in managing Type 2 Diabetes?
    Answer: Regular exercise improves insulin sensitivity and helps control blood sugar levels.
  10. Is insulin required for Type 2 Diabetes?
    Answer: Not initially, but it may be needed in advanced cases or when oral medications fail.
  11. How can I prevent Type 2 Diabetes?
    Answer: By maintaining a healthy weight, eating a balanced diet, and staying active.
  12. What is prediabetes?
    Answer: A condition where blood sugar levels are higher than normal but not high enough for a diabetes diagnosis.
  13. Can stress affect blood sugar?
    Answer: Yes, stress can cause blood sugar to rise.
  14. Is Type 2 Diabetes genetic?
    Answer: There is a genetic predisposition, but lifestyle factors play a significant role.
  15. What is the best diet for Type 2 Diabetes?
    Answer: A diet low in refined carbs and high in fibre, lean proteins, and healthy fats.