Diabetes-Type 2
Causes, incidence, and risk factors
When you have type 2 diabetes, the body does not respond correctly to insulin. This is called insulin resistance. Insulin resistance means that fat, liver, and muscle cells do not respond normally to insulin. As a result blood sugar does not get into cells to be stored for energy.
When sugar cannot enter cells, abnormally high levels of sugar build up in the blood. This is called hyperglycemia. High levels of blood sugar often trigger the pancreas to produce more and more insulin, but it is not enough to keep up with the body's demand.
People who are overweight are more likely to have insulin resistance, because fat interferes with the body's ability to use insulin.
Type 2 diabetes usually occurs gradually. Most people with the disease are overweight at the time of diagnosis. However, type 2 diabetes can also develop in those who are thin, especially the elderly.
Family history and genetics play a large role in type 2 diabetes. Low activity level, poor diet, and excess body weight (especially around the waist) significantly increase your risk for type 2 diabetes.
Other risk factors include:
- Age greater than 45 years
- HDL cholesterol of less than 35 mg/dL or triglyceride level of greater than 250 mg/dL
- High blood pressure
- History of gestational diabetes
- Polycystic ovarian syndrome
- Previously identified impaired glucose tolerance by your doctor
- Race/ethnicity (African Americans, Hispanic Americans, and Native Americans all have high rates of diabetes)
Symptoms
- Blurred vision
- Erectile dysfunction
- Fatigue
- Frequent or slow-healing infections
- Increased appetite
- Increased thirst
- Increased urination
Signs and tests
- Fasting blood glucose level -- diabetes is diagnosed if higher than 126 mg/dL on two occasions.
- Hemoglobin A1c test -- this test has been used in the past to help patients monitor how well they are controlling their blood glucose levels. In 2010, the American Diabetes Association recommended that the test be used as another option for diagnosing diabetes and identifying pre-diabetes. Levels indicate:
- Normal: Less than 5.7%
- Pre-diabetes: Between 5.7% - 6.4%
- Diabetes: 6.5% or higher
- Oral glucose tolerance test -- diabetes is diagnosed if glucose level is higher than 200 mg/dL after 2 hours.
- Random (non-fasting) blood glucose level -- diabetes is suspected if higher than 200 mg/dL and accompanied by the classic symptoms of increased thirst, urination, and fatigue (this test must be confirmed with a fasting blood glucose test).
- Check your blood pressure
- Check the skin and bones on your feet and legs
- Check the sensation in your feet
- Examine the back part of the eye with a special lighted instrument called an ophthalmoscope
- Have your blood pressure checked at least every year (blood pressure goals should be 130/80 mm/Hg or lower).
- Have your glycosulated hemoglobin (HbA1c) checked every 6 months if your diabetes is well controlled; otherwise every 3 months.
- Have your cholesterol and triglyceride levels checked yearly (aim for LDL levels below 70-100 mg/dL).
- Get yearly tests to make sure your kidneys are working well (microalbuminuria and serum creatinine).
- Visit your ophthalmologist at least once a year, or more often if you have signs of diabetic retinopathy.
- See the dentist every 6 months for a thorough dental cleaning and exam. Make sure your dentist and hygienist know that you have diabetes.
Treatment
The primary treatment for type 2 diabetes is exercise and diet.
LEARN THESE SKILLS
You should learn basic diabetes management skills. They will help prevent complications and the need for medical care. These skills include:
- How to test and record your blood glucose (See: Blood glucose monitoring)
- What to eat and when
- How to take medications, if needed
- How to recognize and treat low and high blood sugar
- How to handle sick days
- Where to buy diabetes supplies and how to store them
SELF-TESTING
Self testing refers to being able to check your blood sugar at home yourself. It is also called self-monitoring of blood glucose (SMBG). Regular self-testing of your blood sugar tells you and your health care provider how well your diet, exercise, and diabetes medications are working.
A device called a glucometer can provide an exact blood sugar reading. There are different types of devices. Usually, you prick your finger with a small needle called a lancet. This gives you a tiny drop of blood. You place the blood on a test strip and put the strip into the device. Results are available in 30 - 45 seconds.
A health care provider or diabetes educator will help set up an at-home testing schedule for you. Your doctor will help you set your blood sugar goals.
- Most people with type 2 diabetes only need to check their blood sugar once or twice a day.
- If your blood sugar levels are under control, you may only need to check them a few times a week.
- Tests may be done when you wake up, before meals, and at bedtime.
- More frequent testing may be needed when you are sick or under stress.
Keeping a record for yourself and your health care provider. This will be a big help if you are having trouble managing your diabetes.
DIET AND WEIGHT CONTROL
People with type 2 diabetes should eat at about the same times each day and try to be consistent with the types of food they choose. This helps to prevent blood sugar from becoming extremely high or low. Meal planning includes choosing healthy foods, eating the right amount of food, and eating meals at the right time. You should work closely with your doctor, nurse, and registered dietitian to learn how much fat, protein, and carbohydrates you need in your diet. Your meal plans should fit your daily lifestyle and habits, and should try to include foods that you like.
Managing your weight and eating a well-balanced diet are important. Some people with type 2 diabetes can stop taking medications after losing weight (although they still have diabetes).
See: Diabetes diet
Bariatric (weight loss) surgery may be considered for very overweight patients who are not well managed with diet and medications.
See:
REGULAR PHYSICAL ACTIVITY
Regular exercise is important for everyone, but especially if you have diabetes. Regular aerobic exercise lowers your blood sugar level without medication and helps burn excess calories and fat so you can manage your weight.
Exercise can help your overall health by improving blood flow and blood pressure. It decreases insulin resistance even without weight loss. Exercise also increases the body's energy level, lowers tension, and improves your ability to handle stress.
Consider the following when starting an exercise routine:
- Always check with your health care provider before starting an exercise program.
- Ask your health care provider whether you have the right footwear.
- Choose an enjoyable physical activity that is appropriate for your current fitness level.
- Exercise every day, and at the same time of day, if possible.
- Monitor blood glucose levels at home before and after exercise.
- Carry food that contains a fast-acting carbohydrate in case blood glucose levels get too low during or after exercise.
- Wear a diabetes identification bracelet and carry a cell phone in case of emergency.
- Drink extra fluids that do not contain sugar before, during, and after exercise.
- You may need to modify your diet or medication if you exercise longer or more intensely, to keep blood glucose levels in the correct range.
If diet and exercise do not help maintain normal or near-normal blood glucose levels, your doctor may prescribe medication. Since these drugs help lower your blood sugar levels in different ways, your doctor may have you take more than one. These drugs may also be given along with insulin, if needed.
Some of the most common types of medication are listed below. They are taken by mouth or injection.
- Alpha-glucosidase inhibitors (such as acarbose) decrease the absorption of carbohydrates from the digestive tract to lower after-meal glucose levels.
- Biguanides (Metformin) tell the liver to produce less glucose and help muscle and fat cells and the liver absorb more glucose from the bloodstream. This lowers blood sugar levels.
- Injectable medications (including exenatide, mitiglinide, pramlintide, sitagliptin, and saxagliptin) can lower blood sugar.
- Meglitinides (including repaglinide and nateglinide) trigger the pancreas to make more insulin in response to the level of glucose in the blood.
- Sulfonylureas (like glimepiride, glyburide, and tolazamide) trigger the pancreas to make more insulin. They are taken by mouth.
- Thiazolidinediones (such as rosiglitazone and pioglitazone) help muscle and fat cells and the liver absorb more blood sugar when insulin is present. Rosiglitazone may increase the risk of heart problems. Talk to your doctor.
Insulin preparations differ in how fast they start to work and how long they work. Your healthcare provider will determine the appropriate type of insulin to use and will tell you what time of day to use it.
More than one type may be mixed together in an injection to achieve the best blood glucose control. Usually injections are needed one to four times a day. Your doctor or diabetes educator will show you how to give yourself an injection.
Some people with type 2 diabetes find they no longer need medication if they lose weight and increase activity. When they reach their ideal weight, their own insulin and a careful diet can control their blood glucose levels.
It is not known whether hypoglycemia medications taken by mouth are safe for use in pregnancy. Women who have type 2 diabetes and take these medications may be switched to insulin during pregnancy and while breastfeeding.
MEDICATIONS TO PREVENT COMPLICATIONS
Since those with diabetes have a much higher chance of developing heart disease, kidney disease, and other medical problems, they may need to take certain medicines to treat these problems or prevent them from happening.
An ACE inhibitor (or ARB) is often recommended:
- As the first choice medicine for treating high blood pressure in persons with diabetes
- For those who have signs of early kidney disease
Statin drugs are usually the first choice to treat an abnormal cholesterol level. Aim for LDL cholesterol level less than 100 mg/dL (less than 70 mg/dL in high-risk patients).
Aspirin to prevent heart disease is most often recommended for persons with diabetes who:
- Are 40 or older
- Have a history of heart problems
- Have a family history of heart disease
- Have high blood pressure or high cholesterol
- Smoke
People with diabetes are more likely to have foot problems. Diabetes can damage nerves, which means you may not feel an injury to the foot until a large sore or infection develops. Diabetes can also damage blood vessels.
In addition, diabetes affects the body's immune system. This decreases the body's ability to fight infection. Small infections can quickly get worse and cause the death of skin and other tissues. Amputation may be needed.
To prevent injury to the feet, check and care for your feet every day.
See also: Diabetes foot care
Support Groups
Expectations (prognosis)
Complications
If you have diabetes, your risk of a heart attack is the same as someone who has already had a heart attack. Both women and men with diabetes are at risk. You may not even have the typical signs of a heart attack.
In general, complications include:
- Cataracts
- Damage to blood vessels that supply the legs and feet (peripheral vascular disease)
- Diabetic retinopathy (eye disease)
- Foot sores or ulcers, which can result in amputation
- Glaucoma
- High blood pressure
- High cholesterol
- Kidney disease and kidney failure (diabetic nephropathy)
- Macular edema
- Nerve damage, which causes pain and numbness in the feet, as well as a number of other problems with the stomach and intestines, heart, and other body organs (See: Diabetic neuropathy)
- Stroke
- Worsening of eyesight or even blindness
- Erection problems
- Infections of the skin, female genital tract, and urinary tract
Calling your health care provider
- Chest pain or pressure
- Fainting or unconsciousness
- Seizure
- Shortness of breath
Call your doctor also if you have:
- Numbness, tingling, pain in your feet or legs
- Problems with your eyesight
- Sores or infections on your feet
- Symptoms of high blood sugar (being very thirsty, having blurry vision, having dry skin, feeling weak or tired, needing to urinate a lot)
- Symptoms of low blood sugar (weak or tired, trembling, sweating, feeling irritable, unclear thinking, fast heartbeat, double or blurry vision, feeling uneasy)
Prevention
- Overweight children who have other risk factors for diabetes, starting at age 10 and repeating every 2 years
- Overweight adults (BMI greater than 25) who have other risk factors
- Adults over 45 every 3 years
To prevent complications of diabetes, visit your health care provider or diabetes educator at least four times a year. Talk about any problems you are having.
Stay up-to-date with all your vaccinations and get a flu shot every year.
To prevent diabetes-related foot problems, you should:
- Check and care for your feet EVERY DAY, especially if you already have known nerve or blood vessel damage or current foot problems.
- Get a foot exam by your health care provider at least twice a year and learn whether you have nerve damage.
- Improve control of your blood sugar.
- Make sure you are wearing the right kind of shoes.
- Stop smoking if you smoke.
Cervical Cancer
Worldwide, cervical cancer is the third most common type of cancer in women. It is much less common in the United States because of the routine use of Pap smears.Causes, incidence, and risk factors
Cervical cancers start in the cells on the surface of the cervix. There are two types of cells on the cervix's surface: squamous and columnar. Most cervical cancers are from squamous cells.
Cervical cancer usually develops very slowly. It starts as a precancerous condition called dysplasia. This precancerous condition can be detected by a Pap smear and is 100% treatable. That is why it is so important for women to get regular Pap smears. Most women who are diagnosed with cervical cancer today have not had regular Pap smears or they have not followed up on abnormal Pap smear results.
Undetected precancerous changes can develop into cervical cancer and spread to the bladder, intestines, lungs, and liver. It can take years for precancerous changes to turn into cervical cancer. Patients with cervical cancer do not usually have problems until the cancer is advanced and has spread.
Almost all cervical cancers are caused by HPV (human papilloma virus). HPV is a common virus that is spread through sexual intercourse. There are many different types of HPV. Some strains lead to cervical cancer. (Other strains may cause genital warts, while others do not cause any problems at all.)
Risk factors for cervical cancer include:
- Having sex at an early age
- Multiple sexual partners
- Poor economic status (may not be able to afford regular Pap smears)
- Sexual partners who have multiple partners or who participate in high-risk sexual activities
- Women whose mothers took the drug DES (diethylstilbestrol) during pregnancy in the early 1960s to prevent miscarriage
- Weakened immune system
Most of the time, early cervical cancer has no symptoms. Symptoms that may occur can include:Symptoms
- Abnormal vaginal bleeding between periods, after intercourse, or after menopause
- Any bleeding after menopause
- Continuous vaginal discharge, which may be pale, watery, pink, brown, bloody, or foul-smelling
- Periods become heavier and last longer than usual
- Back pain
- Bone fractures
- Fatigue
- Heavy bleeding from the vagina
- Leaking of urine or feces from the vagina
- Leg pain
- Loss of appetite
- Pelvic pain
- Single swollen leg
- Weight loss
Precancerous changes of the cervix and cervical cancer cannot be seen with the naked eye. Special tests and tools are needed to spot such conditions.Signs and tests
- Pap smears screen for precancers and cancer, but do not make a final diagnosis.
- If abnormal changes are found, the cervix is usually examined under magnification. This is called colposcopy. Pieces of tissue are surgically removed (biopsied) during this procedure and sent to a laboratory for examination.
- Endocervical curettage (ECC) to examine the opening of the cervix
- Cone biopsy
- Chest x-ray
- CT scan
- Cystoscopy
- Intravenous pyelogram (IVP)
- MRI
Treatment of cervical cancer depends on:Treatment
- The stage of the cancer
- The size and shape of the tumor
- The woman's age and general health
- Her desire to have children in the future
Types of surgery for early cervical cancer include:
- Loop electrosurgical excision procedure (LEEP) -- uses electricity to remove abnormal tissue
- Cryotherapy -- freezes abnormal cells
- Laser therapy -- uses light to burn abnormal tissue
Treatment for more advanced cervical cancer may include:
- Radical hysterectomy, which removes the uterus and much of the surrounding tissues, including lymph nodes and the upper part of the vagina.
- Pelvic exenteration, an extreme type of surgery in which all of the organs of the pelvis, including the bladder and rectum, are removed.
- Internal radiation therapy uses a device filled with radioactive material, which is placed inside the woman's vagina next to the cervical cancer. The device is removed when she goes home.
- External radiation therapy beams radiation from a large machine onto the body where the cancer is located. It is similar to an x-ray.
National Cervical Cancer Coalition - http://www.nccc-online.org/Support Groups
Many factors influence the outcome of cervical cancer. These include:Expectations (prognosis)
- The type of cancer
- The stage of the disease
- The woman's age and general physical condition
The 5-year survival rate falls steadily as the cancer spreads into other areas.Complications
- Some types of cervical cancer do not respond well to treatment.
- The cancer may come back (recur) after treatment.
- Women who have treatment to save the uterus have a high risk of the cancer coming back (recurrence).
- Surgery and radiation can cause problems with sexual, bowel, and bladder function.
Call your health care provider if you:Calling your health care provider
- Are a sexually active woman who has not had a Pap smear in the past year
- Are at least 20 years old and have never had a pelvic examination and Pap smear
- Think your mother may have taken DES when she was pregnant with you
- Have not had regular Pap smears (ask your health care provider how often you should have one performed)
Prevention
A vaccine to prevent cervical cancer is now available. In June 2006, the U.S. Food and Drug Administration approved the vaccine called Gardasil, which prevents infection against the two types of HPV responsible for most cervical cancer cases.Studies have shown that the vaccine appears to prevent early-stage cervical cancer and precancerous lesions. Gardasil is the first approved vaccine targeted specifically to prevent any type of cancer.Practicing safe sex (using condoms) also reduces your risk of HPV and other sexually transmitted diseases. HPV infection causes genital warts. These may be barely visible or several inches wide. If a woman sees warts on her partner's genitals, she should avoid intercourse with that person.To further reduce the risk of cervical cancer, women should limit their number of sexual partners and avoid partners who participate in high-risk sexual activities.Getting regular Pap smears can help detect precancerous changes, which can be treated before they turn into cervical cancer. Pap smears effectively spot such changes, but they must be done regularly. Annual pelvic examinations, including a pap smear, should start when a woman becomes sexually active, or by the age of 20 in a nonsexually active woman.See also: Physical exam frequencyIf you smoke, quit. Cigarette smoking is associated with an increased risk of cervical cancer
Diabetic Neuropathy
Causes, incidence, and risk factors
Some people with diabetes will not develop nerve damage, while others may develop this condition early. On average, symptoms begin 10 to 20 years after the diabetes diagnosis. Approximately 50% of people with diabetes will eventually develop nerve damage.
Peripheral nerve injuries may affect nerves in the skull (cranial nerves) or nerves from the spinal column and their branches. This type of nerve injury (neuropathy) tends to develop in stages.
Autonomic neuropathies affect the nerves that regulate vital functions, including the heart muscle and smooth muscles.
Symptoms
- Constipation
- Diarrhea
- Nausea and vomiting
- Swallowing difficulty
- Deep pain, most commonly in the feet and legs
- Loss of the sense of warm or cold
- Muscle cramps
- Numbness (if the nerves are severely damaged, you may be unaware that a blister or minor wound has become infected)
- Tingling or burning sensation in the extremities, particularly the feet
- Weakness
- Dizziness
- Drooping eyelid
- Drooping face
- Drooping mouth
- Impotence
- Light-headedness when standing up (orthostatic hypotension)
- Loss of bladder control
- Rapid heart rate
- Speech impairment
- Vision changes
Signs and tests
Health care providers often test for loss of sensation in the feet with a brush-like instrument called a monofilament.
Electrodiagnostic testing may be done.
Treatment
Tight control of blood sugar (glucose) is important to prevent symptoms and problems from getting worse.
Medications may be used to reduce the symptoms in the feet, legs, and arms. These medications include:
- Antidepressant drugs, such as amitriptyline (Elavil), doxepin (Sinequan), or duloxetine (Cymbalta)
- Antiseizure medications, such as gabapentin (Neurontin), pregabalin (Lyrica), carbamazepine (Tegretol), and valproate (Depakote)
- Drugs that block bladder contractions may be used to help with urinary control problems.
- Erythromycin, domperidone (Motilium), or metoclopramide (Reglan) may help with nausea and vomiting.
- Pain medications (analgesics) may work for some patients on a short-term basis, but in most cases they do not provide much benefit.
- Phosphodiesterase type 5 (PDE-5) drugs, such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are safe and effective for treating impotence in patients with diabetes.
- Capsaicin can be used topically to reduce pain.
Expectations (prognosis)
Complications
- Injury to the feet due to loss of feeling
- Muscle breakdown and imbalance
- Poor blood sugar control due to nausea and vomiting
- Skin and soft tissue breakdown (ulceration) that may require amputation
Calling your health care provider
Prevention
In addition, regular foot care can prevent a small infection from getting worse. This is why no appointment for diabetes care is complete without a thorough foot examination.
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