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Running Header: A Review of Type 2 Diabetes 1 A Review of Type 2 Diabetes Camille Shepherd Utah Valley University
Running Header: A Review of Type 2 Diabetes 1 A Review of Type 2 Diabetes Camille Shepherd Utah Valley University
Camille Shepherd
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
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
Insulin Function
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
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 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
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
A REVIEW OF TYPE 2 DIABETES 5
triglycerides, increased visceral fat, insulin resistance, and may play a causative role in the
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
Hyperglycemia
When the body becomes insulin resistant, glucose does not get used for energy, nor does
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).
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
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
A REVIEW OF TYPE 2 DIABETES 6
starting at age 45. When glucose readings are normal, patients are to repeat screenings every
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
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
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
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.
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,
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
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
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.
(SGLT2) have been shown to be the most successful at lowering insulin, glucose, and body
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
manage type 2 diabetes does not make it any less important to follow a healthy lifestyle of
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
improvements in muscle performance and increases in muscle mass. These adaptations positively
impact insulin responsiveness and glucose control (Goncalves, Madiraju, Pesta, Renata, Sparks,
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.
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,
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
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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