Type 2 Diabetes: treatment by Dr. Maria Pavlatou |

What is diabetes mellitus type 2?

Type 2 diabetes mellitus is a metabolic disorder characterised by elevated blood sugar, insulin resistance and relative insulin deficiency. It accounts for the majority of people with diabetes and develops mainly in adults who are overweight. However, most patients, regardless of the degree of obesity, have some degree of tissue insensitivity to insulin action. The disease usually remains undiagnosed for many years because hyperglycaemia can develop very gradually over the years and initially without symptoms. Despite this silent presentation, patients develop both micro- and macro-vascular complications.

What are the causes of diabetes mellitus type 2?

The causes of type 2 diabetes mellitus are multifactorial – a complex combination of genes and environmental factors. Many genes with varying degrees of involvement are implicated in the disease, but are not capable of causing it on their own. The environment has a huge impact on the development of the disease: A sedentary life, lack of physical activity and a poor quality diet leading to obesity are the necessary conditions for the disease to occur. The majority of patients with type 2 diabetes have excess fat, whether or not they are obese.

What is the likelihood of first-degree relatives developing diabetes?

The likelihood of first-degree relatives of patients with type 2 diabetes developing diabetes in their lifetime is 5 to 10 times higher than in the general population.

At what age does type 2 diabetes mellitus occur?

Type 2 diabetes mellitus occurs mostly in adults. The average age at diagnosis is 45 years. However, since 1990, the incidence of type 2 diabetes has increased in both children and adolescents. The main reason for this is the increased rates of obesity in the children’s population.

What is its impact in Greece?

The prevalence of diabetes in our country is estimated at 7.4%.

What are the signs & symptoms of Type 2 Diabetes Mellitus?

As type 2 diabetics have relative rather than complete insulin deficiency, their symptoms are milder and often go unnoticed.

Asymptomatic presentation
Recurrent blurred vision
Generalised itching
Skin infections
Vulvo-vaginitis
Lower limb sensory disturbances
Polyuria
Polydipsia
Weakness and fatigue
Cramps
Infections

How is Diabetes Mellitus Diagnosed?

Diabetes Mellitus is diagnosed either by measuring blood glucose or by measuring haemoglobin A1c in the blood. Haemoglobin A1c (HbA1c) measures the percentage of glucose that has been attached to haemoglobin A in red blood cells and shows us the average blood sugar 10-12 weeks before the measurement.

Diagnosis and Treatment of Co-morbidities and Risk Factors

Once the type of diabetes mellitus has been determined, evaluation and treatment of diabetes related complications, metabolic co-morbidities and cardiovascular risk factors, such as hyperlipidaemia, obesity, fatty liver disease and other autoimmune diseases (such as autoimmune thyroiditis) in the case of type 1 diabetes, should be performed. In addition, heart and kidney function should be checked, comorbid conditions such as periodontal disease and the patient’s psychological status and acceptance of the disease should also be investigated. Finally, patients with diabetes mellitus have a higher risk of hepatitis B infection, as well as complications due to influenza and pneumococcal infection, and should receive the appropriate vaccines.

What is the treatment for type 2 diabetes mellitus?

/ / /Obesity

Treatment of type 2 diabetes consists of body weight management in addition to glycaemia. Exercise, a balanced diet and weight loss in overweight or obese patients are key elements in the management of type 2 diabetes.

/ / /Diet

A well-balanced, nutritious diet is a fundamental component of type 2 diabetes treatment. The proportions of essential dietary components must be individualized. Generally, 45% of the calories in the diet of patients with diabetes are made up of carbohydrates, 25% to 35% of fats and 10% to 35% of protein.

/ / /Exercise

Exercise is an integral part of diabetes treatment. In addition to the known benefits, cardiovascular protection and body weight maintenance are additional benefits of exercise for the type 2 diabetic patient.

/ / /Anti-hyperglycaemic agents

The choice of the appropriate medication for patients with type 2 diabetes depends on many factors and should therefore be individualised. We now have new classes of drugs available that target both diabetes related complications and co-morbidities such as obesity and cardiovascular disease, at the same time as glycaemic control. In our therapeutic arsenal we currently have 7 classes of drugs. The new drugs target both cardiovascular complications and weight loss. Important factors in the decision of the therapeutic regimen are insulin status and the presence of cardiovascular disease and chronic kidney failure.

Complications of Diabetes Mellitus

/ / / Acute Complications of Diabetes Mellitus

> Hypoglycaemia

Hypoglycaemia is the most common complication seen in insulin-treated diabetic patients. Less commonly, it also occurs in diabetic patients taking drugs that stimulate pancreatic beta cells to secrete insulin, such as sulfonylureas. The lower normal limit of fasting glucose is 70 mg/dl. Below these levels, the body mobilises neuronal and hormonal mechanisms to prevent further drop in glucose levels to ensure normal brain function. The most important hormone that prevents the fall in blood sugar is glucagon. Unfortunately, over the years, diabetic patients gradually lose the mechanisms they have against hypoglycaemia. On the other hand, severe and recurrent hypoglycaemia can lead to coma, irreversible neurological damage or even death. The treatment of hypoglycaemia consists in the intake of 15 g of glucose, such as natural orange juice. In more severe cases, hospital admission may be needed. However, more important is the prevention of hypoglycaemia, which is achieved by proper training of the diabetic patient and compliance with the treatment.

> Diabetic Ketoacidosis/Hyperosmolar Hyperglycaemic State

These are the two most serious acute complications of diabetes, which if not treated in time can lead to death. They are characterised by severe hyperglycaemia, leading to dehydration and metabolic acidosis. Both of these hyperglycaemic crises are due to a combination of relative or absolute insulin deficiency and a rise in stress hormones, which, however, compete the action of insulin and thus exacerbate hyperglycaemia. In the case of diabetic ketoacidosis, which usually occurs in patients with type 1 diabetes, the lack of insulin typically leads to the production of ketones, which further aggravate the metabolic acidosis. The trigger point is usually a stressful condition, such as a severe infection, myocardial infarction or recent surgery. Many times these two emergencies lead to the first diagnosis of diabetes.

Similarly to hypoglycaemia, more important is the prevention of such complications, which is achieved by proper training of the diabetic patient and compliance with his/her treatment. In our clinic, our experience at major diabetes centres abroad allows us to provide an intensive training regimen for patients with diabetes with a focus on the prevention and management of these serious acute complications of the disease.

/ / / Chronic Complications of Diabetes Mellitus

Diabetes is a multisystemic disease that affects most organs of the body at different times of a diabetic patient’s life. However, diabetic vascular disease and neuropathy cause significant morbidity and mortality and therefore need thorough and systematic monitoring.

> What are and how can I prevent the macro-vascular complications of diabetes (Diabetic Vascular Disease)?

The macrovascular complications of diabetes involve the large vessels and are in fact an accelerated form of atherosclerosis, which is responsible for the increased rates of myocardial infarction, strokes, and peripheral gangrene seen in diabetic patients. Indeed, diabetic patients have an increased risk of dying from one of these complications, collectively called atherosclerotic cardiovascular disease, and their life expectancy is 6-8 years shorter than the general population.

> Prevention/Treatment of Macro-Vascular Complications

An important part of the diabetes management is therefore the prevention and/or treatment of macrovascular complications, consisting of not only proper glycaemic control, but also the treatment of the risk factors of atherosclerotic cardiovascular disease. These are obesity, hypertension, dyslipidaemia and smoking. In particular, patients with type 2 diabetes, at the time of diagnosis, already have one or more risk factors or are suffering from some of aforementioned complications. Addressing the risk factors of atherosclerotic cardiovascular disease has been shown to reduce cardiovascular mortality.

> What are and how can I prevent microvascular complications of diabetes (Diabetic Vascular Disease)?

Microvascular complications of diabetes involve the smaller vessels and primarily include diabetic ophthalmopathy and neuropathy.

> Can I lose my vision from diabetic ophthalmopathy?

Diabetic ophthalmopathy is one of the most serious causes of blindness worldwide. Its incidence reaches 75%-95% after 15 years of type 1 diabetes and 60% after 15 years of type 2 diabetes. In addition, end-stage diabetic kidney disease develops in 40% of patients with type 1 diabetes, while this percentage is less than 20% in patients with type 2 diabetes.

“At least once a year all patients with type 2 diabetes and patients with type 1 diabetes of duration ≥5 should have their urinary albumin excretion tested”

“At least once a year all patients with type 2 diabetes and patients with type 1 diabetes of duration ≥5 should have an eye examination by an ophthalmologist”

> Prevention/Treatment of Microvascular Complications

The duration of diabetes and poor glycemic control are key risk factors of microvascular complications. Additional risk factors include hypertension, the presence of other microvascular complications, smoking, obesity, age and genetic factors. As with other complications of diabetes, their prevention is very important and involves a number of actions, such as ongoing evaluation and addressing risk factors.

“Optimizing blood sugar and blood pressure reduces the risk and slows the progression of diabetic kidney disease”

“Optimizing blood sugar and lipid (cholesterol) levels but also blood pressure reduces the risk and slows the progression of diabetic retinopathy”

> Diabetic Neuropathy

Peripheral and autonomic neuropathy are the two most common complications of both type 1 and type 2 diabetes. Up to 50% of patients with type 2 diabetes develop diabetic neuropathy.

Peripheral neuropathy involves the peripheral nerves and the most common is Distal Symmetric Polyneuropathy, characterized by progressive loss of sensation and mobility. The longer nerves are particularly sensitive and therefore the legs are most often affected. Unfortunately, up to 50% of patients are asymptomatic.

If the disease is not diagnosed and treated on time, the patient is at increased risk of injuring his/her feet without realising it due to the lack of sensation and thus developing ulcers, which can eventually lead to amputation, with a significant reduction in the quality and life expectancy of patients. Prevention is therefore of paramount importance here too.

“At least once a year all patients with type 2 diabetes and patients with type 1 diabetes of duration ≥5 should be screened for diabetic peripheral neuropathy”

“Optimizing blood sugar levels prevents or delays the development of neuropathy in patients with type 1 diabetes and slows the progression of neuropathy in patients with type 2 diabetes.”

> Autonomic Neuropathy

Autonomic Neuropathy is a common clinical problem in patients with diabetes as it can go unnoticed and can affect multiple organs, such as blood pressure and pulse, gastrointestinal tract and bladder function and erectile function. Erectile dysfunction is closely associated with the onset of coronary heart disease as it precedes it by 3-5 years. Similar to other complications of diabetes, prevention is the best treatment.

“In our clinic, patients with diabetes mellitus follow a systematic follow-up program, where along with the glycaemic control, the complications of diabetes are thoroughly and systematically examined and treated, based on the international guidelines and our experience from the largest diabetes centres abroad.”