Running header: A REVIEW OF TYPE 2 DIABETES 1

A Review of Type 2 Diabetes

Camille Shepherd

Utah Valley University

A Review of Type 2 Diabetes

Millions of people are living with type 2 diabetes. Type 2 diabetes results from a

combination of insulin resistance and beta cell dysfunction which appears to be triggered by an

excess accumulation of insulin, glucose, and fat in the body. Several risk factors are associated

with the disease, most of which are related to lifestyle choices. People with the disease will

typically develop symptoms gradually; diagnosis is often made before they notice signs. If the

condition is not reversed or controlled, long-term complications can occur which can be

debilitating and life-threatening. Specific strategies such as eating a healthy diet low in processed

foods and sugar, regular exercise, and fasting can slow the progression of the disease and

possibly reverse it.

Prevalence

Type 2 diabetes accounts for more than 90% of all cases of diabetes. Multiple

epidemiologic studies reported that, in 2015, 29.1 million individuals (9.3% of total population)

in the United States over the age of 20 have diabetes. Of those, 8.1 million were unaware of their

disease. Another 86 million people (37%) in the United States aged 20 years or older have

prediabetes. Diabetes affects 25.9% of people who are over the age of 65 (Drexler, Praw, & Shi,

2019).

Etiology

Fung (2018) states, “The underlying core problem of type 2 diabetes is insulin resistance”

(p. 21); a condition in which cells do not respond appropriately to insulin. Defects in pancreatic

beta cell function is another significant pathophysiologic abnormality which underlies type 2

diabetes. The consensus is that both are essential components in the development of the disease

(Halban et al., 2014).

Processes Within the Body

Insulin Function

Karch (2014) defines insulin as:

A hormone secreted by beta cells of the pancreas that, by receptor-mediated

effects, promotes the storage of the body's fuels, facilitating the transport of

metabolites and ions (potassium) through cell membranes and stimulating the

synthesis of glycogen from glucose, of fats from lipids, and proteins from amino

acids. (p. 623)

Absorption and Transport of Glucose

After consuming carbohydrates, specific digestive enzymes in the small intestine called

amylase break them down into single sugar molecules called glucose. The cells that line the

intestine absorb the glucose, transport it through the intestinal wall, and deposit it into the

bloodstream. When the glucose-enriched blood reaches the pancreas, beta cells detect the

increased glucose levels and release insulin into the bloodstream to achieve homeostasis. As this

blood circulates through the body, the insulin and glucose exit the bloodstream and enter the

tissues to reach the body's cells. Most cells of the body have specific receptor proteins on the

surface that recognize and bind with the circulating insulin. When insulin binds to the receptor, a

complex signaling process instructs the cell to take in glucose from the blood to be used as an

energy source (Nucleus Medical Media, 2012).

Energy Storage

There are two primary forms of energy stored within the body: glycogen and fat. If cells

have sufficient amounts of glucose, insulin signals the liver to convert and store the excess or

unused glucose as glycogen. (E. Reisner, H. Reisner, & Crowley, 2017). Once the liver
A REVIEW OF TYPE 2 DIABETES 4

accumulates roughly 5% of its mass in glycogen, insulin signaling mechanisms synthesize any

additional glucose into glycerol and fatty acids which fat cells use to create triglyceride fats

(Bowen, 2019).

Insulin Resistance

Freeman and Pennings (2018) identify insulin resistance as an impaired cellular response

to normal levels of circulating insulin. Insulin acts only on target tissues or organs that have the

appropriate receptor sites for insulin. When the body becomes insulin resistant these target

tissues, primarily organ and muscle tissue, fail to take in glucose. In response to this, the

pancreas secretes more insulin. The body now requires higher concentrations of insulin to

normalize blood glucose levels.

Risk Factors and Early Signs

Individuals who have a family history of diabetes and obesity have a predisposed risk of

type 2 diabetes. Demographic risk factors include age (45 years or older) and ethnicity (Hispanic,

African American, Asian American, Native American, or Pacific Islander). Behavioral risk

factors include a sedentary lifestyle, unhealthy eating habits, chronic steroid use, and chronic

sleep deprivation. Physiological risk factors include excess visceral fat (abdominal fat), obesity,

hypertension, increased triglycerides, impaired glucose tolerance, low HDL cholesterol level,

history of gestational diabetes, and polycystic ovary syndrome (Drexler, Praw, & Shi, 2019).

Hyperinsulinemia

The Journal of Obesity and Weight-Loss Medication considers fasting insulin serum

levels to be normal if between a reference range of 2.6 and 24.9 uIU/ml (Wu, Zeng, Zhang,

2019). Hyperinsulinemia exists when insulin levels are above 24.9 uIU/ml. Corkey and Erion

(2017) hypothesized that hyperinsulinemia leads to increased food consumption, higher blood
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triglycerides, increased visceral fat, insulin resistance, and may play a causative role in the

development of beta cell dysfunction.

Beta Cell Dysfunction

With beta cell dysfunction, the beta cells within the pancreatic islets are unable to

produce and release sufficient amounts of insulin to overcome insulin resistance, leading to

persistent hyperglycemia (Park & Woo, 2019).

Hyperglycemia

When the body becomes insulin resistant, glucose does not get used for energy, nor does

it get stored as glycogen. Consequently, glucose accumulates in the bloodstream, resulting in

hyperglycemia (E. Reisner, H. Reisner, & Crowley, 2017).

Obesity and Increased Abdominal Fat

The American Diabetes Association (2019) notes that most patients with type 2 diabetes

are obese. “Those who are not obese by traditional weight criteria may have an increased

percentage of body fat distributed predominantly in the abdominal region” (p. S13-S28).

Increased Urination, Thirst, and Weight loss

When the kidneys filter blood to make urine, they reabsorb glucose and return it to the

bloodstream. When blood glucose levels rise above the kidneys' ability to reabsorb it, the glucose

is filtered out of the blood and into the urine, along with large amounts of water, which results in

abnormally frequent urination and severe thirst. This chronic loss of glucose may lead to rapid

weight loss (Fung, 2018).

Screening and Diagnosis

Screening is recommended for adults and children of any age who are overweight and

have one or more risk factors for type 2 diabetes. Screenings are recommended for all adults
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starting at age 45. When glucose readings are normal, patients are to repeat screenings every

three years (Freehill & Funnell, 2018).

Criteria for diagnosing type 2 diabetes: fasting plasma glucose at or above 126 mg/dL

(7.0 mmol/L), 2-hour plasma glucose at or above 200 mg/dL (11.1 mmol/L) during oral glucose

tolerance test (OGTT), A1C at or above 6.5% (48 mmol/mol), a random plasma glucose at or

above 200 mg/dL (11.1 mmol/L), or manifestation of classic symptoms of hyperglycemia or

hyperglycemic crisis (American Diabetes Association, 2019).

Long-term Complications

Diabetic Neuropathy

When blood sugar levels remain higher than normal for a long period of time, blood

vessels and nerves throughout the central and peripheral nervous system become damaged.

Neuropathy can be very painful. Patients can experience numbness, weakness, tingling, and poor

circulation in the legs, feet, and hands. Diabetic neuropathy can lead to problems in multiple

systems such as the digestive system, urinary tract, heart, and brain. “About 50% of diabetics

eventually develop neuropathy” (Greger & Stone, 2015, pg. 118).

Liver and Kidney Disease

Type 2 diabetics have an increased risk of developing non-alcoholic fatty liver disease

(NAFLD). It has been estimated that in Western countries, approximately 70% to 80% of

patients with type 2 diabetes have some level of NAFLD. (Byrne, Lonardo, & Targher, 2018).

Diabetic kidney disease (nephropathy) is kidney damage that results from having

diabetes. When the kidneys become damaged they fail to properly filter the blood, resulting in

toxic buildup within the body. If kidneys lose over 90% of their function, dialysis is required to
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remove toxins from the blood. “Approximately 2% of type 2 diabetic patients develop kidney

disease each year” (Fung, 2018, p.25).

Cataracts and Blindness

Cataracts are a clouding of the lens of the eye that impairs vision and is the leading cause

of blindness globally. Individuals with type 2 diabetes are twice as likely to develop cataracts (T.

Davis, W. Davis, & Drinkwater, 2019).

Heart Disease and Stroke

A stroke is a sudden impairment of cerebral circulation in one or more of the blood

vessels leading to or within the brain. A stroke interrupts or diminishes oxygen supply resulting

in cell death which can cause severe damage in brain tissue (Kantor, 2019). The CDC (2016)

reported that diabetes is one of the leading causes of stroke, killing about 1 in 6 people.

Current Treatment

Bariatric surgery

Good evidence supports bariatric surgery for preventing the progression of diabetes. In an

ethnically diverse population study, bariatric surgery resulted in significant long-term weight loss

and lower fasting plasma glucose levels for three years post-surgery. Patients with well-

controlled type 2 diabetes can consider this as an effective intervention (Cantillep, Dungan,

Newberry, & Shubrook, 2018).

Very Low Carbohydrate Diet

Research indicates that low carbohydrate eating plans, particularly those which reduce or

eliminate refined carbohydrates and foods high in sugar, may result in improved blood glucose

control, decreased body weight, and have the potential to reduce the need for anti-diabetic

medications (American Diabetes Association, 2019).

Fasting

Elmasry, Fung, Furmli, & Ramos (2018) presented a case series to demonstrate the

effectiveness of dietary education and therapeutic fasting to reverse insulin resistance. The case

series documented three patients who had been previously diagnosed with insulin-dependent

type 2 diabetes. The patients follow a medically-supervised and scheduled 24-hour fast, three

times per week, for several months. By the end of the study, all three patients had eliminated the

need for insulin. Further, all patients improved in other clinically significant health outcome

measures, such as hemoglobin A1c (the average of 2-3 months of blood sugars), body mass

index, and waist circumference.

Water fasting is the act of abstaining from all food and drink, except water for a defined

period of time. Fasting allows the body to lower glucose and insulin, naturally. It is key for

individuals to find which fasting regimen works best for them. Some patients with long-standing

type 2 diabetes reverse the disease within months, while others see much slower progress.

Fasting while under medical supervision is recommended (Fung, 2018).

Oral Hypoglycemic Medication

Acarbose, Glucagon-like peptide 1 (GLP-1), and Sodium-glucagon cotransporter 2

(SGLT2) have been shown to be the most successful at lowering insulin, glucose, and body

weight. Other hypoglycemic medications such as Insulin, Sulfonylureas (SUs), and

Thiazolidinediones (TZDs) increase insulin levels and body weight. Dipeptidyl peptidase-4

(DPP-4) inhibitors and Metformin have little effect on insulin and fat levels (Fung, 2018). It is

important to understand the side-effects of each medication. Taking medication as a way to

manage type 2 diabetes does not make it any less important to follow a healthy lifestyle of

exercise, proper diet, and weight loss.

Prevention Strategies

Regular Exercise

Moderate-intensity aerobic exercise, such as brisk walking or dancing, performed for 20-

30 minutes on most days of the week, has been shown to improve insulin sensitivity and reduce

abdominal fat. Breaking up prolonged sitting or sedentary time is also encouraged as it appears

to help normalize blood sugar levels (American Diabetes Association, 2019).

Resistance training is a strategy which promotes overall metabolic health through

improvements in muscle performance and increases in muscle mass. These adaptations positively

impact insulin responsiveness and glucose control (Goncalves, Madiraju, Pesta, Renata, Sparks,

& Strasser, 2017).

C. Shanahan and L. Shanahan (2016) state that exercise is important because it builds

new blood vessels by expanding the network of capillaries in the body’s tissue. This process

enables the body to generate more energy and burn more fat. Exercise also reduces cortisol.

Excess cortisol can cause fat deposition in and around the organs.

The National Diabetes Prevention Program

The National Diabetes Prevention Program is a community-based, lifestyle-change

program working to prevent or delay type 2 diabetes. Participants are facilitated by a trained

lifestyle coach while working toward increasing weekly physical activity and improving diet by

consuming more fresh vegetables, fresh fruits, whole grains, healthy fats, and lean proteins while

consuming less processed foods and unhealthy fats. The weight loss goal for participants is to

lose 7% of initial body weight. Progress is tracked throughout to ensure the program is having a

positive impact on health. One of the main goals is for participants to apply the knowledge
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acquired from the program to successfully lead a more healthful lifestyle (Cantillep, Dungan,

Newberry, & Shubrook, 2018).

Diabetes Education

Okada, Sugino, Tanaka, & Torimoto (2017) investigated the relationship between blood

glucose profile and diabetes education in hospital patients with type 2 diabetes. Patients went

through a 2-week educational program which included at least one personalized nutrition

education session provided by a dietician; lectures using brochures, slides, and videos; guidance

on how to use self-monitoring blood glucose devices; education on target glucose levels and

hypoglycemia; and techniques for self‐injection of insulin and glucagon‐like peptide 1 (GLP-1).

The results of the study showed that participants were able to improve overall levels of

hemoglobin A1c (HbAlc) and reverse their disease in a short amount of time. The researchers

considered diabetes education useful for achieving glycemic control and preventing vascular

complications.

Future Outlook

Type 2 diabetes is rapidly increasing in prevalence. The financial burden of this disease

exceeds $245 billion per year. If current trends continue, evidence suggests that the incidence of

type 2 diabetes will increase to as many as 1 in 3 Americans by 2050 (Drexler, Praw, & Shi,

2019, p. 755).

Insulin plays a vital role in metabolizing the body’s fuels. Beta cells play a vital role in

detecting increased glucose levels and releasing insulin into the bloodstream to achieve

homeostasis. Type 2 diabetes can be understood as a disease of insulin resistance and beta cell

dysfunction. These abnormalities appear to be caused by an excess accumulation of insulin,

glucose, and fat in the body. Serious complications such as neuropathy, cataracts, heart disease
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and stroke can arise when the disease is poorly managed. The most effective strategies to

normalize blood sugar levels include regular physical activity, fasting, and eating a healthy diet

high in fresh vegetables, fresh fruits, whole grains, healthy fats, and lean proteins. Diabetes

presents a major health crisis in terms of prevalence, morbidity, and costs. For these reasons, it is

crucial to enhance screenings, education and support programs to reduce the diabetes epidemic.
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