This action might not be possible to undo. Are you sure you want to continue?
, possibly neuropathic), macrovascular (ie, coronary, peripheral vascular), and neuropathic (ie, autonomic, peripheral) complications. Unlike patients with type 1 diabetes mellitus, patients with type 2 are not absolutely dependent upon insulin for life, even though many of them are ultimately treated with insulin. See below for images on diagnosis and treatment.
Diagnostic criteria (American Diabetes Association) for diabetes mellitus type 2.
Treatment of type 2 diabetes mellitus. Click here to view a slideshow on Diabetic Microvascular Complications. Pathophysiology Hyperglycemia results from lack of endogenous insulin, which is either absolute, as in type 1 diabetes mellitus, or relative, as in type 2 diabetes mellitus. Relative insulin deficiency usually occurs because of resistance to the actions of insulin in muscle, fat, and the liver and an inadequate response by the pancreatic beta cell. Insulin resistance, which has been attributed to elevated levels of free fatty acids in plasma,1 leads to decreased glucose transport in muscle, elevated hepatic glucose production, and increased breakdown of fat. The genetics of type 2 diabetes are complex and not completely understood, but presumably this disease is related to multiple genes (with the exception of maturity-onset diabetes of the young [MODY]). Evidence supports inherited components for pancreatic beta-cell failure and insulin resistance. Considerable debate exists regarding the primary defect in type 2 diabetes mellitus. Most patients have insulin resistance and some degree of insulin deficiency. However, insulin resistance per se is not the sine qua non for type 2 diabetes mellitus because many people with insulin resistance (particularly those who are obese) do not develop glucose intolerance. Therefore, insulin deficiency is necessary for the development of hyperglycemia. Insulin concentrations may be high, yet inappropriately low for the level of glycemia. MODY is associated with autosomal dominant inheritance and is characterized by onset in at least 1 family member younger than 25 years, absence of autoantibodies, correction of fasting hyperglycemia without insulin for at least 2 years, and absence of ketosis. At least 6 genetically different types of MODY have been described.2 Some patients ultimately require insulin to control glycemia. Variants in 2 of the genes associated with MODY (HNF-1alpha and, to a lesser extent, HNF-4alpha) have been shown to predict future type 2 diabetes.3 Presumably, the defects of type 2 diabetes mellitus occur when a diabetogenic lifestyle (ie, excessive caloric intake, inadequate caloric expenditure, obesity) is superimposed upon a susceptible genotype. The body mass index at which excess weight increases risk for diabetes varies with different racial groups. For example, compared with persons of European ancestry, persons of Asian ancestry are at increased risk for diabetes at lower levels of overweight.4 In addition, an in utero environment resulting in low birth weight may predispose some individuals to develop type 2 diabetes mellitus.5,6 A simplified scheme for the pathophysiology of abnormal glucose metabolism in type 2 diabetes mellitus is depicted in the image below.
weight gain and type 2 diabetes mellitus are becoming virtually epidemic. determine cardiovascular risk.9 The National Eye Institute estimates that laser surgery and appropriate follow-up care can reduce the risk of blindness from diabetic retinopathy by 90%. With increasing obesity in the population. smoking. International Type 2 diabetes mellitus is less common in non-Western countries where the diet contains fewer calories and caloric expenditure on a daily basis is higher. . elevated fibrinogen) abnormalities.8% (23. and an increase in the population of higher-risk minority groups (see Race). renal. asserting that the clock starts ticking for microvascular risk at the onset of hyperglycemia. while the clock starts ticking for macrovascular risk at some antecedent point. with another $40 billion in indirect costs. Increased cardiovascular risk appears to begin prior to the development of frank hyperglycemia. small dense low-density lipoprotein [LDL] particles. elevated low-density lipoprotein-cholesterol [LDL-C]. The 2002 estimate for direct medical costs due to diabetes in the United States was $92 billion.000-24. and women have a 3. are the major sources of expenses for patients with diabetes mellitus. Hyperglycemia appears to be the determinant of microvascular and metabolic complications. and cardiovascular disease.10 Diabetes mellitus is the leading cause of end-stage renal disease (ESRD). Frequency United States In 2007. accounting for 44% of new cases. presumably with the onset of insulin resistance. glycemia is much less related to macrovascular disease. particularly cardiovascular disease (~50-75% of medical expenditures).to 4-fold increased risk.6 million people).11 In 2005. according to the Centers for Disease Control and Prevention (CDC). However. 1 of every 7 health care dollars in the United States was spent on patients with diabetes mellitus. Approximately two thirds of people with diabetes die from heart disease or stroke. low high-density lipoprotein-cholesterol [HDL-C] levels. However. family history. as well as conventional atherosclerotic risk factors (eg. Mortality/Morbidity Diabetes mellitus is one of the leading causes of morbidity and mortality in the United States because of its role in the development of optic. Insulin resistance with concomitant lipid (ie. Men with diabetes face a 2-fold increased risk for coronary heart disease. hypertension. as people in these countries adopt Western lifestyles. the estimated prevalence of diabetes in the United States was 7. Diabetes mellitus is the leading cause of blindness in working-age adults in the United States. diabetic retinopathy accounts for 12. These complications. elevated type-1 plasminogen activator inhibitor [PAI-1].000 newly blind persons every year. Approximately 20% of Medicare funds are spent on these patients. Stern in 19967 and Haffner and D'Agostino in 19998 developed the "ticking clock" hypothesis of complications. elevated triglyceride-rich remnant lipoproteins) and thrombotic (ie. low HDL-C).9 More than 90% of cases of diabetes are type 2 diabetes mellitus. prevalence is increasing.Simplified scheme for the pathophysiology of type 2 diabetes mellitus. In 1994. neuropathic. presumably because of the effects of insulin resistance. almost one third of cases were undiagnosed. an older population.
Asian American. Prevalence of diabetes mellitus type 2 in various racial and ethnic groups in the United States (2007 estimates). polyuria. lower extremity paresthesias. patients with a first-degree relative with type 2 diabetes mellitus. However. The risk of retinopathy and nephropathy appears to be greater in blacks. it is being recognized increasingly in younger persons. none of whom were known to have diabetes. Type 2 diabetes mellitus is becoming virtually pandemic in some groups of Native Americans and Hispanic people. For example. Hispanic. patients with hypertension. In some areas. more type 2 than type 1 diabetes mellitus is being diagnosed in prepubertal children. about 71. Native American.000 nontraumatic lower limb amputations were performed related to neuropathy and vasculopathy.to 40-fold increase in risk over that of the nondiabetic population. screening these women may be . The image below shows data for various groups. The prevalence of diabetes mellitus by age is shown in the image below. and young adults. the asymptomatic state does not mean that hyperglycemia is not affecting the individual.739 people in the United States and Puerto Rico began renal replacement therapy.689 people with diabetes were on dialysis or had received a kidney transplant. Other symptoms that might suggest hyperglycemia include blurred vision. and Hispanics.12 Because polycystic ovary disease is an insulin-resistant state.9 Diabetes mellitus is the leading cause of nontraumatic lower limb amputations in the United States. particularly balanitis in men.9 Race The prevalence of type 2 diabetes mellitus varies widely among various racial and ethnic groups. While the United States Public Health Service and the American College of Physicians do not recommend routine screening for diabetes. or patients with high triglycerides (>250 mg/dL) or low HDL-C (<35 mg/dL). admission and fasting plasma glucose testing identified diabetes in 27%. and 178. or yeast infections. most patients with type 2 diabetes mellitus are asymptomatic for years. women with a previous delivery of a large infant (>9 lb) or with a history of gestational diabetes mellitus. teenagers. Sex Type 2 diabetes mellitus is slightly more common in older women than men. Age While type 2 diabetes mellitus traditionally has been thought to affect individuals older than 40 years. polyphagia. Prevalence of diabetes mellitus type 2 by age in the United States (2007 estimates). with a 15. weight loss).46. members of high-risk ethnic groups (ie. The possible presence of diabetes mellitus should be considered in obese patients. Pacific Islander). targeted screening may be useful. In 2004. in one study of patients admitted to the hospital with acute coronary syndrome. polydipsia. particularly in highly susceptible racial and ethnic groups and the obese. Virtually all cases of diabetes mellitus in older individuals are type 2. Clinical History While a diagnosis of diabetes mellitus is readily entertained when a patient presents with classic symptoms (ie. Native Americans. black.
Physical Early in the course of diabetes mellitus. . However. pheochromocytoma).warranted. Secondary diabetes may occur in patients taking glucocorticoids or when patients have conditions that antagonize the actions of insulin (eg. Cushing syndrome. end-organ damage may be observed. prospective study has shown that an energy-dense diet may be a risk factor for the development of diabetes that is independent of baseline obesity. high intake and low expenditure) on a susceptible genotype appears to cause type 2 diabetes mellitus. this would be the recommendation for such patients without a measured glucose value. Potential findings are listed in the image below.13 Diabetes mellitus may be caused by other conditions. Whether at-risk persons should be screened for prediabetes is unclear at present. The therapy would generally be lifestyle changes to facilitate weight loss and improve cardiovascular fitness. Possible physical examination findings in patients with type 2 diabetes mellitus. acromegaly. population-based. the physical examination findings are likely to be unrevealing. A large. and in virtually all cases. ultimately. Causes Superimposition of caloric excess (typically.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.