Thursday, April 19, 2012

Diabetes mellitus type 2


What is type 2 diabetes?
Two major forms of diabetes are type 1 (formerly known as diabetes mellitus or insulin dependent diabetes, which occurs in the youthful age) and type 2 (formerly known as diabetes mellitus or insulin-independent diabetes that occurs in adulthood). Both forms share a basic feature: elevated blood sugar (glucose) levels due to absolute or relative deficiency of insulin, a hormone which is manufactured by the pancreas. The pancreas is an elongated, tapered gland behind the stomach that secretes digestive enzymes and the hormones insulin and glucagon. Insulin secreted by the so-called. beta cells arranged in clusters called islets of Langerhans. Insulin is a key regulator of body metabolism. After the meal, the food is digested in the stomach and intestines, carbohydrates are broken down to sugar molecules one of which is glucose, and proteins are broken down into amino acids. Glucose and amino acids are absorbed directly into the bloodstream and blood glucose concentration increases. Under normal conditions an increase in blood glucose stimulates beta cells of the pancreas to secrete insulin, which overflows into the bloodstream. Insulin allows the penetration of glucose into the cells of the body (pogotovomišićne cells) with the other hormones determine if these nutrients into energy to burn, or will be stored for future use. When the blood sugar level back to level before meals, reduced production of insulin in the pancreas and the body uses the stored energy until your next meal in which acquires new nutrients.

Diabetes mellitus type 2 - a description of the disease
Type 2 diabetes is by far the most common form of diabetes - occurs in 90% of cases. Most patients with type 2 products changed or even normal amounts of insulin, but due to disturbances in muscle and liver cells leads to resistance to insulin action. Insulin binds to cell receptors, but glukozane can enter the cell and this condition is known as insulin resistance. Because many patients who suffer from type 2 diabetes do not secrete enough insulin to overcome insulin resistance, it is assumed that in such patients there is further damage to the pancreatic beta cells impairs the secretion of insulin. Thus, type 2 diabetes is likely a combination of inadequate insulin secretion and an inability to properly act on the entry of glucose into the cell.

Diabetes in young adulthood
Diabetes in young adulthood (MODY) is a rare form of genetic forms of type 2 diabetes usually occurs in lean adolescents. This form represents 2% to 5% of all cases of type 2

Gestational diabetes
Approximately 0.5% of pregnant women, there is type 2 diabetes in the third trimester of pregnancy, called gestational diabetes. After delivery, blood glucose levels usually return to normal, but in one third to one half of these women within 10 years of type 2 diabetes occurs

Diabetes as a secondary disease
Diseases that damage or destroy the pancreas such as pancreatitis or pancreatic surgery (tumors) can lead to diabetes. The use of some medications can also cause the appearance of temporary diabetes. A rare gene disorders and hormonal disorders also increase risk of diabetes.

What causes type 2 diabetes?

Causes of insulin resistance
It is assumed that the occurrence of obesity and insulin resistance to elevated levels of three important factors.These are: the concentration of free fatty acid (acid in the blood that decomposition of fat), leptin (protein produced by fat cells) and tumor-necrosis factor, or TNF (a component of the immune system). The manner in which these factors contribute to the occurrence of type 2 diabetes is still being investigated.

Genetic factors
In Type 2 diabetes genetic factors play an important role, but not fully explained by their mechanism of action, since it includes both disturbed beta cell function and improper response to insulin.

Who gets type 2 diabetes?
Diabetes, especially type 2, reaching epidemic proportions throughout the world as more and more take on Western food habits. It is estimated that around 100 million people suffering from the disease, and experts predict that by 2010. that number doubled.

Age
Type 2 diabetes typically occurs after the age of 40. Aging itself may increase susceptibility to glucose intolerance and diabetes. In one study diabetes was found in only 5.9% of men and 3.8% of women younger than 60 years, but at almost 20% of men and women older than 85 years. Although still rare, very concerned about a significant increase 2 diabetes in children, probably due to increased rates of childhood obesity.

Obesity
Obesity is very common in people with type 2 diabetes, so that even moderate weight gain can increase susceptibility to disease from diabetes. Excess body fat is important in insulin resistance, but also do it the way it is distributed. Fatty tissue around the abdomen and upper body (apple shape) is associated with insulin resistance, heart disease, high blood pressure, stroke and high cholesterol. Pear body shape, with thickness distributed around the hips and thighs, less is associated with this disease.

Smoking
Smokers are more susceptible to type 2 diabetes mellitus and its complications.

Family history
Between 25% and 33% of all patients have a family history of disease, a person whose first-degree relatives of diabetic patients were exposed to 40% risk for a lifetime.

What are the symptoms of type 2 diabetes?
The disease usually begins gradually and progresses slowly. Symptoms may not appear for years, even decades.In advanced disease there are excessive thirst, increased urination, fatigue, blurred vision and weight loss. In women, frequent vaginal yeast infections. Fungal infections can occur under the breasts or in the groin. Severe changes in the gums, deteriorating vision, itching, impotence and abnormal sensations in the extremities, such as tingling or burning, can also indicate the type 2 diabetes Type 2 diabetes is usually detected by routine examinations by a physician (physical examination) findings of elevated levels of glucose in blood and urine before the onset of symptoms.

Complications and prognosis of type 2 diabetes

Hypoglycemia
Providing intensive insulin or insulin-releasing drugs such as sulfonylureas, increases susceptibility to hypoglycemia that occurs when glucose concentrations fall below the normal range. Causes of hypoglycemia may also be insufficient food intake, physical activity or alcohol consumption. It is usually treated, but can sometimes be a severe form, or even life-threatening, especially if the patient does not recognize the symptoms. For moderately low concentrations of glucose in the blood that can be easily corrected, the symptoms are usually mild and include sweating, trembling, hunger, fast heartbeat. Very low concentrations of glucose in the blood can improve the neurological symptoms - confusion, weakness, disorientation, aggression, and in rare cases that coma, convulsions and death. Patients with recurrent episodes of hypoglycemia can become insensitive to the symptoms, even just one recent episode of hypoglycemia may make it difficult to recognize the following. Strict avoidance of low blood glucose concentrations, these patients can regain the ability to recognize symptoms. Most experts recommend that patients frequently measuring blood levels - four or more times a day. This is especially important in patients who have repeatedly noticed symptoms before the onset of mental changes. Diabetics should always by his side should have hard candy, juice and sugar packets. Family and friends must know the symptoms. If a crisis should give him candy 3-5, 2-3 packets of sugar and half cup of fruit juice (provided you can swallow). If within 15 minutes does not appear to react, the patient should be given more sugar or provide him with emergency medical treatment including intravenous provision of glucose. Family members and friends can learn to give injections of glucagon, a hormone that unlike insulin, raises blood glucose levels.

Long-term complications of diabetes
The most significant complications of diabetes occur due to vascular abnormalities and nerve damage (neuropathy). Damage to major blood vessels threaten the heart, especially in heart patients and people with high blood pressure and can cause pathological changes in the legs. Changes in small blood vessels (microvascular) can cause eye damage and kidney.

Complications of cardiovascular system
In a large percentage of cases the cause of death in patients with diabetes is heart attack, stroke and the cause of death in 25% of patients. I diabetes mellitus type 1 and type 2 accelerates atherosclerosis, a process in which the layers of yellow deposits of cholesterol, fat and other substances accumulate on the walls of arteries. Arteries constrict, blood flow slows down and can lead to blocked blood vessels. Thus a coronary artery (which supplies the heart with blood) and as a result of a heart attack (myocardial infarction). Hypertension is also a major cause of heart attack, stroke or heart failure. In patients with d type 2 diabetes have elevated concentrations of triglycerides and decreased high-density lipoprotein (HDL). Both these phenomena are the risk factors for heart disease.

Neuropathy (nerve damage) and amputation
Neuropathy is decreased or impaired function of the nerves, especially sensory. Symptoms include tingling and burning sensation. Usually begin in the fingers, and then spread to the arms and legs. Patients sometimes do not feel pain, and will not feel that there is an infection of small blisters or ulcers especially on the feet. This problem becomes even greater because of the problems with blood circulation caused by damage to blood vessels. Even minor infections can cause deep tissue injury. Sometimes it requires a major surgical procedure, and in extreme cases, even amputation of feet or legs. Early and proper treatment of people exposed to particular problems with the feet and legs, amputations can be prevented in 50% of cases.
If diabetes interventions autonomic nervous system may occur in pathological changes in blood pressure control, bowel and bladder function and sexual function in men. In some cases, neuropathy can block anginal chest pain that warns of heart disease and heart attack (myocardial infarction). People with diabetes should recognize other warning signs of heart attack, including sudden fatigue, sweating, shortness of breath, nausea and vomiting.

The complications of the eyes
Diabetes is a major cause of blindness occur in adults aged from 20 to 74 year. Because of the long duration of disease, most patients with type 2 diabetes at some point in time there is retinopathy, pathological changes in retinal blood vessels. However, only a minority becomes so severe retinopathy that occurs wholly or partly blinded. Approximately 20% of patients with type 2 diabetes, the diagnosis is noted for some eye damage, while the cluttered look normal .. Although the feeling that you can see flashes of light may indicate a separation of the retina, often has no symptoms progresirajuće retinopathy. Diabetics are also at increased risk of developing cataracts and certain types of glaucoma.

Kidney damage (nephropathy)
Kidney disease is a serious complication of diabetes mellitus type 2 The risk of this complication increases with high blood pressure and disturbances in the function of the urinary tract. Symptoms include swelling of the feet and joints, fatigue and pale skin. Often kidney damage is irreversible and must be treated with hemodialysis.

Mental function
Tests show that people with type 2 diabetes were more susceptible to dementia because Alzheimer's disease or because of problems with blood vessels in the brain. Attention and memorization can occur even in people under 55 years of age who have been suffering from diabetes.

Other complications
People with diabetes are more vulnerable to flu and its complications, including pneumonia, probably because this disorder neutralizes the effects of protective proteins on the surface of the lungs. Probably even some cancers occur more frequently in patients with diabetes.

What are the diagnostic tests for type 2 diabetes?
Today, experts recommend regular annual measurement of glucose in the blood of all persons older than 45 years. People in the younger adult age should be tested in the following cases: if their weight is 20% higher than the ideal, if you have high blood pressure, low HDL cholesterol (below 35 mg / dl), high triglyceride concentration (above 250 mg / dl) , a close relative who suffers from diabetes, if they belong to high-risk ethnic group, if it is a mother of newborn weighs more than 4 kg, or a pregnant woman who had gestational diabetes. All pregnant women should be tested for gestational diabetes between 24 and 28 weeks of pregnancy. Pregnant women at high risk of diabetes should be tested earlier.

Glucose was measured in plasma glucose
Test to measure glucose in plasma glucose (glucose) has become a standard diagnostic test. This is a simple blood test that is done after eight hours of fasting. It is believed that the concentration of glucose in the blood glucose to 6.0 mmol / l (110 mg / dl) of normal. Diabetes is diagnosed when the glucose concentration in blood glucose measured by two different days was 7.0 mmol / l (126 mg / dl) or more. Concentrations between 6.0 and 7.0 mmol / l (110 and 126 mg / dl) are interpreted as abnormal fasting plasma glucose, and are considered a risk factor for diabetes and its complications. The test is not always reliable. If a person has normal levels, but the symptoms and family history of diabetes or other risk factors, you should exclude diabetes and to do other tests.

Glucose tolerance test
Glucose tolerance test is more complex. First, make a test concentration of fasting glucose, and then after two hours of taking special blood glucose testing. Moderate increase in blood sugar after taking a drink with glucose in healthy individuals is reduced after two hours. In diabetics, the excessive increase in the beginning, and its concentration remains high and later.

Testing for glycosylated hemoglobin
This diagnostic test for examining the concentration of hemoglobin A1c (HbA1c) and glycosylated hemoglobin.Hemoglobin protein molecule in red blood cells, changes when glucose binds to it. To what extent will change depends on the average concentration of sugar in the blood protein that is exposed during its lifetime .. This test is used to monitor treatment efficacy.

Tests to detect complications
The earliest symptom of kidney damage is mikroalbuminuria, in which very small amounts of protein called albumin (30 to 300 mg per day) found in urine. Approximately 20% of patients of type 2 diabetes microalbuminuria is detected at diagnosis. Microalbuminuria is also a sign of other complications related to vascular damage. You should check your blood pressure and tested cholesterol and lipids, to make an electrocardiogram, and eventually to test thyroid function.

What are the general guidelines for the treatment of type 2 diabetes?
In the third of patients with diabetes type 2 disease can be controlled only with diet and exercise, which reflects favorably on the concentration of glucose and blood pressure. Others must take medications that stimulate insulin secretion or residual increases sensitivity to insulin. But ultimately supplies of natural insulin in the pancreas, ie.Langerhans islets are exhausted and must be replaced. Strict control of blood glucose concentration may decrease vulnerability to the development of complications, especially retinopathy, and kidney and nerve damage. Control of high blood pressure reduces the risk of heart attack and kidney disease. Suffering from type 2 diabetes should aim to be glycosylated hemoglobin concentration of 6%, the concentration of glucose in plasma glucose measured below 6.0 mmol / l (110 mg / dl) and blood pressure oko130/80 mm Hg. In this way, the complications could be reduced by 25% to 33%. These target values ​​are different in some specific cases, such as pregnant women, very old or very young population and in patients with other concomitant diseases.

What kind of lifestyle is needed in the treatment and prevention of type 2 diabetes?

Diet
In most patients diet is the key to treatment. Diet, however, extremely difficult to implement. There is no single diet that would suit the needs of all patients. However there are a few constants. All people with diabetes would have to maintain a normal lipid levels (cholesterol and triglycerides) and blood pressure control. If patients and obese, are equally important to lose weight and control blood glucose. Most beneficial effect on health has an initial weight loss, and so have 10% weight loss may curb progression of diabetes. Obese patients who can not control weight diet will need medications. People taking oral agents (pills) should coordinate calorie intake with insulin intake and exercise. The weight can be achieved and maintained shall be considered acceptable, and not one that the environment itself as a desirable or ideal. General rules of a healthy diet apply to everyone: limit your intake of fat, protein and cholesterol, and consume large amounts of fiber and fresh fruits. Patients with diabetes should plan your individual diet, in agreement with the dietitian that will meet their needs.

Physical Activity
Exercise reduces blood glucose levels and increases sensitivity to insulin. Is also reduced blood pressure, cholesterol, body fat and the risk of heart and blood vessels. Regular exercise, even moderate intensity, increases sensitivity to insulin. Due to the risk of "silent" heart disease (without threatening pain), before joining the exercise should consult a physician. Exercise, especially exercise sotporom and high efficiency, it may be hard for the weakened blood vessels in retinopathy. Practices with high performance can also cause injury to the feet of blood vessels.

Treatment
Unlike type 1 diabetes, patients with diabetes type 2 still produce some insulin, though not enough to bridge the resistance to insulin. Therefore, patients who need medication, starting with the means to increase the production of residual insulin or insulin sensitivity rather than insulin to be directly replaced, as is standard with type 1 diabetes With such drugs is usually a tendency to weight gain and less hypoglycemia than insulin. It is now recommended for initial treatment of sulfonylurea drugs and metformin. Other drugs are showing very effective.Particularly effective are the various combinations in which these drugs are used with low doses of insulin. Finally Tablets usually fail and patients yet to be given insulin.

Sulfonylurea
Sulfonylurea drugs in tablet form, which stimulate the pancreas to produce insulin. The market has a number of these drugs, for example. glibenclamide and gliclazide. For the purpose of adequate control of blood glucose concentration, these drugs should be taken 20 to 30 minutes before eating. Sulphonylureas may cause weight gain, so the thinner patients better candidates than those with overweight. It is possible, and fluid retention.Although the risk of minor hypoglycemia with glyburide than with insulin, hypoglycemia caused by sulfonylureas can be quite time consuming and dangerous. In addition, these drugs entering the interaction with many other drugs. These medications are effective in most patients during the 7 to 10 years, and their beneficial effect may be extended if combined with small amounts of insulin or other newer drugs, particularly metformin.

Metformin
Metformin is a biguanide whose activity consists in reducing the production of glucose in the liver and increased tissue sensitivity to insulin is taken in pill form. Combinations with other drugs such as repaglinide, sulfonylurea and acarbose, showed a particularly effective. Metformin does not cause hypoglycemia or does not cause weight gain, and is therefore suitable for obese patients with type 2 diabetes It seems that metformin also has a beneficial effect on cholesterol and lipids. People with kidney or liver disease should avoid this medication.

Alpha-glucosidase inhibitors
Miglitol and acarbose as inhibitors of alpha-glucosidase. They reduce the concentration of glucose by preventing its absorption in the small intestine. Acarbose lowers the concentration of insulin after a meal, which is an advantage because elevated concentrations of insulin after meals associated with increased exposure to heart disease. This drug alone is not as efficient as the other pills, but in combinations, such as with metformin, a sulfonylurea or insulin to its efficiency increases. When used alone does not cause hypoglycemia, but it occurs in combination with other drugs. In such cases it is important that the patient receives a solution of glucose or lactose as acarboza inhibits the breakdown of complex sugars and starches, including sugar. The most common adverse side effect is bloating, especially after meals rich in carbohydrates. The drug can also interfere with iron absorption.

Derivative of benzoic acid
Repaglinide is a derivative of benzoic acid, stimulates beta cells to secrete insulin as do sulphonylureas, but is less likely to cause hypoglycemia because it is rapidly metabolized and short works. Repaglinide is taken before each meal, and mimics the normal action of insulin after meals. With this drug patients can take meals at different times, since the only requirement to be taken before meals. It is especially effective in combination with metformin. It is shown to be effective in treating people with signs of kidney damage. Side effects were diarrhea and headache.

Tijazolidindioni
Tijazolidindioni (pioglitazone, rosiglitazone) improves insulin sensitivity by activating certain genes involved in the synthesis of fat and carbohydrate metabolism .. When used alone, does not cause hypoglycemia. Mainly used with insulin or in combination with sulfonylurea.

Insulin
Some patients can not only control the disease with diet or drugs that stimulate insulin secretion or increase insulin sensitivity. Therefore, in such patients effectively giving long-acting insulin at bedtime in combination with sulfonylurea. However, many patients need after a time completely replace insulin.

Hormone replacement therapy
Hormone replacement therapy (HRT) may be particularly beneficial for women with type 2 diabetes In a series of tests showed that the glucose control improved in women on HRT and even comes to improving the function of beta cells.

Monitoring of blood glucose
In patients who are treated with insulin, drugs that stimulate insulin release or increased sensitivity to insulin, it is important to carefully monitor blood glucose levels to avoid hypoglycemia. Patients should strive for glucose concentrations between 4.5 to 6.5 mmol / l (80 and 120 mg / dl) before meals and between 5.5 to 7.5 mmol / l (100-140 mg / dl) before going on sleep. Blood glucose concentrations are generally more stable in type 2 diabetes than type 1, so experts usually recommend measuring only one or two times a day. Usually a drop of blood from a finger is applied to a chemically treated strip. The concentration of glucose is read on a standard meter or on a small, portable device with a digital display.

Daily foot care
Preventive foot care could reduce the risk of amputation by 44 to 85%. Patients should review your feet every day and look for any changes in color, texture and the smell and strong and hardened parts, which could indicate infection and potential lesions. Water for washing the feet should be warm (not hot), and the feet and areas between the toes should be thoroughly dried after washing .. Corns and calluses should be gently scrape and toenails cut short and turpijati edges so as not to hurt the neighboring fingers. Patients are not advised to use medicated patches or try to cut corns and calluses. Avoid high heels, sandals, straps and should not walk barefoot.The shoes are recommended during the day often change, and tight socks or clothes that squeeze your legs and feet should be avoided. In case of any problem, you should consult a physician.

Other Recommendations

Vaccinations
It is strongly recommended annually vaccinated against influenza. Diabetics should also be consulted with a doctor on one-time pneumococcal vaccination, the most common cause of pneumonia.

Other drugs
Those suffering from diabetes type 2 recommended daily intake of low-dose aspirin. In one study it was found that a dose of 100 mg can reduce the complications associated with increased concentrations of glucose in the blood.

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