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Diabetes Mellitus Type 2Published by: Domus Medica | SSMGLast published: 2017Diabète sucré de type 2Published by: SSMG | Domus MedicaLast published: 2017Key diagnostic factors
common
asymptomatic
It is very common for type 2 diabetes to be asymptomatic and detected on screening. Symptoms, when present, may indicate more overt hyperglycemia.
polydipsia
Usually in patients with fasting plasma glucose >300 mg/dL (>16.7 mmol/L), HbA1c >11% (>97 mmol/mol).
polyuria
Usually in patients with fasting plasma glucose >300 mg/dL (>16.7 mmol/L), HbA1c >11% (>97 mmol/mol). As polyuria occurs when there is considerable hyperglycemia, it is rarely seen in people with type 2 diabetes (and is a more common presentation in people with type 1 diabetes).
unintentional weight loss
If marked hyperglycemia is present.
polyphagia
Usually in patients with fasting plasma glucose >300 mg/dL (>16.7 mmol/L), HbA1c >11% (>97 mmol/mol).
uncommon
hyperglycemic crisis
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) may be the initial presentation of type 2 diabetes, particularly in ethnic and racial minorities, or if there is an underlying infection.[2] People with DKA/HHS present with hyperglycemia (polyuria, polydipsia, weakness) and significant volume depletion (dry mucous membranes, poor skin turgor, tachycardia, hypotension, and, in severe cases, shock). These are life-threatening emergencies, which require early diagnosis and management.[105] Compared with the acute presentation of DKA, which is most common in patients under the age of 45 years, people with HHS have an insidious onset (over days or weeks) of symptoms and are usually older.[3][106] Certain drugs, particularly antipsychotic agents, may precipitate HHS.[105] It should be noted that clinical overlap between DKA and HHS has been reported in more than one third of people with hyperglycemic crises.[3] See Diabetic ketoacidosis and Hyperosmolar hyperglycemic state.
Other diagnostic factors
common
fatigue
Increased fatigability may be an early warning sign of progressive cardiovascular disease; clinicians should have a low threshold for cardiac evaluation.
blurred vision
Due to elevated glucose.
nocturia
Due to glucose-induced diuresis.
candidal infections
Most commonly vaginal, penile, or in skin folds.
skin infections
Cellulitis or abscesses.
urinary tract infections
Cystitis or pyelonephritis.
uncommon
paresthesias
May occur in the extremities as a result of neuropathy in those with prolonged undiagnosed diabetes.
acanthosis nigricans
A velvety, light brown-to-black marking, usually on the neck, under the arms, or in the groin. Can occur at any age. Most often associated with obesity-related hyperinsulinemia. [Figure caption and citation for the preceding image starts]: Acanthosis nigricans involving the axillaFrom the collection of Melvin Chiu, MD; used with permission [Citation ends].
Risk factors
strong
older age
Although not present in all older adults, insulin resistance and reducing beta-cell function appear to be associated with aging.[35] Older patients are at increased risk of type 2 diabetes, with the incidence peaking between 70 and 79 years.[42] However, the incidence of type 2 diabetes in children and adolescents is increasing.[43] The American Diabetes Association recommends, in the absence of other risk factors, that screening should begin for all people at age 35 years.[2]
overweight/obesity
Overweight/obesity appears to be the precipitating factor leading to clinical expression of type 2 diabetes.[44][45] There is a graded increase in risk of diabetes with increasing body mass index (BMI).[46] A larger waist circumference, independent of overall adiposity, is strongly and linearly associated with increased risk.[47] Clinical trials have shown that weight loss is associated with delayed or decreased onset of diabetes in high-risk adults.[48][49][50][51] For adults at any age, screening should be considered if BMI is ≥25 kg/m² (≥23 kg/m² for Asian-Americans), in the presence of at least one other risk factor.[2] The threshold is lower for Asian-Americans than other ethnicities as data indicate a higher risk in this population at lower BMIs.[2][10]
gestational diabetes
Gestational diabetes mellitus affects 4% to 10% of pregnancies worldwide.[52] Women with a history of gestational diabetes have an increased lifetime maternal risk for diabetes estimated at 50% to 60% and a 10-fold increased risk of developing type 2 diabetes compared with those without gestational diabetes.[2][53] Gestational glucose intolerance, which includes conditions not meeting gestational diabetes criteria, has also been found to confer a high risk of type 2 diabetes in young adulthood.[54] All women with gestational diabetes should be screened with a 75 g oral glucose tolerance test (OGTT), using nonpregnant OGTT criteria, either in the immediate postpartum period (during delivery hospitalization) or at 4-12 weeks postpartum.[2][55] Up to one third will be diagnosed with type 2 diabetes or impaired glucose metabolism within 12 weeks of delivery.[56] Lifelong screening for diabetes at least every 3 years is then recommended.[2] Risk factors for progression from gestational diabetes mellitus to type 2 diabetes include pregnancy-specific risk factors (hypertensive disorders of pregnancy, preterm delivery, and early gestational age at onset of gestational diabetes mellitus [though the latter could reflect early detection of preexisting dysglycemia]) and generic risk factors for diabetes (raised body mass index, nonwhite ethnicity, and family history of diabetes).[52] See Gestational diabetes.
prediabetes
Is defined by a single fasting plasma glucose of 100-125 mg/dL (5.6-6.9 mmol/L), or plasma glucose of 140-199 mg/dL (7.8-11.0 mmol/L) 2 hours after 75 g oral glucose, or an HbA1c of 5.7% to 6.4% (39-47 mmol/mol) in the absence of diabetes, and is a major risk factor for onset of type 2 diabetes.[2] In the US, 97 million people ages 18 years or older have prediabetes (38% of the adult population) and the prevalence is increasing.[57][58] Progression from prediabetes to overt type 2 diabetes occurs at the rate of about 2% to 4% per year.[1] Annual screening for type 2 diabetes is recommended for people with prediabetes.[2]
first-degree relative with type 2 diabetes
Although the specific genetic profile that confers risk has yet to be fully elucidated, epidemiological observations leave little doubt of a substantial genetic component.[5]
African, Latino, Asian or American-Indian ancestry
physical inactivity
While the impact of physical inactivity on increased risk of diabetes is mediated in part through an increased likelihood of having obesity/overweight, reduced levels of physical activity also seem to be an independent risk factor for developing type 2 diabetes. In people with or at risk for developing type 2 diabetes, extended sedentary time is associated with poorer glycemic control and clustered metabolic risk.[2] Increased levels of physical activity have been shown to delay or decrease onset of diabetes in high-risk adults.[49][60]
polycystic ovary syndrome (PCOS)
PCOS is one of the most common endocrine disorders in women of reproductive age, with a global prevalence of between 7% and 12%.[52] PCOS is associated with elevated risk of type 2 diabetes; testing for diabetes should be considered in women with overweight or obesity (BMI ≥25 kg/m² or ≥23 kg/m² in Asian-Americans) with PCOS.[2] Risk factors for progression to type 2 diabetes mirror those generic factors seen in gestational diabetes mellitus (e.g., high body mass index, family history of type 2 diabetes, nonwhite ethnicity) but might also include factors specific to PCOS such as hyperandrogenism.[52] See Polycystic ovary syndrome.
hypertension
Often associated with type 2 diabetes. Testing for diabetes should be considered in adults with overweight or obesity (BMI ≥25 kg/m² or ≥23 kg/m² in Asian-Americans) whose blood pressure is ≥130/80 mmHg or who are on therapy for hypertension.[2]
dyslipidemia
Dyslipidemia is common in type 2 diabetes, especially low HDL (<35 mg/dL [0.9 mmol/L]) and/or high triglycerides (>250 mg/dL [2.82 mmol/L]). Testing should be considered in adults with overweight or obesity (BMI ≥25 kg/m² or ≥23 kg/m² in Asian-Americans) whose HDL cholesterol level is <35 mg/dL (0.9 mmol/L) and/or who have a triglyceride level >250 mg/dL (2.82 mmol/L).[2]
cardiovascular disease
stress
smoking
According to the World Health Organization, there is increasing evidence from clinical and epidemiologic studies highlighting the role of tobacco in the development and exacerbation of type 2 diabetes and diabetes-related health complications.[63] Research indicates that nicotine impairs the function and mass of pancreatic beta cells, which in turn affects the production of insulin and regulation of glucose production.[64][65] There is also evidence to suggest that nicotine induces insulin resistance through activation of oxidative stress.[66][67] Secondhand smoke also seems to increase risk of type 2 diabetes.[68]
suboptimal sleep
An American Heart Association statement emphasizes that multidimensional sleep health, beyond just duration, significantly impacts cardiometabolic risk factors relevant to type 2 diabetes, including glucose regulation, obesity, and hypertension.[69] Sleep can be characterized using three key constructs: quantity, quality, and timing (i.e., chronotype).[2] Evidence indicates a U-shaped association between nightly sleep duration and the likelihood of developing type 2 diabetes. Specifically, around 7 hours of sleep is correlated with the lowest risk, while both insufficient sleep (typically <6 hours) and excessive sleep (typically >9 hours) are associated with an increased risk of up to 50% for type 2 diabetes development, including progression from a prediabetic state.[2] Sleep quality is defined as an individual's self-satisfaction with all aspects of the sleep experience.[70] In one meta-analysis, poor sleep quality was associated with a 40% to 84% increased risk of developing type 2 diabetes.[71] Chronotype preference has also been linked to type 2 diabetes.[2] One study found that those with a preference for evenings (i.e., going to bed late and getting up late) had a 2.5-fold higher odds ratio for developing type 2 diabetes than those with a preference for mornings (i.e., going to bed early and getting up early), independent of sleep duration and sleep sufficiency.[72]
low levels of testosterone/hypogonadism in men
Around one third of male patients with type 2 diabetes and/or obesity have low levels of testosterone.[73] Mean levels of testosterone are lower in men with diabetes compared with age-matched controls without diabetes. The relationship between low testosterone levels and type 2 diabetes is not completely understood and is thought to be bidirectional: low testosterone is associated with an increased risk of developing obesity and/or type 2 diabetes, and type 2 diabetes and/or obesity may lead to secondary hypogonadism.[74] Use of testosterone replacement therapy is an area of active research; studies have shown that long-term testosterone replacement therapy in patients with type 2 diabetes and hypogonadism can result in sustained remission of diabetes.[75] However, no prospective data or clinical practice guidelines currently recommend testosterone administration for the prophylactic or therapeutic management of diabetes mellitus.
mental illness
Patients with severe mental illness have a 1.5 to 2-fold increased risk of diabetes compared with the general population.[76] Diabetes can be exacerbated by antipsychotic treatments which alter glucose metabolism and promote weight gain. Furthermore, patients with severe mental illness are more likely to smoke, struggle with weight management, and have obstructive sleep apnea, leading to an increased risk of type 2 diabetes.[76]
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