Diabetes (Type 2)

Diabetes is a condition that relates to the body’s ability to control the amount of glucose in the blood. Insulin is a hormone naturally produced by the pancreas. It is responsible for regulating a person’s blood sugar levels. Insulin works in the body to extract glucose from the blood and move it into the cells, where it can be converted into energy. If this process is inhibited, the glucose will remain in the blood and cannot be used as fuel. The body will naturally try to reduce the amount of glucose in the blood by expunging the excess in the urine. Typical symptoms of type 2 diabetes include:

• Fatigue
• Extreme thirst
• Passing urine more often
• Weight loss

Diabetes can be divided into three main types:

• Type 1 diabetes – the pancreas does not produce any insulin.
• Type 2 diabetes – the pancreas does not produce enough insulin, or the body’s cells fail to react to the insulin.
• Gestational diabetes – this form of diabetes can occur during pregnancy, with the symptoms usually resolving after birth.

Type 2 diabetes is the result of the pancreas not producing enough insulin to control the glucose in the blood. Alternatively, the condition can occur when the body is unable to successfully use what insulin is being produced- this is known as insulin resistance.

The onset of type 2 diabetes can be caused by several factors. The four main risk factors are:

• Age – the risk of developing type 2 diabetes increases with age. On average, as people get older, they tend to exercise less and gain weight.
• Genetics – your risk of developing type 2 diabetes increases if you have a blood relative with the condition.
• Weight – Being overweight or obese significantly increases the chances of developing type 2 diabetes.
• Ethnicity – South Asian, Chinese, African -Caribbean and Black-Africans are genetically more prone to developing type 2 diabetes. The condition is six times more prevalent within south Asian communities compared with the general UK population.

Type 2 diabetes affects around 3 million people in The UK. The condition can cause serious health complications, including:

• Heart disease/stroke
• Nerve damage
• Diabetic retinopathy (damage to the retina of the eye)
• Kidney disease
• Foot problems, such as foot ulcers (resulting from nerve damage and poor circulation)
• Sexual dysfunction
• Miscarriage and stillbirth.

This is why it’s very important to spot the symptoms early. Even pre-diabetes can increase the chance of developing heart disease.

Typical symptoms of type 2 diabetes include:

• Constant feelings of thirst
• Increased hunger (particularly after eating)
• Passing urine more frequently, especially at night
• Fatigue or lethargy
• Weight loss and loss of muscle mass
• Genital itching
• Dry mouth
• Headaches
• Frequent bouts of thrush
• Slow-healing wounds
• Blurred vision (caused by the eye’s lenses becoming dry)
• Loss of consciousness (rare).

In many cases, type 2 diabetes goes undiagnosed until further health complications arise as a result. The symptoms of type 2 diabetes can develop very gradually, making it quite difficult to spot. It is recommended to seek medical advice if you experience any of the related symptoms.

Other symptoms of type 2 diabetes can include:

• Frequent yeast infections
• Acanthosis nigricans – dark, velvety skin changes to the neck, armpit and groin
• Erectile dysfunction in men
• Tingling or numbness in the hands and feet.

If you present with any of the symptoms of diabetes, it is important to visit your GP as soon as possible. Your doctor will ask about your symptoms and will likely perform a blood glucose test, before deeming whether any additional testing is required.

A blood glucose test is usually the first course of action. It’s easy, convenient, and less expensive than other testing methods. It involves using a small plastic lancet to pierce the skin, typically on the side of the finger. This will provide a drop of blood, which a testing strip can then absorb and analyse. The testing strip is attached to a compact battery-powered meter that will calculate and display the blood glucose levels.

If your blood glucose results are high within the normal range, or just marginally over, your doctor may recommend you monitor your blood glucose levels at home. This can be done using a blood glucose testing kit, which is available in most pharmacies.

Your doctor will likely ask you to test your blood glucose levels at the same time each day for one or two weeks. It will be important to note down when and what you’ve eaten during each day. This will help your GP to better gauge your results, and to identify any rogue or anomalous readings. In a home testing kit, blood glucose levels are measured by how many millimoles are present in a litre of blood. This measurement will help define the concentration of glucose in the blood, and will be expressed as mmol/l. A normal blood glucose level would be:

• Between 4-6 mmol/l before meals
• Less than 10 mmol/l two hours after meals

These levels can vary slightly from person to person. To provide the most accurate reading, it is recommended to abstain from eating or drinking, with the exception of water, for eight hours prior to testing. This is known as a fasting test. If the results of your initial fasting test are outside the normal range, or if after home testing, your results are still inconclusive, your doctor will need to perform further tests in order to gain a firm diagnosis. This could be in the form of a blood or urine test, or both. Urine doesn’t normally contain glucose. However, glucose can overflow through the kidneys and into your urine if diabetes is present. If your urine sample tests positive for glucose, a specialised blood test can be performed to determine whether you have diabetes. This blood test is known as glycated haemoglobin (HbA1c). In some cases, the urine test is bypassed in favour of the HbA1c test.

Diabetes treatment is designed to keep the body’s blood glucose level as normal as possible. This will help manage the symptoms of diabetes, whilst helping to prevent the associated health problems from developing later in life. Type 2 diabetes will usually get worse over time. Adjusting your lifestyle and diet may initially help control the condition, but eventually, there may be a need to take medication.

The first line of treatment is usually in tablet form. This can be one type of tablet or a combination of two or more types of tablets. Type 2 diabetes treatment can also include injecting insulins or other medications. A more detailed breakdown of type 2 diabetes treatment is listed below:

Metformin – this is usually the first line of treatment for type 2 diabetes. Metformin works to reduce the amount of glucose the liver releases into the bloodstream. Also, metformin works to heighten the body’s cells responsiveness to insulin. Metformin is also recommended for adults who present with a higher risk of developing diabetes, where their blood glucose levels are progressing towards the condition, despite having made the necessary lifestyle changes. If you are diabetic and classed as overweight, you will likely be prescribed metformin. Unlike other diabetic medicines, metformin usually doesn’t cause any additional weight gain. In a small number of cases, as with most all medicines, metformin can carry the risk of side effects. The most common being diarrhoea and nausea. Metformin isn’t tolerated by everyone. For example, if you have kidney damage then this medicine may not be suitable.

Sulphonylureas – are medicines that increase the amount of insulin produced by the pancreas. These medicines are usually prescribed where there is an intolerance to metformin, or if the patient is not overweight. Alternatively, sulphonylureas and metformin are often prescribed together, where one medication alone isn’t enough to control a patient’s blood glucose levels. Sulphonylureas carry an increased risk of hypoglycaemia, which is the result of low blood sugars. This is due to the increased amount of insulin the body is now producing. The most common side- effects associated with sulphonylureas are; weight gain, nausea, and diarrhoea. Examples of sulphonylureas medicines include; glibenclamide, gliclazide, and glipizide.

Pioglitazone (glitazones) – this is a type of thiazolidinedione medicine. This type of medication heightens the body’s cells sensitivity to the hormone insulin, which results in more glucose being taken from the blood. Pioglitazone is typically prescribed in combination with either metformin or sulphonylureas, or in some cases both. Pioglitazone isn’t suitable for everyone. This medicine should be avoided if the patient is suffering from heart failure, or if they have a high risk of bone fracture. The most common side-effects associated with pioglitazone include; weight gain and swelling in the ankles (oedema).

Gliptins (DPP-4 inhibitors) – these medicines work by inhibiting the breakdown of a hormone called GLP-1. This hormone helps the body to produce insulin in response to high blood glucose levels, however, it is rapidly broken down. By preventing GLP-1’s breakdown, more insulin can be produced by the body at the appropriate times, without causing episodes of hypoglycaemia. Gliptins are generally prescribed for patients who are unable to take sulphonylureas or glitazones, or in combination with them. Unlike sulphonylureas and glitazones, gliptins aren’t associated with any weight gain. Examples of gliptins include; linagliptin, saxagliptin, sitagliptin, and vildagliptin.

SGLT2 inhibitors – work to increase the amount of glucose that is excreted in the urine. These medicines are usually considered in cases where metformin and DPP-4 inhibitors are unsuitable. The main side-effect associated with SGLT2 inhibitors is a higher risk of developing a genital and urinary tract infection. Examples of SGLT2 inhibitors include; dapagliflozin, canagliflozin, and empagliflozin.

GLP-1 agonists – these medicines work in a similar fashion to gliptins. Administered by injection, GLP-1 agonists work to increase insulin production during periods where the blood glucose levels are high, thus reducing said levels without causing hypoglycaemia.

Acarbose – Acarbose works by slowing down the rate at which the digestive system breaks down carbohydrates into glucose. Acarbose isn’t often prescribed to treat type 2 diabetes, due to its inherent side-effects, which include bloating and diarrhoea. Its use is usually reserved for instances where other types of treatment are either unsuitable or ineffective.

Nateglinide & repaglinide – these medicines help stimulate the release of insulin by the pancreas. They aren’t always deemed a suitable treatment because their effects are short-lasting and they carry a risk of side-effects, such as weight gain and hypoglycaemia. However, they may prove to be a suitable option for patients who eat their meals at irregular times. This is because they are effective when taken just before eating.

Insulin – Insulin is a hormone produced by the pancreas, which helps the body use the glucose in the blood. If the body is naturally producing too little or no insulin, then it will become necessary to inject the hormone. Insulin must be injected subcutaneously, as the oral route would cause it to be broken down by the stomach. Insulin injections are administered via a syringe or an injection pen (insulin pen or autoinjector). In most cases, doses of insulin are administered between two and four times a day. If you need to inject insulin, your diabetes care team will help teach you how and when to do so. They will also teach either a close friend or relative how to inject insulin properly.

Treating hypoglycaemia – Depending on what medication you are taking, type 2 diabetes can carry a risk of experiencing episodes of hypoglycaemia. Hypoglycaemia occurs when the blood sugar levels become too low, causing the sufferer to feel shaky, weak, or hungry. In most cases, the condition can be managed by eating or drinking something sugary, such as glucose tablets or sugary drinks.

If the sufferer develops severe hypoglycaemia, they may become confused and drowsy, even to the point where they lose consciousness. Under these circumstances, an injection of glucagon into a muscle, or glucose into a vein will be required. Your diabetes team will advise you on how best to avoid a hypoglycaemia attack, and what to do during one.

Other treatments – having type 2 diabetes will increase a person’s risk of developing heart disease, stroke, and kidney disease. To help manage the potential risk of developing these conditions, other medicines may be prescribed. These include:

• Statins – which will help reduce high cholesterol. Examples include; simvastatin and atorvastatin.
• Anti-hypertension medicines – also known as blood pressure tablets, these medicines will help control high blood pressure.
• Aspirin (low dose) – low dose Aspirin (75mg) is usually taken once daily to help prevent strokes.
• Angiotensin-converting enzyme (ACE) inhibitors – these medicines will help reduce the risk of developing diabetic kidney disease. Examples of ACE inhibitors include; Enalapril, Lisinopril, and Ramipril.

It is estimated that up to 90% of cases of type 2 diabetes can be prevented by adopting healthy lifestyle habits.

Maintain a healthy weight – being overweight or obese will significantly increase the chances of developing type 2 diabetes. Maintaining a healthy weight is an essential element for preventing the onset of the condition. Losing just 5kg, even over the course of several years, can reduce the risk of developing type 2 diabetes by up to 50%. Your aim should be to achieve a healthy body mass index (BMI), which for the general population is a reading between 18.5 and 25. Your BMI is calculated using your height and weight.

Reduce your intake of sugary foods – your risk of developing type 2 diabetes can be reduced by being more vigilant about the amount and type of carbohydrates that you ingest.

Increase the amount of high-fibre foods you eat - This can include wholegrain bread, fruit, vegetables, cereals, beans and lentils.

Choose foods that are low in fat – replace butter with a low-fat spread. Try to eat more fish and lean meats, such as chicken, instead of fatty, processed meats, such as burgers and sausages.

Change the way you cook food - try to avoid frying and roasting foods. Instead, you can steam, grill, poach or bake.

Substitute sugary snacks for healthier options, such as fruit, unsalted nuts, or low-fat yoghurts. Avoid snacks like crisps, pastries, cakes and biscuits.

Being physically active is very important in helping to prevent the onset of type 2 diabetes. It is recommended to partake in at least 150 minutes of moderately intense aerobic activity a week. This can include; brisk walking, cycling and jogging. It is also recommended to include muscle- strengthening activities as part of your workout regime. These should aim to work all the major muscle groups – arms, legs, shoulders, back, hips and abdomen.

In cases where these physical activity targets are unrealistic, even minor increases in your activity levels will prove beneficial to your health. A minor increase in activity may also act as a springboard for future improvements.

Your GP, dietitian, or diabetes care team can provide more tailored advice about what diet and exercise programme will work best for you.