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Diabetes: Type 2

* Please note that most treatment modalities listed below are based on conventional medicine. PreventDisease.com does advocate the use of any pharmaceutical drug treatments. Long-term drug therapy is detrimental to human health. All drug information is for your reference only and readers are strongly encouraged to research healthier alternatives to any drug therapies listed.

WHAT IS TYPE 2 DIABETES?

The two major forms of diabetes are type 1 (previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes) and type 2 (previously called noninsulin-dependent diabetes mellitus (NIDDM) or maturity-onset diabetes).

Insulin

Both diabetes type 1 and type 2 share one central feature: elevated blood sugar ( glucose) levels due to absolute or relative insufficiencies of insulin, a hormone produced by the pancreas. Insulin is a key regulator of the body's metabolism. It normally works in the following way:

During and immediately after a meal the process of digestion breaks carbohydrates down into sugar molecules (of which glucose is one) and proteins into amino acids.
Right after the meal, glucose and amino acids are absorbed directly into the bloodstream, and blood glucose levels rise sharply. (Glucose levels after a meal are called postprandial levels.)
The rise in blood glucose levels signals important cells in the pancreas, called beta cells , to secrete insulin, which pours into the bloodstream. Within ten minutes after a meal insulin rises to its peak level.
Insulin then enables glucose and amino acids to enter cells in the body, particularly muscle and liver cells. Here, insulin and other hormones direct whether these nutrients will be burned for energy or stored for future use. (It should be noted that the brain and nervous system are not dependent on insulin; they regulate their glucose needs through other mechanisms.)
When insulin levels are high, the liver stops producing glucose and stores it in other forms until the body needs it again.
As blood glucose levels reach their peak, the pancreas reduces the production of insulin.
About two to four hours after a meal both blood glucose and insulin are at low levels, with insulin being slightly higher. The blood glucose levels are then referred to as fasting blood glucose concentrations .

Type 2 Diabetes

Type 2 diabetes is most common form of diabetes, accounting for 90% of cases. An estimated 16 million Americans have type 2 diabetes and half are unaware they have it. The disease mechanisms in type 2 diabetes are not wholly known, but some experts suggest that it may involve the following three stages in most patients:

The first stage in type 2 diabetes is the condition called insulin resistance; although insulin can attach normally to receptors on liver and muscle cells, certain mechanisms prevent insulin from moving glucose (blood sugar) into these cells where it can be used. Most type 2 diabetics produce variable, even normal or high, amounts of insulin, and in the beginning this amount is usually sufficient to overcome such resistance.
Over time, the pancreas becomes unable to produce enough insulin to overcome resistance. In type 2 diabetes the initial effect of this stage is usually an abnormal rise in blood sugar right after a meal (called postprandial hyperglycemia ). This effect is now believed to be particularly damaging to the body.
Eventually, the cycle of elevated glucose further impairs and possibly destroys beta cells, thereby stopping insulin production completely and causing full-blown diabetes. This is made evident by fasting hyperglycemia , in which elevated glucose levels are present most of the time.

Type 1 Diabetes

In type 1 diabetes, the disease process is more severe and onset is usually in childhood:

Beta-cells in the pancreas that produce insulin are gradually destroyed. Eventually insulin deficiency is absolute.
Without insulin to move glucose into cells, blood glucose levels become excessively high, a condition known as hyperglycemia.
Because the body cannot utilize the sugar, it spills over into the urine and is lost.
Weakness, weight loss, and excessive hunger and thirst are among the consequences of this "starvation in the midst of plenty."
Patients become dependent on administered insulin for survival. [ See Report # 9 , Diabetes: Type 1. ]

Diabetes Secondary to Other Conditions

Conditions that damage or destroy the pancreas, such as pancreatitis, pancreatic surgery, or certain industrial chemicals can cause diabetes. Polycystic ovaries are highly associated with diabetes. Certain drugs can also cause temporary diabetes, including corticosteroids, beta-blockers, and phenytoin. Rare genetic disorders (Klinefelter's syndrome, Huntington's chorea, Wolfram's syndrome, leprechaunism, Rabson-Mendenhall syndrome, lipoatrophic diabetes, and others) and hormonal disorders (acromegaly, Cushing's syndrome, pheochromocytoma, hyperthyroidism, somatostatinoma, aldosteronoma) are associated with or increase the risk for diabetes.

WHAT CAUSES TYPE 2 DIABETES?

Type 2 diabetes is caused by a complicated interplay of genes, environment, insulin abnormalities (reduced insulin secretion in the beta cells and insulin resistance in muscle cells), increased glucose production in the liver, increased fat breakdown, and possibly defective hormonal secretions in the intestine. The recent dramatic increase indicates that lifestyle factors (obesity and sedentary lifestyle) may be particularly strong in releasing the genetic elements that cause this type of diabetes.

Causes of Insulin Resistance

The characteristic feature of diabetes type 2 is the body's resistance to the actions of insulin. In many people, before diabetes develops, normal or even excessive levels of insulin compensate for this resistance. Over time however, insulin production often drops and resistance worsens. Researchers are trying to determine why these events occur.

Elevated levels of free fatty acids and the hormones resistin and leptin have been associated with insulin resistance at different phases. Such factors are also present in obesity. It is not known yet if elevated levels are simply a product of obesity or play some causal role in diabetes.
Some researchers suggest that proteins called calpains may play an important role in both insulin secretion and insulin action.
Elevated growth hormone during puberty appears to increase the risk for insulin resistance in overweight adolescents.
Some experts theorize that abnormal regulation of certain important peptides (amylin and CGRP) may occur, thus affecting both the nervous and circulatory systems. One effect is to alter blood flow, which may contribute to insulin resistance. How each of these factors contributes to type 2 diabetes is under investigation.
One 2001 study found high levels of interleukin 6 (IL-6) and C-reactive protein (CRP) in people with diabetes. Both of these substances are markers for inflammation and damage caused by an over-active immune response. Some researchers believe such inflammation may contribute to the disease process leading to diabetes.

Genetic Factors

Genetic factors play an important role in type 2 diabetes, but the pattern is complicated, since both impairment of beta-cell function and an abnormal response to insulin are involved. Researchers have identified a number of genetic suspects:

Researchers have identified genes responsible for maturity-onset diabetes in youth (MODY), a rare genetic form of type 2 diabetes that develops only in Caucasian teenagers. (It should be noted that this is not the diabetes associated with obesity that is now being seen increasingly in young people.)
Some research is now investigating genes that may be responsible for inherited cases of type 2 diabetes in middle-aged Caucasians.
A defective fatty-acid binding protein 2 (FABP2) gene may result in higher levels of unhealthy fat molecules (particularly triglycerides), which may be critical in the link between obesity and insulin resistance in some people with diabetes type 2.
A defective lipoprotein lipase (LpL) gene may pose a risk for coronary artery disease and type 2 diabetes in people who have it.
Variations in a gene that regulates a protein called calpain-10 is proving to affect insulin secretion and action and may play a role in diabetes type 2. There is some disagreement, however, about its significance.
Defective genes that regulate a molecule called peroxisome proliferator-activated receptor (PPAR) gamma may contribute to both type 2 diabetes and high blood pressure in some patients.
A defective gene has been detected that reduces activity of a protective substance called beta ₃-adrenergic receptor, which is found in visceral fat cells (those occurring around the abdominal region). The result is a slow-down in metabolism and an increase in obesity. The defective gene has been found in Pima Indians and other populations with a very high incidence of type 2 diabetes and obesity.

The Thrifty Gene. One theory suggests that some cases of type 2 diabetes and obesity are derived from normal genetic actions that were once important for survival. Some experts postulate the existence of a so-called "thrifty" gene, which regulates hormonal fluctuations to accommodate seasonal changes. In certain nomadic populations, hormones are released during seasons when food supplies have traditionally been low, which results in resistance to insulin and efficient fat storage. The process is reversed in seasons when food is readily available. Because modern industrialization has made high-carbohydrate and fatty foods available all year long, the gene no longer serves a useful function and is now harmful because fat, originally stored for famine situations, is not used up. Such a theory could help explain the high incidence of type 2 diabetes and obesity found in Pima tribes and other Native American tribes with nomadic histories and Western dietary habits. It is also used to explain the relationship between low birth weight and future diabetes in Pima tribes: poor nutrition in fetuses or infants cause changes that reduce insulin sensitivity so that fat storage increases, leading to later obesity and diabetes.

WHO GETS TYPE 2 DIABETES?

Diabetes type 2 affects at least 16 million Americans, and the incidence is sharply rising. A major 2000 US study reported that the prevalence of type 2 diabetes increased by one-third between 1990 and 1998 and the biggest increase (70%) was among young adults in their 30s. Type 2 diabetes typically has developed after the age of 40. In 1999 alone it rose by 6% overall with an increase of 10% in African Americans. The primary reason for this dramatic increase appears to be the parallel increase in obesity. And as more and more cultures adopt Western dietary habits, it is likely that diabetes type 2 will reach epidemic proportions throughout the world.

Diabetes in Children and Adolescents

Until recently, diabetes in children was almost always type 1 (an autoimmune disease). Of major concern, however, are estimates that between 8% and 45% of new diabetes cases in children are type 2. (The significant differences in estimates are due to the difficulties in detecting the disease in children.) It is evident that diabetes is on the increase, not only in the US but also in other nations, including Europe and Japan. Diabetes is usually recognized in children who are in middle to late puberty. It most often occurs in girls and children who are overweight.

Low Birth Weight

Research now indicates that low birth weight is a risk factor for type 2 diabetes. Some research indicates that malnutrition in the pregnant woman may be responsible for causing metabolic abnormalities in the developing fetus that eventually lead to diabetes.

Obesity

In a 2001 study of nearly 85,000 nurses, obesity was the number one risk factor for diabetes type 2. It is estimated that 80% to 95% of the current dramatic increases in type 2 diabetes is due to obesity and having excess fat in the abdominal region. Excess body fat appears to play a strong role in insulin resistance, but the way the fat is distributed is also significant. Weight concentrated around the abdomen and in the upper part of the body (apple-shaped) is associated with insulin resistance and diabetes, heart disease, high blood pressure, stroke, and unhealthy cholesterol levels. Fat that settles in a "pear-shape" around the hips and flank appears to have a lower association with these conditions. One study suggested that waist circumferences greater than 35 inches in women and 40 inches in men signify increased risk for heart disease and diabetes.

Of note, however, obesity does not explain all cases of diabetes type 2, which is also common among people in countries where weights tend to be low, such as Asia or India.

Family History

Between 25% to 33% of all type 2 patients have family members with diabetes. Having a first-degree relative with the disease poses a 40% risk of developing diabetes. One study reported that people with positive family histories have a higher risk for developing the disease at an earlier stage with more severe features.

Because families share many lifestyle features (eating and exercise habits) it is difficult to determine when genetics or environment play the major role. When clusters of diabetes type 1 and 2 appear within families, genetic factors should be strongly suspected. Interestingly, one study reported that type 2 patients who had relatives with type 1 and type 2 diabetes tended to need insulin therapy but also had lower risks for heart disease than patients with only a type 2 family history.

Ethnicity

The risk for type 2 diabetes varies among population groups. Diabetes also seems to pose higher or lower risks for specific complications among ethnic groups. Genetic, socioeconomic factors, or both seem to be involved in ethnic differences.

African Americans. A 2000 study reported that African American men have one and a half times the risk of developing type 2 diabetes and African American women have twice the risk as their Caucasian peers. An earlier 1999 study also found that African Americans with diabetes are also at higher risk for amputations than diabetic Caucasians, which is most likely due to a higher incidence of high blood pressure and smoking as well as poorer health care. Genetic factors also play a role. For example, there is some evidence that African Americans have insulin abnormalities unrelated to dietary or other factors.
Native Americans. The Pima tribe in Arizona has an incidence of type 2 diabetes that is 19 times higher than that of the white population. The risk for diabetic complications among young Pima adults is also very high. Other Native American tribes in North America are also at high risk for type 2 diabetes. The association between diet and diabetes among this population remains critical, however, in assessing these ethnic differences. In one study, Pimas who lived in Mexico exercised more and ate less fat (but consumed more calories) than Pima tribes in Arizona. The incidence of diabetes in their Arizona Pima relatives was about 50%, while it was only 6% in the Mexican Pima tribes (about the same as their non-Pima neighbors).
Hispanic Americans. The rate of type 2 diabetes is also very high among Mexican Americans, approximately double that for Caucasians.
Maturity-Onset Diabetes in Caucasian Youth. Maturity-onset diabetes in youth (MODY) is a rare genetic form of type 2 diabetes that develops only in Caucasian teenagers. It accounts for 2% to 5% of type 2 cases. (It should be noted that this is not the diabetes associated with obesity that is now being seen increasingly in young people, including Caucasians.)

Diabetes in the Pregnant Woman (Gestational Diabetes)

An estimated 5% of pregnant women develop a form of type 2 diabetes, usually temporary, in their third trimester called gestational diabetes. [ See Box Gestational Diabetes.]

GESTATIONAL DIABETES

Gestational diabetes is a diabetic condition (nearly always temporary) that develops during the third trimester. After delivery, blood glucose levels generally return to normal, although between one-third and one-half of these women develop type 2 diabetes within 10 years.

Who Gets Gestational Diabetes?

Estimates for the prevalence of gestational diabetes are generally about 4%. Some studies, however, have suggested significantly higher rates. For example in one German study, 13% of pregnant women were diagnosed with this form of diabetes, including many who did not have any risk factors.

Risk factors include the following:

Even modest weight gain (11 to 22 pounds) during early adulthood.
Family history of diabetes.
Smoking.
Belonging to African American, Hispanic, or Asian ethnic groups.
Gaining weight before getting pregnant.
Being an older mother.

It should be noted that some studies suggest that women who develop gestational diabetes during pregnancy and take progestin-only contraceptives while breast feeding are at high risk for developing full-blown type 2 diabetes.

Who Should be Tested for Gestational Diabetes?

A number of expert groups now recommend that nearly all pregnant women be tested for gestational diabetes between their 24th and 28th week. Pregnant women at high risk for diabetes should be tested earlier. The only women who do not need to be tested are those at very low risk. Generally they have the following characteristics:

Under 25 years old.
Normal weight.
No first-degree relatives with diabetes.
Not belonging to the following ethnic groups: Native American, Hispanic, Asian or African-American.

How Serious Is Diabetes in the Pregnant Patient?

Because glucose crosses the placenta, a woman with diabetes can pass high levels of blood glucose to the fetus. In response, the fetus secretes high level of insulin. Studies indicate that such conditions may effect the developing fetus as soon as it is conceived, placing the unborn child at risk for the following:

Birth defects.
Excessive growth of the fetus.
Delayed lung development.
Possibly a higher risk for future diabetes and obesity in the child.

In addition to endangering the fetus, diabetes also presents risks to the pregnant woman.

In one German study, 25% of women with gestational diabetes required a cesarean section. (The non-diabetic rate in the study was also high however, 19.6%.)

The most serious potential complications from diabetes are high blood pressure and preeclampsia, a potentially dangerous condition. In one study blood pressure was abnormally high in 6.5% of women with gestational diabetes compared to 1.7% of pregnant women without diabetes. (It should be noted that one study suggested that mortality rates in the pregnant women with gestational diabetes vary widely, and normal rates have been reported in some countries, suggesting that good prenatal care can be fully protective.)

How Is Gestational Diabetes Managed?

Some suggestions for preventing complications include the following:

In most cases, increases in glucose levels can be managed with diet and exercise. Aerobic exercise before and during pregnancy may lower glucose levels and may be protective for women at risk or who have gestational diabetes. (Any pregnant woman should check with her physician before embarking on a vigorous exercise regimen.)
If a woman with gestational diabetes cannot keep her glucose under control with life-style measures, then she usually is given insulin.
Oral sulfonylureas, which are standard agents in type 2 diabetes, have not been routinely prescribed because of a higher risk for birth defects and severe hypoglycemia in the newborn. Studies suggest that newer sulfonylurea agents, such as glyburide, however, may be effective and safe alternatives to insulin.

Other Medical Conditions

Sleep Loss. Some interesting research suggests that people who do not sleep enough (six hours or less a night) are at higher risk for obesity and ineffective use of insulin, possibly putting them at risk for diabetes.

Polycystic Ovary Syndrome. Polycystic ovary syndrome (PCO) is a condition that affects about 6% of women and results in the ovarian production of high amounts of androgens (male hormones), particularly testosterone. It appears to be an important cause of many menstrual disorders. Women with PCO are at higher risk for insulin resistance, and about half of PCO patients also have diabetes.

Hepatitis C. Patients with hepatitis C appear to have a higher incidence of diabetes type 2.

Peridontal Disease. Some research has found an association between peridontal disease and diabetes type 2. Bacteria that cause peridontal disease may enter the bloodstream and activate immune cells that produce an inflammatory response. Theoretically, this response could damage cells responsible for insulin production in the pancreas, thereby triggering diabetes type 2. More research is needed.

WHAT ARE THE SYMPTOMS OF TYPE 2 DIABETES?

Type 2 diabetes usually begins gradually and progresses slowly. Symptoms in adults include the following:

Excessive thirst.
Increased urination.
Fatigue.
Blurred vision.
Weight loss.
In women, vaginal yeast infections or fungal infections under the breasts or in the groin.
Severe gum problems.
Itching.
Impotence in men.
Unusual sensations, such as tingling or burning, in the extremities.

Symptoms in children are often different:

Most children are obese or overweight.
Increased urination is mild or even absent.
Many develop a skin problem called acanthosis, which is characterized by velvety, dark colored patches of skin.

WHAT ARE THE EMERGENCY CONDITIONS ASSOCIATED WITH TYPE 2 DIABETES?

Hypoglycemia

People with diabetes who need to intensively control glucose levels are at risk for hypoglycemia (also called insulin shock). The condition develops if blood glucose levels fall below normal and may also be caused by insufficient intake of food , excess exercise , or alcohol intake. Usually the condition is manageable, but occasionally, it can be severe or even life threatening, particularly if the patient fails to recognize the symptoms. Mild hypoglycemia is common among people with type 2 diabetes, but severe episodes are rare, even among those who are taking insulin. Still, all patients who are intensively controlling glucose levels should be aware of warning symptoms.

Risk Factors for Severe Hypoglycemia. People at highest risk for severe hypoglycemia are those who intensively control blood glucose and also have one or more of the following conditions:

Long-term diabetes.
Less education on their condition.
A previous history of severe hypoglycemia.
Hypoglycemia unawareness. This is a condition in which people become insensitive to hypoglycemic symptoms. It affects about 25% of those who use insulin, nearly always type 1 diabetics. In such cases, hypoglycemia appears suddenly, without warning, and can escalate to a severe level. Even a single recent episode of hypoglycemia may make it more difficult to detect the next episode. With vigilant monitoring and by rigorously avoiding low blood glucose levels, such patients can often regain the ability to sense the symptoms. It is important to note that even very careful testing may fail to detect a problem, particularly one that occurs during sleep.

Symptoms. Mild symptoms usually occur at moderately low and easily correctable levels of blood glucose. They include the following:

Sweating.
Trembling.
Hunger.
Rapid heartbeat.

Severely low blood glucose levels can precipitate neurologic symptoms:

Confusion.
Weakness.
Disorientation.
Combativeness.
In rare and worst cases, coma, seizure, and death.

Preventive Measures. The following tips may help avoid hypoglycemia or prepare for attacks.

Patients are at highest risk for hypoglycemia at night. Bedtime snacks may be helpful.
Patients who intensively control their blood sugar should monitor blood levels as often as possible, four times or more per day. This is particularly important for patients with hypoglycemia unawareness.
In adults, it is also particularly critical to monitor blood glucose levels before driving, when hypoglycemia can be very hazardous.
Diabetic patients on therapies that put them at risk for hypoglycemia should always carry hard candy, juice, sugar packets, or commercially available glucose substitutes designed for diabetic individuals.

Family and friends should be aware of the symptoms and be prepared:

If the patient is helpless (but not unconscious), family or friends should administer three to five pieces of hard candy, two to three packets of sugar, half a cup (four ounces) of fruit juice, or a commercially-available glucose solution for diabetics.
If there is inadequate response within 15 minutes, additional oral sugar should be provided or the patient should receive emergency medical treatment including the intravenous administration of glucose.
Family members and friends can learn to inject glucagon, a hormone, which, in contrast to insulin, raises blood glucose.

Diabetic Ketoacidosis (DKA)

Diabetic ketoacidosis (DKA) is a life-threatening complication that is caused by insulin depletion. Until recently, it has been a complication almost exclusively of type 1 diabetes. In such cases, it is nearly always due to noncompliance with insulin treatments. However, DKA is being reported increasingly in type 2 diabetes, especially among Hispanic and African Americans. It is not clear, however, what causes total insulin depletion in these patients. Research is needed to find which individuals are at particular risk.

Diabetic ketoacidosis often develop as follows:

The process is usually triggered in insulin-deficient patients by a stressful event, most often pneumonia or urinary tract infections. Other triggers include alcohol abuse, physical injury, pulmonary embolism, heart attacks, or other illnesses.
Severely low insulin levels cause excessive amounts of glucose in the bloodstream (hypergycemia).
Fat breakdown then accelerates and increases the production of fatty acids.
These fatty acids are converted into chemicals called ketone bodies, which are toxic at high levels.

Symptoms and complications include the following:

Nausea and vomiting.
Breathing may be abnormally deep and rapid with frequent sighing.
The heartbeat may be rapid.
If the condition persists, coma and, eventually, death, may occur, although over the past 20 years, death from DKA has decreased to about 2% of all cases.
Other serious complications from DKA include aspiration pneumonia and adult respiratory distress syndrome.

Life-saving treatment employs rapid rehydration using a saline solution followed by low-dose insulin and potassium replacement.

WHAT ARE THE DIAGNOSTIC TESTS FOR TYPE 2 DIABETES?

Diagnosing Diabetes

Experts now recommend that everyone over age 45 be tested regularly for diabetes. Younger adults should be tested who have the following conditions:

A weight that is 20% more than ideal body weight.
High blood pressure.
Low HDL cholesterol levels (under 35 mg/dl) and high triglyceride levels (over 250 mg/dl).
A close relative with diabetes.
A high-risk ethnic group background.
Delivered a baby weighing over nine pounds.
A history of gestational diabetes.

Some experts recommend that any child over 10 should be tested for type 2 diabetes (even if they have no symptoms), if they are overweight and have at least two of the above mentioned risk factors. It should be noted that children who have symptoms of diabetes are usually diagnosed with type 1. This is of particular concern given the rise in childhood type 2 diabetes, and some centers report a misdiagnosis in 25% of cases.

Testing for Diabetes

Fasting Plasma Glucose. In order to simplify the diagnosis of diabetes, the American Diabetes Association has recommended the sole use of the fasting plasma glucose (FPG) test. It is a simple blood test taken after eight hours of fasting. In general results indicate the following:

FPG levels are considered normal up to 110 mg/dl (or 6.1 mmol/L).
Levels between 110 and 125 (6.1 to 6.9 mmol/L) are referred to as impaired fasting glucose. They are only slightly above normal but are considered to be risk factors for diabetes type 2 and its complications.
Diabetes is diagnosed when FPG levels are 126 mg/dl (7.0 mmol/L) or higher on two different days.

The FPG test is not always reliable and there is considerable controversy about using it as the sole basis for diagnosing diabetes. Arguments against its sole use are the following:

Some experts argue that the 126 mg/dl cut-off causes many people to be diagnosed with diabetes type 2 who are only at very small risk for actual complications.
On the other hand, the test may show normal results in many people who are still at risk for diabetes. For example, people who take the test in the afternoon and show normal results may have abnormal (and more accurate) levels if they are tested in the morning.
It is it not as useful as the glucose tolerance test for predicting people at high risk for diabetes, heart disease or death, nor is it as useful as the glycated hemoglobin test for identifying people with diabetes at risk for severe complications.
Some research indicates that the FPG is not as accurate as the glucose tolerance test for detecting diabetes in specific groups (eg, women with a history of gestational diabetes or certain Asian populations.)

At this time, even if a person has normal FPG levels but still has symptoms of diabetes and a family history or other risk factors, then diabetes should not be ruled out and a glucose tolerance test should also be performed.

Glucose Tolerance Test. A glucose tolerance test uses the following procedures:

It first employs an FPG test.
A blood test is then taken two hours later after drinking a special glucose solution.

The following results suggest different conditions:

In people without diabetes, blood sugar increases modestly after drinking the glucose beverage and decreases after two hours.
In diabetes, the initial increase is significant and the level remains high, 200 mg/dL (11.1 mmol/L) or more.
Measurements that fall between 7.8 and below 11.1 mmol/l puts a person at risk for diabetes and are referred to as impaired glucose tolerance . This condition is now strongly associated with a high risk for future diabetes and a higher than average risk for heart disease and poorer survival rates. (Studies suggest it is a much stronger predictor of diabetes than impaired fasting glucose. See Above.)

Test for Glycated Hemoglobin. Another test examines blood levels glycated hemoglobin , also known as hemoglobin A1c (HbA1c). Measuring glycated hemoglobin is not currently used for an initial diagnosis, but it may be useful for determining the severity of diabetes. Some experts think it should be used to help predict complications in people who have FPG levels between 110 and 139, which are above normal but do not indicate full-blown diabetes.

The basis for its use as a diagnostic measurement in diabetes is as follows:

Hemoglobin is a protein molecule found in red blood cells. When glucose binds to it, the hemoglobin becomes modified, a process called glycosylation.
Glycosylation affects a number of proteins, and elevated levels of glycolated hemoglobin is strongly associated with complications of diabetes.
A glycated hemoglobin level of 1% above normal range identifies diabetes in 98% of patients. Normal HbA1c levels do not necessarily rule out diabetes, but if diabetes is present and levels are normal, the risk for complications is low.

The test is not affected by food intake so it can be taken at any time. A home test has been developed that might make it easier to measure HbA1c. In general, measurements suggest the following:

Normal HbA1c levels should be below 7%.
Levels of 11% to 12% glycolated hemoglobin indicate poor control of carbohydrates. High levels are also markers for kidney trouble.
for Insulin Resistance. Investigators hope that some day a simple test for insulin resistance will be available that will be able to identify people at risk for diabetes. Some research suggests that measuring insulin and triglyceride levels during a fasting period may predict a person's sensitivity to insulin.

Screening Tests for Complications

Screening for Heart Disease. All patients should be tested for hypertension and unhealthy cholesterol and lipid levels and given an electrocardiogram. Other tests may be warranted in patients with signs of heart disease.

Screening for Kidney Damage. The earliest manifestation of kidney damage is microalbuminuria, in which tiny amounts (30 to 299 mg per day) of protein called albumin are found in the urine. About 20% of type 2 patients show evidence of microalbuminuria upon diagnosis of diabetes. It should be noted, however, that only a small percentage of type 2 diabetics eventually develop kidney disease. Microalbuminuria is also a marker for other complications involving blood vessel abnormalities, including heart attack and stroke.

Screening for Thyroid Abnormalities. Thyroid function tests should be administered.

WHAT ARE THE GUIDELINES FOR TREATING TYPE 2 DIABETES?

General Guidelines for Treatments

Treatment for type 2 diabetes generally follows certain stages that depend on the amount of residual insulin and ability to control blood glucose levels:

Healthy lifestyle habits are the cornerstone of diabetes treatment. A healthy diet, weight control, and exercise are essential for any treatment program. Many type 2 diabetics can control their condition with diet and exercise alone for years.
If they cannot, then medication is introduced. Most often a single oral agent that stimulates or preserves any residual insulin is the first choice. (Some physicians are recommending a very aggressive initial approach for newly-diagnosed patients who have type 2 diabetes. Knowing that many patients have had diabetes for years prior to diagnosis, these physicians believe that physicians should not wait to initiate treatment with one or more medications.)
Some patients may be able to control their glucose levels with a single drug. One study reported, however, that after three years, half of the patients needed more than one agent, and at nine years, only 25% could remain on a single drug. In fact, according to a 1999 survey, 90% of diabetes specialists reported that they prescribed three or more medications for their patients.
Eventually, natural insulin may completely fail; in such cases patients then require insulin replacement. Some people may even need to start off with insulin. Such patients may include those with severe hyperglycemia, those with signs of autoimmune diabetes, and women during pregnancy.

Treatment Goals and Intensive Control of Blood Glucose Levels

Major studies have now reported that, as in type 1 patients, rigorous control of blood glucose levels can help reduce the risk for complications in type 2 diabetics, including retinopathy, kidney and nerve damage. Even short-term control of blood glucose may improve their quality of life. (It may also help prevent impotence in men. )

It is not clear, however, if controlling blood glucose has any major benefits on the heart, and heart disease is the most serious complication in type 2 diabetes. Studies are mixed on the effects of intensive glucose control, with some even reporting some harm. Of particular concern is weight gain from insulin therapies, a major problem and health risk in most patients with type 2 diabetes. Newer insulin-sensitizing medications may pose less of a risk for weight gain, however, and new weight loss drugs are also proving to be helpful in offsetting weight gain from other drugs.

Until more is known, at this time patients should still aim for the following test results:

Fasting plasma glucose concentrations below 110 mg/dL.
Glycolated hemoglobin (HbA1c) levels of less than 7%. Type 2 diabetics with normal or low HbA1c levels have the lowest risk for complications. According to one 2000 study, a 1% reduction in people with elevated glycolated hemoglobin levels lowers the risk for complications by 21%.

Patients should discuss all options with their physicians.

Medications Used for Treatment of Type 2 Diabetes

Oral Agents that Use Patients' Insulin Stores. There are now many oral medication for type 2 diabetes with different mechanisms of action that might benefit specific patients. Most agents for these patients are aimed at using or increasing sensitivity to the patient's own natural stores of insulin:

Sulfonylureas (examples include but are not limited to glyburide, glipizide, and glimepiride). Stimulate insulin secretion.
Meglitinides (repaglinide, nateglinide). Stimulate insulin secretion. These newer agents are better than sulfonylureas in controlling glucose spikes after meals.
Biguanides (metformin). Increase tissue sensitivity to available insulin. Such agents may have beneficial effects on cholesterol, blood pressure, and clotting factors. Does not cause weight gain or hypoglycemia.
Thiazolidinediones (pioglitazone and rosiglitazone). Reduce insulin resistance. These agents all improve cholesterol levels, including HDL levels (the so-called good cholesterol), and may reduce the risk for blood clots. These effects should reduce heart disease risk. They can cause swelling from fluid build-up and weight gain.
Alpha-glucosidase inhibitors (acarbose and miglitol). Slow intestinal absorption of carbohydrates. Have only modest effects and have gastrointestinal side effects.

Combinations of these agents are often used to increase effectiveness.

Insulin Replacement. Eventually many patients lose their insulin stores and require insulin replacement, which may be initiated in combination with oral agents. Some forms of insulin analogues may be beneficial for patients with type 2 diabetes. These include rapid- or long-acting insulin derivatives that mimic the normal insulin response. The possible adverse effects of insulin on weight gain and the heart are troublesome, however. In one 2001 report, metformin achieved the lowest mortality rates (8%) compared to insulin (28%), a sulfonylurea (16%), and a thiazolidinedione (14%).

details on all these drugs, see What Are the Specific Drugs Used for Type 2 Diabetes?]

Treating Special Populations

Different goals may be required for specific individuals, including pregnant women, very old and very young people, and those with accompanying serious medical conditions. Treating children with diabetes type 2 depends on the severity of the condition at diagnosis. Until recently, insulin was the only approved medication for treating children. In January 2001, however, metformin became the first oral agent approved by the Food and Drug Administration for that purpose, although even before the ruling some pediatric diabetes specialists had recommended using this and other oral medications.

Measures for Preventing Complications

Taking any necessary treatments or preventive measures for heart disease and stroke is also essential. This includes controlling high blood pressure (which is also a risk factor for kidney disease) as well as unhealthy cholesterol levels. [For more information, see the Reports #3 Coronary Artery Disease and Angina , #23, Cholesterol, Other Lipids, and Lipoproteins ; #14, High Blood Pressure ; and #45, Stroke.]

WHAT ARE THE LIFESTYLE MEASURES FOR TREATING AND PREVENTING TYPE 2 DIABETES?

Healthy lifestyle habits are the cornerstone of diabetes treatment. Lifestyle changes are difficult to initiate and sustain, however. Patients should be certain to surround themselves with a solid network of doctors, dietitians, family, and friends who understand both their condition and their needs. At least one study has found that family involvement plays a large role in adhering to lifestyle and medical regimens.

A Diabetic Diet and Weight Loss

The Diabetic Diet. The current state of the diabetic diet is in flux, and at this time, there is no single diet that meets all the needs of everyone with diabetes. Patients should meet with a professional dietitian to plan an individualized diet that takes into consideration all health needs. There are some constants, however:

Limit fats (particularly saturated fats and trans-fatty acids).
Limit dietary cholesterol.
Consume plenty of fiber-rich foods in the form of whole grains and fresh fruits and vegetables.
Limit protein.
Reduce salt.

[For detailed information, see the report #42 Diabetes Diet ]

Weight Loss. Being overweight is the number one risk factor for diabetes type 2. A number of studies have suggested that healthy habits might prevent diabetes, but they have had significant flaws. Now, an important well-conducted 2001 study inFinland has added very strong evidence on the value of weight loss and exercise. In the study, individuals at risk for developing type 2 diabetes were put on a weight loss and exercise program. Although the average weight loss was relatively small (about 10 pounds), the risk for diabetes in this group was 58% lower than the comparison group who were given no intervention. Health benefits are highest with the first pounds lost, and losing only 10% of body weight can control progression of diabetes.

Unfortunately, not only is weight loss difficult to sustain, but many of the oral medications used in type 2 diabetes cause weight gain as a side effect. For obese patients who cannot control weight using dietary measures alone, weight-loss drugs, such as orlistat (Xenical) or sibutramine (Meridia), may be beneficial. In some studies, for example, orlistat not only helped subjects to reduce weight but also improved glucose, cholesterol, and lipid levels. Surgical procedures are proving to be extremely beneficial in selected cases. [For detailed information, see the report #53, Obesity.]

Exercise

Regular exercise, even of moderate intensity (such as brisk walking), improves insulin sensitivity and can even prevent type 2 diabetes. In fact, studies of older people who engage in regular to moderate aerobic exercise (eg, brisk walking, biking) lower their risk for diabetes even if they don't lose weight. Exercise also helps lower blood pressure, improve cholesterol levels, and decrease body fat. All in all, even moderate exercise reduces the risk of heart disease in people with type 2 diabetes, even if they have no cardiac risk factors other than diabetes. Low-impact aerobic exercise is best. Resistance or high impact exercises can strain weakened blood vessels in the eyes of patients with retinopathy. High-impact exercise may also injure blood vessels in the feet.

In general, experts recommend the following:

Before starting exercise, individuals over age 40 or anyone under age 40 with heart disease should take a stress test. (Because diabetics may have silent heart disease, they should always check with their physicians before undertaking vigorous exercise.)
Patients who are taking medications that lower blood glucose, particularly insulin, should take special precautions before embarking on a workout program.
For best and fastest results, frequent high-intensity (not high-impact) exercises are best for people who are cleared by their physicians.
For people who have been sedentary or have other medical problems, lower-intensity exercises are recommended using regimens designed with physicians.

[For more detailed information, see the Report #29, Exercise.]

Monitoring Blood Glucose

In patients being treated with insulin or insulin-producing or sensitizing drugs, it is important to monitor blood glucose levels carefully to avoid hypoglycemia. Patients should aim for the following measurements:

Pre-meal glucose levels of between 80 and 140 mg/dL .
Bedtime levels of between 100 and 160.

Different goals may be required for specific individuals, including pregnant women, very old and very young people, and those with accompanying serious medical conditions.

Blood glucose levels are generally more stable in type 2 diabetes than in type 1, so experts usually recommend measuring blood levels only once or twice a day. Usually, a drop of blood obtained by pricking the finger is applied to a chemically treated strip. The glucose level is read on a standard meter or a small, portable digital display device. A noninvasive device called the GlucoWatch, measures glucose by sending tiny electric currents through the skin and is showing promise for detecting hypoglycemia.

Improving Sleep

Some research suggests that not getting enough sleep may impair insulin use and increase the risk for obesity. More research is needed, but it is always wise to improve sleep habits.

WHAT ARE THE SPECIFIC DRUGS USED FOR TYPE 2 DIABETES?

Sulfonylureas

Sulfonylureas are oral drugs that stimulate the pancreas to release insulin. For adequate control of blood glucose levels, the drugs should only be taken 20 to 30 minutes before a meal. A number of brands are available, including chlorpropamide (Diabinese), tolazamide (Tolinase), acetohexamide, glipizide (Glucotrol), tolbutamide (Orinase), glimepiride (Amaryl), glyburide (DiaBeta, Micronase), glibenclamide, and gliclazide. Some of these agents may have specific benefits for the heart.

Most patients can take sulfonylureas for seven to 10 years before they lose effectiveness. Combinations with small amounts of insulin or with other drugs (such as metformin or a thiazolidinedione) may extend their benefits. In fact, a combination of glyburide and metformin in one pill (Glucovance) is now available and may prove to be beneficial. Also encouraging was a 2000 study of patients with severe type 2 diabetes reporting that combinations of insulin with either chlorpropamide or glipizide (two different sulfonylureas) achieved better glucose control over the long term than insulin alone.

Side Effects and Complications. In general, sulfonylureas should not be used by women who are pregnant or nursing or by individuals who are allergic to sulfa drugs. Side effects include the following:

Weight gain.
Water retention.
Although sulfonylureas pose a lower risk for hypoglycemia than insulin does, the hypoglycemia produced by sulfonylureas may be prolonged and dangerous. The newer sulfonylureas, such as glimipiride, appear to have about one tenth the risk of hypoglycemia than do older sulfonylureas.
They may pose a slight risk for cardiac events.

Sulfonylureas interact with many other drugs, and patients should be sure to inform their physician of any medications they are taking, including alternative or over-the-counter drugs.

Meglitinides

Meglitinides stimulate beta-cells to produce insulin. They include repaglinide (Prandin), nateglinide (Starlix), and mitiglinide. These agents are rapidly metabolized and short acting and if taken before every meal, they actually mimic the normal effects of insulin after eating. Patients, then, can vary their meal times with this drug. (Nateglinide appears to work more quickly and is shorter-acting than repaglinide). These agents may be particularly effective in combination with metformin or other agents. And they may be good agents for people with potential kidney problems.

Side Effects. Side effects include diarrhea and headache. As with the sulfonylureas, repaglinide poses a slightly increased risk for cardiac events. (Newer agents, such as nateglinide, may pose less of a risk.)

Metformin (Biguanides)

Metformin (Glucophage) is an agent known as a biguanide. It appears to work by reducing glucose production in the liver and by making tissues more sensitive to insulin. Combinations with insulin-secreting drugs, other insulin-sensitizing drugs, or insulin itself are proving to be particularly effective. Metformin does not cause hypoglycemia or add weight, so it is particularly well suited for obese type 2 patients. (In some studies, in fact, patients lost weight.) Metformin also appears to have a beneficial effects on cholesterol and lipid levels. In one comparison study, it achieved the lowest mortality rates (8%) compared to insulin (28%), a sulfonylurea (16%), and a thiazolidinedione (14%). There are a number of implications of this report, including a possible significant increase in heart events with insulin, and more research is needed. It is also the first choice for children who need oral agents and is proving to be very effective for women with polycystic ovaries and insulin resistance.

Side Effects. Side effects include the following:

A metallic taste.
Gastrointestinal problems, including nausea, and diarrhea.
It may also reduce absorption of vitamin B12 and folic acid, which are important for protection against heart disease.
There have been some reports of lactic acidosis, a potentially life-threatening condition, particularly in people with risk factors for it.

Certain people should not use this drug, including anyone with congestive heart failure or kidney or liver disease. Rarely is it suitable for adults over 80.

Thiazolidinedione

Thiazolidinediones (also called TZDs or glitazones) improves insulin sensitivity by activating certain genes involved in fat synthesis and carbohydrate metabolism. Thiazolidinediones do not cause hypoglycemia when used alone, although they are usually taken in combination with sulfonylureas, insulin, or metformin. Rosiglitazone (Avandia) and pioglitazone (Actos) are the currently approved thiazolidinediones. These drugs are usually taken once or twice per day; however, it may take several days before the patient notices any results from them and several weeks before they take full effect. They cause less weight gain than other oral agents. In some encouraging studies, thiazolidinediones have produced very favorable effects on the heart, including reducing blood pressure and improving triglyceride and cholesterol levels (including increasing HDL levels, the good cholesterol). One study also suggested that rosiglitazone may even improve beta-cell function and so help prevent progression of diabetes. Combinations with other drugs, such as metformin and a sulfonylurea, may also be helpful.

Side Effects. Troglitazone (Rezulin) was the first of these agents approved but was withdrawn after a few reports of heart failure, liver failure, and death. The current thiazolidinediones do not appear to pose the same dangers on the liver, although there have been a few reports of liver damage. At this time patients taking them must be monitored regularly. Other side effects of thiazolidinediones include anemia and fluid-build up (edema).

Alpha-Glucosidase Inhibitors

Alpha-glucosidase inhibitors, including acarbose (Precose, Glucobay) and miglitol (Glyset) reduce glucose levels by interfering with its absorption in the small intestine. Acarbose tends to lower insulin levels after meals, a particular advantage, since higher levels of insulin after meals are associated with an increased risk for heart disease. Alpha-glucosidase inhibitors are not as effective alone as other single oral drugs, but combinations, such as with metformin, insulin, or a sulfonylurea, increase their effectiveness.

Side Effects. The most common unpleasant side effects are flatulence and diarrhea, particularly after high-carbohydrate meals, which cause about a third of patients to stop taking it. These medications need to be taken with meals. The drug may also interfere with iron absorption.

Alpha-glucosidase inhibitors do not cause hypoglycemia when used alone, but combinations with other drugs do. In such cases, it is important that the patient receive a solution that contains glucose or lactose, not table sugar. This is because acarbose inhibits the breakdown of complex sugar and starches, which includes table sugar.

Insulin

For some people who cannot control their diabetes with diet or oral agents, combinations of insulin and other oral agents are proving to be very effective. Insulin may also be a temporary option, such as during pregnancy. Eventually, however, the disease deteriorates in many people with type 2 diabetes and full insulin replacement is required. There are several forms of insulin that are available or under investigation that may prove to be particularly beneficial for type 2 diabetics who require insulin:

NPH is a standard insulin.
Long acting forms (insulin glargine, ultralente insulin) that simulate natural secretion of insulin may be beneficial.
Insulin lispro and insulin aspart are fast-acting insulins. They are taken before meals, and their short action reduces the risk for hypoglycemic events afterward. In one study of people with type 2 diabetes, insulin lispro improved quality of life and overnight hypoglycemia rates compared to regular insulin, while achieving equal control over blood glucose.
Investigative oral insulin forms are receiving a lot of attention as a viable replacement for insulin shots in treating type 2 diabetes. Some are inhaled or administered using a oral spray that is absorbed in the cheek lining (Oralin). Oral administration may help reduce heart complications compared to injections, although a study on mice reported possible liver problems and increased triglyceride levels. More research is needed. .

Some experts are investigating the use of starting insulin earlier in certain patients with type 2 diabetes in order to ensure strict control of blood glucose. Unlike people with diabetes type 1 who are deficient in insulin, however, people with type 2 usually have normal or even high natural stores. Of concern is the possibility that excess insulin can injure the heart in people with type 2 diabetes. A major analysis of studies reported no evidence of prolonged survival or reduced risk for heart disease and stroke. In a 2001 comparison study of patients with type 2 diabetes and heart disease, insulin therapy was associated with a significantly higher risk for death (28%) compared to metformin especially (8%) and other agents that simply use the body's own existing insulin stores. [For detailed information on insulin therapy, see Report #9, Diabetes: Type 1 .]

Investigative Agents

Glucagon-like Insulinotropic Peptide (GLP-1). Glucagon-like insulinotropic peptide, or GLP-1 (Betatropin) appears to help metabolize glucose and reduce appetite. Betatropin is administered using injections. Early studies report that it is effective in controlling blood glucose levels and has also been associated with weight reduction. A transmucosal tablet (placed between the lip and gum) is also under investigation and is showing benefits.

Pramlintide. Pramlintide (Symlin), known as an amylin analog, is derived from a natural hormone that acts in concert with the body's insulin in the pancreas to control hyperglycemia. It slows stomach emptying and delays absorption of nutrients in the intestine. Some studies indicate that it helps control glucose levels without increasing the risk for hypoglycemia or increasing weight when added to insulin regimens. It is being considered for approval for both type 1 and type 2 insulin-requiring diabetes.

D-Chiro-Inositol. D-chiro-inositol (INS-1) is an investigational agent that increases sensitivity to insulin. It is showing promise in treating people with less severe diabetes and women with polycystic ovary syndrome. More research is underway.

WHAT ARE THE LONG-TERM COMPLICATIONS OF TYPE 2 DIABETES AND HOW ARE THEY TREATED?

A very grim British study released in 2001 found that the risk of death is higher in people with diabetes regardless of sex, age, or affluence. Another 2001 study found higher mortality rates from all causes, even in people with impaired glucose tolerance (mildly high blood sugar levels but not yet full-blown diabetes). The main cause of death in these studies was heart disease. These and similar studies are of particular concern in the light of the dramatic increase in diabetes type 2. Other complications associated with diabetes include nerve damage (neuropathy) and vascular (blood vessel) abnormalities in both small and large blood vessels. Although these complications tend to be more serious in type 1 diabetes, they still are of concern in type 2 diabetes. In patients with type 1 diabetes, intensive control of blood glucose is proving to be very important in reducing many diabetes-associated complications and is proving to be important for many patients with type 2 diabetes.

Complications of Heart and Circulation

Heart attacks account for 60% and strokes for 25% of deaths in all diabetics. A 1998 study reported that people with type 2 diabetes and no history of heart disease have the same seven-year risk for a heart attack as nondiabetics who have been diagnosed with heart disease. Insulin resistance alone injures the heart whether or not the patient has full-blown diabetes, is obese, or has unhealthy fat distribution. In addition, a 2000 study indicated that people with diabetes who suffer a heart attack are less likely than nondiabetics to receive aggressive life-saving therapies using clot-busting drugs. People with diabetes are at risk for the following heart-risk conditions, and the more of these conditions they have, the worse the outlook:

High blood pressure (hypertension) . Up to 75% of cardiovascular problems in people with diabetes may be due to hypertension. There are strong biologic links between insulin resistance (with or without diabetes) and hypertension. And, it is not altogether clear which condition causes the other.
Very unhealthy cholesterol and lipid balances (high triglyceride levels and lower high density lipoprotein).
Blood clotting problems.
Impaired nerve function (neuropathy). Abnormal nerve functions can also damage the heart. In fact, some experts estimate that the mortality rates from neuropathy-related heart conditions ranges from 15% to 53%. [See also Neuropathy, below.]
with heart disease may have a higher risk for silent ischemia , a condition in which people have blocked arteries but do not experience the angina, the chest pain that signals heart disease. Without such warning signs, the patient may be unaware of a dangerous condition. [ Coronary Artery Disease and Angina , and Heart Attack and Acute Coronary Syndrome .]

Improving Cholesterol and Lipid Levels. At this time the best agents for improving cholesterol and lipid levels in people with diabetes are those known as statins. They include pravastatin (Pravachol), simvastatin (Zocor), fluvastatin (Lescol), atorvastatin (Lipitor), and rosuvastatin (Crestor) and many others. Studies suggest that they can reduce the risk for adverse heart events in people with diabetes, even if their cholesterol levels are normal or if their diabetes is mild. Further, in one study, a statin was shown to reduce the risk of developing diabetes by 30% in people with high cholesterol. Another cholesterol-lowering drug, fenofibrate, may also be especially useful for people with type 2 diabetes. Niacin (nicotinic acid) has the best effect on the cholesterol profile of people with diabetes but it also increases blood sugar levels. One well-controlled study, however, found that diabetics who used niacin had little trouble with glucose control, and some experts believe it now may be used as an alternative to or in combination with statins.

Reducing the Risk for Blood Clots. Taking a daily aspirin has also been shown to be protective because of its anti-clotting properties. In one 2000 study, low-dose aspirin was associated with a 30% lower risk for death from heart disease in adults with type 2 diabetes.

Reducing Blood Pressure. Reducing blood pressure is very important for preventing complications of diabetes. Lowering systolic pressure (the higher and first number in a blood pressure measurement) may be particularly important for diabetics. (Diastolic pressure is the second number.) In general, the optimal blood pressure is less than 120/80 mm Hg (systolic/diastolic). Angiotensin-converting enzyme (ACE) inhibitors are proving to have remarkable benefits for people with diabetes, including reducing the risks of heart attack, stroke, and death. These drugs also delay the onset and progression of kidney disease by 30% to 60% and may even help prevent or limit progression of foot ulcers and retinopathy. Some experts recommend ACE inhibitors for all middle-aged type 2 diabetics. Newer agents called angiotensin-receptor blockers (ARBs) may have similar benefits. In one study a combination of an ACE inhibitor and candesartan, an ARB, reduced blood pressure and risk factors for kidney disease better than either agent alone.

Of concern are studies reporting an increase of type 2 diabetes in people who take beta blockers, which reduce blood pressure and are important heart protective agents. More research is needed, and experts do not discourage use of beta blockers based on any current evidence.

[For more information, see the reports, Report #23, Cholesterol, Other Lipids, and Lipoproteins , Report #14, High Blood Pressure , and Report #03, Angina and Coronary Artery Disease .]

Neuropathy

Diabetes reduces or distorts nerve function causing a condition called neuropathy. It particularly affects sensation. It is a common complication that affects nearly half of both type 1 and type 2 diabetics after 25 years. Neuropathy usually starts in the fingers and toes and moves up to the arms and legs (called a stocking-glove distribution). Symptoms include the following:

Tingling.
Weakness.
Burning sensations.
Loss of the sense of warm or cold.
Numbness. (If the nerves are damaged sufficiently, the person may be unaware that even a blister or minor wound has become infected.)
Deep pain.
In some cases, neuropathy may block angina, the warning chest pain for heart disease and heart attack. Diabetic patients should be aware of other warning signs of a heart attack, including sudden fa