Clinical:Type 2 Diabetes Mellitus

Diabetes is a long-term (chronic) condition caused by too much glucose (sugar) in the blood. It is also sometimes known as diabetes mellitus. Diabetes affects two million people in England and Wales. It is also thought that there are a further 750,000 people who have the condition but are unaware of it.

Introduction

How does diabetes occur?

Normally, the amount of sugar in the blood is controlled by a hormone called insulin, which is produced by the pancreas (a gland that is located behind the stomach). When food is digested and enters the bloodstream, insulin helps to move any glucose out of the blood and into cells, where it is broken down to produce energy. However, in diabetes, because there is either not enough insulin, or because there is a poor response (resistance) to insulin, the body is unable to fully use the glucose in the blood stream. There are two types of diabetes: diabetes type 1 and diabetes type 2. This article focuses on type 2 diabetes. See Useful links for information about type 1 diabetes.

What is type 2 diabetes?

Type 2 diabetes occurs when not enough insulin is produced by the body for it to function properly, or when the body’s cells do not react to insulin. This is called insulin resistance. Type 2 diabetes is far more common than type 1 diabetes, which occurs when the body does not produce any insulin at all. Around 95% of all people with diabetes have type 2 diabetes. If you have type 2 diabetes, you may be able to control your symptoms simply by eating a healthy diet, and monitoring your blood glucose level. However, as type 2 diabetes is a progressive condition, you may eventually need to take insulin medication, usually in the form of injections. Type 2 diabetes is often associated with obesity. Obesity-related diabetes is sometimes referred to as maturity onset diabetes because it is more common in older people.

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Gestational diabetes (diabetes in pregnancy)

During pregnancy, some women have such high levels of glucose in their blood that their body cannot produce enough insulin to absorb it all. This is known as gestational diabetes, and affects approximately 2-7% of pregnant women. Pregnancy can also sometimes make existing type 1 or type 2 diabetes more difficult to control. If you are pregnant, you may require additional time and effort to manage your diabetes during your pregnancy. Gestational diabetes can increase the risk of health problems developing in an unborn baby, so it is important that you keep the glucose levels in your blood under control. In most cases, gestational diabetes disappears after the baby is born. However, women with the condition have an estimated 30% risk of developing type 2 diabetes later on in life.

Symptoms of type 2 diabetes

Most of the symptoms of diabetes are the same for type 1 and type 2 diabetes. However, there are differences in the way the symptoms develop.

• The main symptoms of diabetes

The main symptoms of diabetes are:

• feeling very thirsty,
• producing excessive amounts of urine (going to the toilet a lot),
• extreme tiredness (fatigue), and
• weight loss and muscle wasting (loss of muscle bulk).

Other symptoms of diabetes can include:

• itchiness around the vagina or penis,
• recurring thrush as a result of the excess glucose in your urine, and
• blurred vision caused by the lenses of your eyes becoming very dry.

However, not everyone will experience these other symptoms, and they are not usually severe in those who do get them.

If you have type 2 diabetes, the symptoms will usually develop over weeks or months. Your symptoms may develop so slowly that you do not realise that you are unwell for some time. Type 2 diabetes may also cause additional symptoms. For example, if you have cuts and sores, they may take longer to heal. It is sometimes possible to develop type 2 diabetes without having any symptoms at all, or only having a few symptoms. However, you will still require treatment to prevent other health problems such as kidney disease, from developing later on.

Hypoglycaemia (low blood glucose)

Main Article: Hypoglycemia

If you have diabetes and you are receiving treatment, your blood glucose levels can become very low. This is known as hypoglycemia, or a 'hypo'. A hypo occurs when any insulin that is in your body moves too much glucose out of your bloodstream. Hypoglycemia often occurs if you take too much insulin, although it can also occur if you skip a meal, exercise very vigorously or drink alcohol on an empty stomach.

Symptoms of a ‘hypo’ include:

• feeling shaky and irritable,
• sweating,
• tingling lips,
• feeling weak,
• hunger, and
• nausea (feeling sick).

A hypo can be brought under control simply by eating or drinking something that is sugary, such as a fizzy drink (but not a diet drink), sugar cubes or raisins. This should stop the attack. After you have had something sugary, you should eat a longer-acting carbohydrate food, such as some biscuits or a sandwich.

If a hypo is not brought under control it can lead to:

• confusion,
• slurred speech, and
• unconsciousness.

If this occurs, you will need emergency treatment. One widely used treatment is an injection of a hormone called glucagon. Glucagon raises the level of glucose in your blood. See the Treatment section, above, and Useful links for more information about hypoglycemia and hypos.

Hyperglycaemia (high blood glucose)

Type 2 diabetes occurs because your body is unable to produce enough insulin, or because the cells in your body do not respond properly to insulin. This means that insulin cannot regulate your blood glucose level and, as a result, your blood glucose levels may become very high. This happens because there is no insulin to move glucose out of your bloodstream and into your cells to produce energy. If your blood glucose levels become too high, you may experience what is known as hyperglycemia. The symptoms of hyperglycemia are similar to the main symptoms of diabetes but they may be more severe and come on suddenly.

They include:

• extreme thirst,
• a dry mouth,
• blurred vision,
• drowsiness, and
• a frequent need to pass urine.

Hyperglycaemia can occur for several reasons including:

• eating too much,
• being unwell, or
• not taking enough insulin.

If left untreated, hyperglycaemia can lead to diabetic ketoacidosis, which can eventually cause unconsciousness and even death. Diabetic ketoacidosis occurs when your body begins to break down fats for energy, instead of glucose, leading to a build up of acids in your blood. However, diabetic ketoacidosis is a rare complication of diabetes. See the Treatment section, above, and Useful links section for more information about hyperglycaemia and diabetic ketoacidosis.

Causes of type 2 diabetes

Insulin is a hormone that is needed to control the amount of glucose (sugar) in your blood. Type 2 diabetes occurs either because your body cannot produce enough insulin, or because the cells in your body do not react properly to insulin. It is also possible to have type 2 diabetes as a result of both of these reasons.

When you eat, your digestive system breaks down food and passes its nutrients into your bloodstream. Normally, insulin is produced by your pancreas to take any glucose out of your blood and move it into your cells where it is broken down to produce energy.

If you have type 2 diabetes, there is either not enough insulin to move glucose out of your bloodstream, or the insulin that is there is ineffective in moving glucose.

Risk factors for type 2 diabetes

The exact cause of type 2 diabetes is not fully understood, although there are many factors that make developing the condition more likely. The more factors that apply to you, the higher your risk of developing type 2 diabetes.

Being overweight or obese

In most cases, type 2 diabetes is thought to be linked to having excess body fat. If you are overweight or obese, the cells in your body become less responsive to the effects of insulin. This explains why 80% of people who develop type 2 diabetes are overweight or obese, tend not to get much exercise, and have a large waist.

Women are thought to be at a higher risk of developing type 2 diabetes if they have a waist size of 31.5 inches (80cm), or over. Men are thought to be at a higher risk if they are Asian and their waist is 35 inches (90cm) or over, or if they are white, or black, with a waist size of 37 inches (94cm) or over.

Ethnic origin

It is not known why people of certain ethnicities are more at risk of developing type 2 diabetes than others. You are at least five times more likely to develop type 2 diabetes if you are African-Caribbean or of south Asian origin and living in the UK, compared with someone who is white.

Age

Your risk of developing type 2 diabetes also increases as you get older, which may be due to the fact that people usually gain weight and exercise less as they get older.

You are considered to be at risk of developing type 2 diabetes if you are over 40 years of age and white or over 25 years of age and black, Asian, or from a minority ethnic group. However, some children as young as seven are now being diagnosed with type 2 diabetes.

Genetic factors

There is also a genetic risk factor for type 2 diabetes. You are more likely to develop the condition if you have a close relative such as a parent or sibling (brother or sister) who has type 2 diabetes.

You also have an increased risk of developing type 2 diabetes if you have either impaired fasting glycaemia (IFG), or impaired glucose tolerance (IGT). These conditions are sometimes also known as pre-diabetes, and mean that your blood glucose level is higher than usual, but not high enough to cause diabetes. IFG and IGT can both progress into type 2 diabetes if you do not take steps to prevent it.

Diagnosing type 2 diabetes

It is important that diabetes is diagnosed as early as possible so that treatment can be started. You should see your GP as soon as possible if you experience the symptoms of diabetes. They will ask you some questions about your symptoms and will also request a urine sample.

Blood and urine tests

Your urine sample will be tested to see if it contains glucose. Normally, urine does not contain glucose, but if your blood glucose level is high, some glucose can overflow through your kidneys and into your urine.

If your urine contains glucose, your GP will carry out a blood test in order to confirm the diagnosis of diabetes. A sample of your blood will be taken in the morning before you have had anything to eat and it will be tested to measure your blood glucose levels.

If your blood glucose levels are not high enough for your GP to diagnose diabetes, you may need to have an oral glucose tolerance test. This is also sometimes referred to as a glucose tolerance test (GTT). Your GP will give you a glucose drink and take blood tests every half an hour, for two hours to see how your body is dealing with the glucose.

Diagnosing type 2 diabetes

If you are diagnosed with diabetes, your GP may do further blood and urine tests to find out whether you have type 1 or type 2 diabetes. However, in some cases, it may be clear to your GP from your symptoms and medical history which type of diabetes you have.

There are no specific tests to diagnose type 2 diabetes, but you may be diagnosed with the condition if the results of the tests for type 1 diabetes are negative.

Treating type 2 diabetes

Diabetes cannot be cured but the aim of treatment is to keep your blood glucose level as normal as possible and to control your symptoms to prevent health problems developing later on in life.

If you have been diagnosed with diabetes, you will be referred for specialist treatment from a diabetes care team. Your care team will be able to:

• explain your condition to you in detail,
• help you to understand your treatment, and
• answer any questions you may have.

They will also closely monitor your condition in order to identify any other health problems that may occur.

If you are diagnosed with type 2 diabetes, you will need to look after your health carefully for life. This may seem daunting but your diabetes care team can offer support and advice about all aspects of your treatment.

If you have type 2 diabetes, there are a number of things you can do yourself to remain healthy, such as taking regular exercise, eating a healthy diet, and losing weight if you are overweight or obese. These measures may be enough to keep your blood glucose at a safe and healthy level, without the need for other treatment.

See the Self help section, above, for more information about how to look after your health when you have type 2 diabetes.

Type 2 diabetes usually gets worse over time and, even if they work at first, diet and exercise may not be enough to control your blood glucose levels.

If you have type 2 diabetes, you may need (or eventually need) medicines that reduce high levels of blood sugar. At first this will usually be tablets, sometimes a combination of more than one type of tablet. It may also include injectable insulin.

The various ways that type 2 diabetes can be treated are outlined below.

Blood glucose testing

If you have type 2 diabetes your GP or diabetes care team will need to take a reading of your long term blood glucose level about every 2-6 months. This shows how stable your glucose levels have been in the recent past and how well your treatment plan is working.

The test that is used to measure your blood glucose levels over the previous 6-12 weeks is known as the HbA1c test. HbA1c is a form of haemoglobin, the oxygen-carrying chemical in red blood cells, that has glucose attached to it.

A high HbA1c level means your blood glucose level has been consistently high over recent weeks, and your diabetes treatment plan may need to be changed. Your diabetes care team will be able to help you to set a target HbA1c level for you to aim for. This will usually be less than 7.5% HbA1c (59 mmol/mol). It can be as low as 6.5% (48mmol/mol) for some people, or higher for some people who experience frequent episodes of hypoglycaemia ('hypos').

A new way of reporting HbA1c results was introduced on June 1 2009, initially alongside the way of recording it that many diabetes patients will already be familiar with.

For more information on these changes and why they happened, watch this video:

Monitoring your blood glucose levels

As well as having your blood glucose level checked by a health professional every 2-6 months, you may also choose to monitor your own blood glucose levels.

Even with treatment with tablets and/or insulin therapy and a healthy diet, many factors such as exercise, illness and stress, can affect blood glucose levels. Other factors that may also affect your blood glucose levels include drinking alcohol, taking other medicines and, for women, changes to hormone levels during the menstrual cycle.

Many people with diabetes monitor their blood glucose levels at home using a simple finger prick blood test. This is to ensure that your blood glucose level is as normal and stable as possible. Blood sugar levels vary thoughout the day so you may need to do it several times a day, depending on the type of treatment that you are taking.

How blood glucose is measured

In home testing, blood glucose levels are usually measured in terms of how many millimoles of glucose there is in a litre of blood. A millimole is a measurement that is used to define the concentration of glucose in your blood. The measurement is expressed as millimoles per litre, or mmol/l, for short.

Blood glucose levels vary from person to person and the amount of glucose in your blood will also change throughout the day. Therefore, there is no such thing as an ‘ideal' blood glucose level.

However, a normal blood glucose level is between 4.0-6.0 mmol/l before meals (preprandial), and less than 10.0 mmol/l two hours after meals (postprandial). Your diabetes care team will be able to discuss your blood glucose level in more detail with you.

Find out how to test your glucose levels

Medicines for type 2 diabetes (glucose-lowering tablets)

If regular exercise and a healthy diet are not effective in controlling your blood glucose levels, you may need medicines to treat type 2 diabetes.

There are several different types of medicines, taken as tablets, that are used to treat type 2 diabetes, You may need to take a combination of two or more medicines to control your blood glucose level. Some of the medicines that may be prescribed for you are outlined below.

In the UK it is usual to give metformin as the initial tablet treatment for type 2 diabetes. If a second glucose lowering drug is needed a sulphonylurea is often added. If a third glucose lowering treatment is needed this could be a glitazone, a gliptin, exenatide or insulin.

Metformin

Metformin is often the first medicine that is recommended to treat type 2 diabetes. It works by reducing the amount of glucose that your liver releases into your bloodstream. It also makes your body's cells more responsive to insulin.

If you are overweight, it is likely that you will be prescribed metformin. Unlike some other medicines that are used to treat type 2 diabetes, metformin should not cause additional weight gain. However, it can sometimes cause mild side effects, such as nausea and diarrhea and you may not be able to take it if you have kidney damage.

Sulphonylureas

Examples of sulphonylureas include:

• glibenclamide,
• gliclazide,
• glimerpirizide,
• glipizide, and
• gliquidone.

These medicines increase the amount of insulin that is produced by your pancreas. You may be prescribed one of these medicines if you cannot take metformin or if you are not overweight.You may be prescribed a sulphonylurea and metformin, if metformin does not control blood glucose on its own.

Sulphonylureas can increase the risk of hypoglycaemia (low blood glucose) because they increase the amount of insulin in your body. Sulphonylureas may sometimes cause side effects including weight gain, nausea and diarrhoea.

Glitazones (thiazolidinediones, TZDs)

Pioglitazone and rosiglitazone are both examples of thiazolidinediones. These medicines make your body’s cells more sensitive to insulin so that more glucose is taken from your blood. They are not often used alone, but are usually used in addition to metformin or sulphonylureas, or both.They may cause weight gain and ankle swelling. There have been some recent reports that rosiglitazone might be associated with a small increased risk of getting a heart attack

Gliptins (DPP-4 inhibitors)

Gliptins are a new group of treatments for type 2 diabetes that work by preventing the breakdown of a naturally occurring hormone called GLP-1. GLP-1 helps the body produce insulin in response to high blood glucose levels , but is rapidly broken down.

By preventing this breakdown, the gliptins (sitagliptin and vildagliptin) act to prevent high blood glucose levels, but do not result in episodes of hypoglycaemia. They are not associated with weight gain. Because they are new, they are used cautiously, but may be added to metformin or sulphonylureas if blood glucose does not come under control with one

Exenatide

Exenatide is a new injectable treatment that acts in a similar way to the natural hormone GLP-1 (see section on gliptins, above). It boosts insulin production when there are high blood glucose levels and so reduces blood glucose without the risk of hypogycaemic episodes ('hypos'). It also results in a modest weight loss in many people who take it. It is mainly used in people on metformin plus sulphonylurea who are obese (with a BMI of 35 or above).

Acarbose

Acarbose helps to prevent your blood glucose level from increasing too much after you eat a meal. It slows down the rate at which your digestive system breaks carbohydrates down into glucose.

Acarbose is not often used to treat type 2 diabetes because it usually causes side effects, such as bloating and diarrhoea. However, you may be prescribed acarbose if you cannot take other types of medicines for type 2 diabetes.

Nateglinide and repaglinide

Nateglinide and repaglinide stimulate the release of insulin by your pancreas. They are not commonly used but may be an option if you have meals at irregular times. This is because their effects do not last very long, but they are effective when taken just before you eat.

Nateglinide and repaglinide can cause side effects, such as weight gain and hypoglycaemia (low blood glucose).

Insulin treatment

You may need to have insulin treatment if glucose-lowering tablets are not effective in controlling your blood glucose levels. Insulin treatment can be taken instead of or alongside your tablets, depending on the dose and the way that you take it.

Insulin comes in several different preparations and each work slightly differently. For example, some are long-acting (lasting up to a whole day), some are short-acting (lasting up to eight hours), and some are rapid-acting (they work quickly but do not last very long). Your treatment may include a combination of these different insulin preparations.

Insulin injections

In most cases of diabetes, you will need to have insulin injections. Insulin must be injected because it is a protein. The enzymes in your stomach would digest it, like a food, if it was taken as a tablet. It could not then be absorbed in the gut.

If you need to take insulin by injection, your diabetes care team will advise you about when you need to take it. They will also show you how to inject it yourself. They will also give you advice about storing your insulin and disposing of your needles properly.

Insulin injections are given using either a syringe, or an injection pen, which is also called an insulin pen (auto-injector). Most people need between 2-4 injections a day. Your GP or diabetes nurse will also teach one of your close friends or relatives how to inject the insulin properly.

Insulin pump therapy

Insulin pump therapy is an alternative to injecting insulin. An insulin pump is a small device (about the size of a pack of playing cards) that holds insulin.

The pump is attached to you by a long piece of thin tubing, with a needle at the end, which is inserted under your skin. Most people insert the needle into their stomach but you could also insert it into your hip, thigh, buttock or arm.

The pump allows insulin to flow into your bloodstream at a rate that you control. This means that you no longer need to give yourself injections, although you will need to monitor your blood glucose levels very closely to ensure that you are receiving the right amount of insulin.

Insulin pump therapy can be used by adults, teenagers and children (with adult supervision) who have type 2 diabetes. However, it may not be suitable for everyone. Your diabetes care team may suggest pump therapy if you often have hypoglycaemia (low blood glucose), or if you can manage your own day-to-day diabetes treatment and look after your health carefully.

See the Useful links section, above, for further information about insulin pump therapy.

Insulin jet system

The insulin jet system is a new device for delivering insulin without using a needle. It is available on the NHS and it can be used on your stomach, buttocks, and thighs.

The insulin jet system works by forcing a very small stream of insulin through a nozzle that is placed against your skin. The insulin travels at a very high speed and passes through your skin. Your diabetes care team will be able to advise you about whether this needle free method of insulin delivery is suitable for you.

Treatment for hypoglycaemia (low blood glucose)

Hypoglycaemia can occur when your blood glucose levels become very low. Mild hypoglycaemia (a 'hypo') can make you feel shaky, weak and hungry, but it can usually be controlled by eating or drinking something sugary.

If you have a hypo, you should initially have a form of carbohydrate that will act quickly, such as a sugary drink or glucose tablets. This should be followed by a longer-acting carbohydrate such as a cereal bar, sandwich or piece of fruit. In the majority of cases, these measures will be enough to raise your blood glucose level to normal, although it may take a few hours.

However, if you develop severe hypoglycaemia, you may become drowsy and confused, and you may even lose consciousness. If this occurs, you will need to have an injection of glucagon into your muscle. Glucagon is a hormone that quickly increases your blood glucose levels.

If you have type 2 diabetes, you may need to carry glucagon with you at all times, and your diabetes care team may show several of your family members and close friends how to inject the glucagon into your muscle if you need it.

If you do lose consciousness because of hypoglycaemia you will need to eat something sugary when you come round.There is a risk that it may happen again within a few hours, so you will need to rest afterwards and have someone with you.

If the glucagon injection into your muscle does not work and you are still drowsy or unconscious 10 minutes after the injection, you will need urgent medical attention. If you are with someone who is in this situation, you should call 999 to request an ambulance.

You will need to have another injection of glucagon straight into a vein, which must be given by a trained healthcare professional.

Treatment for hyperglycaemia (high blood glucose) and diabetic ketoacidosis

Hyperglycaemia is a condition that can occur when your blood glucose levels become too high. It can happen for several reasons such as eating too much, being unwell or, if you have insulin treatment, not taking enough insulin.

If hyperglycaemia occurs, you may need to adjust your diet or your dosage of insulin to keep your glucose levels normal. Your diabetes care team will advise you about the best way to do this.

However, if hyperglycaemia is left untreated, it can lead to diabetic ketoacidosis, which can eventually cause unconsciousness and even death.

Diabetic ketoacidosis occurs when your body begins to break down fats for energy instead of glucose, leading to a build up of acids in your blood. See the Symptoms section, above, for the warning signs of diabetec ketoacidosis.

If you develop diabetic ketoacidosis, you will need urgent treatment in hospital. You will be given insulin directly into a vein (intravenously). If you are dehydrated, you may also need other fluids given by a drip, including saline (salt solution) and potassium.

Other treatments

If you have either type of diabetes, you have an increased risk of developing heart disease, stroke and kidney disease. To reduce the chance of this, you may be advised to take:

• Anti-hypertensive medicines to control high blood pressure.
• A statin, such as simvastatin or atorvastatin, to reduce high cholesterol levels.
• Low dose aspirin to prevent stroke.
• An angiotensin converting enzyme (ACE) inhibitor, such as enalapril, lisinopril, or ramipril, if you have the early signs of diabetic kidney disease.

Diabetic kidney disease is identified by the presence of small amounts of albumin (a protein) in your urine. If it is treated early enough, diabetic kidney disease is often reversible. For more information about ACE inhibitors, see the Useful links section.

It is also recommended that you have an influenza (flu) vaccine each year and a one-off vaccination that protects against some forms of pneumonia and meningitis (pnemococcal disease). These infections can be particularly unpleasant and more serious if you have diabetes.

Regular check-ups

Your GP or diabetes care team will need to check your eyes, feet and nerves regularly because they can be affected by diabetes (see the Complications section, above).

Diabetes in pregnancy

• If you have gestational diabetes, you'll need more antenatal appointments and check-ups than a pregnant woman without diabetes.
• Your diabetes care team will show you how to check your blood glucose levels every day.
• You may need to alter your diet and increase the amount of moderate exercise that you do.
• You may need to have injections of insulin (your care team will help you with this).

If you developed diabetes while you were pregnant, it is likely your blood glucose levels will return to normal after your baby is born. If you had diabetes before you became pregnant, you'll need to continue to treat and manage your condition with the help of your care team.

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Self-help advice

If you have type 2 diabetes, you will need to look after your health very carefully.

Ensuring that you lead a healthy lifestyle by eating a healthy, balanced diet, exercising regularly and looking after your condition can, in many cases, be enough to control your blood glucose levels without the need for further treatment.

Caring for your health will also make treating your diabetes easier and minimise your risk of developing any complications.

Your GP and diabetes care team will be able to advise you about what you need to do to ensure that you remain healthy and reduce your risk of developing further problems. They may also refer you to other specialists within your care team, such as a dietician, for further advice and support.

Some of the advice that you will receive in order to treat your condition is outlined below.

Eat healthily

The belief that if you have diabetes you will have to eat special foods is untrue. Your diet should be the same as that of anyone else - high in fibre, fruit and vegetables and low in fat, salt and sugar.

However, different foods will affect you in different ways, so it is important to know what to eat so you get the right amount of glucose for the insulin that you are taking. A diabetes dietician can help you to work out a diet plan that can be fitted to your specific needs.

Please see the 'lifestyle' section for more information on diet and recipe ideas.

Exercise regularly

Physical activity lowers your blood glucose level, so it is particularly important to exercise regularly if you have diabetes.

Like anyone else, you should aim to do at least 30 minutes of moderate exercise, at least five times a week. This can be any activity that gets you slightly out of breath and raises your heart rate. However, you should not start a new activity without consulting your GP or diabetes care team first.

As exercise will affect your blood glucose level, you and your care team may have to adjust your insulin treatment, or diet plan, in order to keep your glucose level steady.

Do not smoke

If you have diabetes, you have an increased risk of developing a cardiovascular disease, such as a heart attack or stroke. If you also smoke, you are increasing this risk even further, as well as increasing your risk of many other serious smoking-related conditions, including lung cancer.

If you smoke and you would like to give up, your GP will be able to provide you with advice, support, and treatment to help you quit.

Drink alcohol in moderation

If you have diabetes, you should only drink alcohol in moderation, and you should never drink alcohol on an empty stomach. Depending on the amount that you drink, alcohol can cause either high, or low, blood glucose levels (hyperglycaemia or hypoglycaemia).

Drinking alcohol may also affect your ability to carry out insulin treatment, or blood glucose monitoring, so always be careful not to drink too much. For men, the recommended daily amount of alcohol is between 3-4 units and, for women, the recommended daily amount is between 2-3 units.

Let others know about your condition

If you have type 2 diabetes, you should wear an identity bracelet in order to let others know that you have the condition. This will ensure that if you blackout or collapse, emergency healthcare professionals will quickly know that you have diabetes.

You should also carry a glucagon kit with you in case of hypoglycaemia (low blood glucose). Your diabetes care team should train you, plus several of your family members, and close friends, in how to use it.

See the Symptoms and Treatment sections, above, for more information about hypoglycaemia.

Look after your feet

Having diabetes means that you are more likely to develop problems with your feet, including foot ulcers and infections from minor cuts and grazes. This is due to the possibility of high blood glucose damaging the nerves in your feet (see the Complications section above).

To prevent problems with your feet, you should keep your nails short and wash your feet daily using warm water. Wear shoes that fit properly and see a podiatrist or chiropodist (a specialist in foot care) regularly so that any problems are detected early.

You should also regularly check your feet for any cuts, blisters or grazes because you may not be able to feel them if there is damage to the nerves in your feet. See your GP if you have a minor injury to your foot that does not start to heal within a few days.

Have regular eye tests

If you have type 2 diabetes, you should have your eyes tested at least once a year to check for retinopathy.

Retinopathy is an eye condition where the small blood vessels in your eye become damaged. It can occur if your blood glucose level is too high for a long period of time (hyperglycaemia). If left untreated, retinopathy can eventually cause blindness.

Regular eye tests should help to ensure that any signs of retinopathy are picked up as soon as they appear.

Complications caused by diabetes

If your diabetes is not treated, it can lead to many different health problems. Large amounts of glucose can damage blood vessels, nerves and organs, and even a mildly raised glucose level that does not cause any symptoms can have damaging effects in the long term.

Heart disease and stroke

If you have diabetes, you are up to five times more likely to suffer heart disease and stroke compared with people without diabetes. Prolonged, poorly controlled blood glucose levels increase the likelihood of atherosclerosis (furring up and narrowing of the blood vessels). This may result in poor blood supply to the heart, causing angina. It also increases the chance that a blood vessel in your heart or brain will become completely blocked, causing a heart attack or stroke.

Nerve damage

High blood glucose levels can damage the tiny blood vessels of your nerves. This can lead to a tingling or burning pain that spreads from your fingers and toes up through your limbs. If the nerves in your digestive system are affected, you may experience nausea, vomiting, diarrhoea or constipation.

Retinopathy (damage to the retina at the back of the eye)

Blood vessels in the retina of your eye can become blocked, leaky or grow haphazardly. This prevents the light from fully passing through to your retina. If left untreated, it can damage your vision.

The better you control your blood sugar levels, the less chance you have of developing serious eye problems. Having an annual eye check by a specialist (an ophthalmologist or an optometrist) can help to pick up signs of any potentially serious eye problems early on, so that they can be treated.

If it is caught early enough, diabetic retinopathy can be treated using laser treatment. However, it is important to realise that this will only preserve the sight you have, not make it better.

Kidney disease

If the small blood vessels of your kidney become blocked and leaky, your kidneys will work less efficiently. In rare, severe cases this can lead to kidney failure and the need for a kidney transplant.

Foot problems

Damage to the nerves of the foot can mean that small nicks and cuts are not noticed, leading to the development of a foot ulcer. About one in 10 people with diabetes get foot ulcers, which can cause serious infection.

Check your feet every day and report any changes to your doctor, nurse or podiatrist. Look out for sores and cuts that do not heal, puffiness, or swelling, and skin that feels hot to the touch. You should also have a foot examination at least once a year.

Sexual dysfunction

In men with diabetes (especially those who smoke), damage to the nerves and blood vessels can lead to erection problems. This may be treated with medication.

Women with diabetes may experience a reduced sex drive, reduced pleasure from sex, a lack of vaginal lubrication, a reduced ability to orgasm, or painful sex. Women who suffer from a lack of vaginal lubrication or painful sex may find a vaginal lubricant or water-based gel very helpful.

Miscarriage and stillbirth

Pregnant women with diabetes have an increased risk of miscarriage and stillbirth. If their blood sugar level is not carefully controlled in the early stages of pregnancy, there is also an increased risk of the baby developing a serious birth defect.

Pregnant women with diabetes will usually have their antenatal check-ups in hospital or in a diabetic clinic, where healthcare professionals can keep a close eye on their blood sugar levels and control their insulin dosage more easily.

Preventing type 2 diabetes

The exact cause of type 2 diabetes is not fully understood but there are many factors that can increase your chance of developing it. For example, you may be at risk of developing type 2 diabetes if you are:

• overweight or obese, and
• if you do not get enough regular exercise.

See the Causes section, above, for more information about the risk factors for type 2 diabetes.

It may not be possible to prevent developing type 2 diabetes but by controlling the risk factors, you may be able to reduce your chances of getting the condition. For example, you should:

• Lose weight, if you are overweight or obese.
• Keep your waist size under 31.5 inches (80cm) if you are a woman, 35 inches (90cm) if you are an Asian man, and 37 inches (94cm) if you are a man who is white, or black.
• Get at least 30 minutes of exercise every day.
• Do not smoke.
• Keep your blood pressure and cholesterol levels under control.
• Only drink alcohol in moderation.

This advice can help anyone to reduce their risk of developing type 2 diabetes, but it is particularly important for those who have an increased risk of developing the condition.

Video: Findings from The Diabetes Prevention Program

In this video from BigThink, David L. Katz MD MPH, Director of Yale University’s Prevention Research Center, discusses how to put the findings of the Diabetes Prevention Program to work in every town in America:

Dr. Katz also describes how the gap between knowledge and action belies the notion that knowledge is power, when it comes to preventing chronic disease (particularly Type 2 Diabetes and heart disease):

External Links

• Diabetes Teaching Center at the University of California, San Francisco

References

• Diabetes in pregnancy. Bupa, January 2008

• Causes and Risk Factors. Diabetes UK, 2006

• Diabetes symptoms. Diabetes UK, 2006

• Insulin pump therapy: also known as continuous subcutaneous insulin infusion (CSII). Diabetes UK, 2006

• What is diabetes? Diabetes UK, 2006

• Hicks, R. Symptoms of diabetes. BBC Health, (2006)

• Hicks, R. What is diabetes? BBC Health, 2006

• Type 2 diabetes. MayoClinic.com, Oct 24 2007

• Treatments for Type 2 Diabetes. Patient UK, 2006

• Type 2 Diabetes. Patient UK, 2008