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
| Drug | Indication | Dose | Common Side Effects |
|---|---|---|---|
| Metformin | First-line therapy | 500–2,000 mg daily | GI upset, lactic acidosis (rare) |
| Glimepiride | Sulfonylurea | 1–4 mg daily | Hypoglycaemia, weight gain |
| Sitagliptin | DPP-4 inhibitor | 100 mg daily | Headache, nasopharyngitis |
| Empagliflozin | SGLT2 inhibitor | 10–25 mg daily | UTIs, dehydration |
| Semaglutide | GLP-1 receptor agonist | 0.25–1 mg weekly (injection) | Nausea, weight loss |
Table 2: Brand Names and Approximate Costs (USD)
| Drug | Brand Names | Approx. Cost |
|---|---|---|
| Metformin | Glucophage | $10–$30 per month |
| Glimepiride | Amaryl | $10–$50 per month |
| Sitagliptin | Januvia | $200–$300 per month |
| Empagliflozin | Jardiance | $300–$400 per month |
| Semaglutide | Ozempic | $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
- What is Type 2 Diabetes?
Answer: A chronic condition where the body becomes resistant to insulin or does not produce enough insulin. - What causes Type 2 Diabetes?
Answer: A combination of genetic predisposition and lifestyle factors like obesity and inactivity. - How is Type 2 Diabetes treated?
Answer: With lifestyle changes, oral medications, and, in some cases, insulin therapy. - Can Type 2 Diabetes be reversed?
Answer: In some cases, weight loss and lifestyle changes can lead to remission. - What foods should I avoid with Type 2 Diabetes?
Answer: Sugary drinks, processed foods, and refined carbohydrates. - 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. - What is HbA1c?
Answer: A measure of average blood glucose levels over the past 2–3 months. - Can Type 2 Diabetes cause complications?
Answer: Yes, it can lead to complications like heart disease, kidney damage, and vision problems. - What is the role of exercise in managing Type 2 Diabetes?
Answer: Regular exercise improves insulin sensitivity and helps control blood sugar levels. - Is insulin required for Type 2 Diabetes?
Answer: Not initially, but it may be needed in advanced cases or when oral medications fail. - How can I prevent Type 2 Diabetes?
Answer: By maintaining a healthy weight, eating a balanced diet, and staying active. - What is prediabetes?
Answer: A condition where blood sugar levels are higher than normal but not high enough for a diabetes diagnosis. - Can stress affect blood sugar?
Answer: Yes, stress can cause blood sugar to rise. - Is Type 2 Diabetes genetic?
Answer: There is a genetic predisposition, but lifestyle factors play a significant role. - 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.
