Type 2 Diabetes Overview

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Questions and Answers

What is the relative risk (RR) associated with shoulder dystocia in women with gestational diabetes?

2.9 (correct)

1.5

1.6

1.3

What factors should lead to screening women for gestational diabetes in their first trimester?

History of stress fractures and migraines

Obesity and advanced maternal age (correct)

Age below 20 years and low physical activity

Family history of heart disease

What percentage of women with gestational diabetes may have persistently abnormal glucose tolerance at 6-12 weeks postpartum?

24%

36% (correct)

50%

10%

In women with gestational diabetes, what is the likelihood of the child being overweight in childhood or adolescence?

1.5 times greater Signup and view all the answers

What waist circumference is considered a risk factor for Type 2 diabetes in men?

<blockquote> 40 inches </blockquote> Signup and view all the answers

Which of the following is a common symptom of Type 2 diabetes at diagnosis?

Weakness or fatigue Signup and view all the answers

What is the screening recommendation for adults with a body mass index (BMI) of ≥25 kg/m²?

Screen with one or more risk factors Signup and view all the answers

What aspect of lifestyle or pharmacologic interventions was noted about Type 2 diabetes in the long term?

The interventions help in delaying the disease progression. Signup and view all the answers

Which of the following factors is NOT commonly associated with Type 2 diabetes?

Family history of Type 1 diabetes Signup and view all the answers

What does the term 'Metabolic Syndrome' primarily identify?

Individuals at higher risk for developing diabetes and cardiovascular disease Signup and view all the answers

What is a potential benefit of screening for Type 2 diabetes according to long-term studies?

Potential benefits in mortality at 23- to 30-year follow-up Signup and view all the answers

Which symptom is more prominent in Type 1 diabetes compared to Type 2 diabetes?

Wasting or weight loss Signup and view all the answers

What term is used to describe the presence of increased visceral fat in patients with Type 2 diabetes who do not exhibit overt obesity?

Metabolic obesity Signup and view all the answers

Which factor is NOT associated with impaired insulin signaling in adipose tissue?

High levels of adiponectin Signup and view all the answers

Which symptom is specifically related to a chronic skin condition seen in Type 2 diabetes?

Acanthosis nigricans Signup and view all the answers

What is the financial burden for the majority of patients with diabetes regarding out-of-pocket spending on medications?

More than 3% of their income Signup and view all the answers

Which population demographic is associated with a higher prevalence of diabetes among individuals who have not completed high school?

5.2 times more than university graduates Signup and view all the answers

Which chronic skin condition is known to occur in males with Type 2 diabetes?

Balanoposthitis Signup and view all the answers

What percentage of Canadians with Type 2 diabetes feel uncomfortable disclosing their disease to others?

33% Signup and view all the answers

Which environmental factor is linked to the secretion of adipokines that impair insulin signaling?

Abnormal adipose tissue characteristics Signup and view all the answers

What percentage of pregnancies were comprised by gestational diabetes in 2020?

7.8% Signup and view all the answers

Which method has a higher sensitivity for diagnosing gestational diabetes?

One-step testing with a threshold of 130 mg/dL Signup and view all the answers

What is the recommendation for screening gestational diabetes to reduce complications?

Screening should occur between 24-28 weeks’ gestation. Signup and view all the answers

Which factor is known to increase the prevalence of gestational diabetes?

Advanced maternal age Signup and view all the answers

What is the typical outcome associated with a diagnosis of gestational diabetes?

Increased psychological and emotional burden Signup and view all the answers

What is a criterion for a positive result in the three-hour fasting 100g glucose challenge test?

At least one abnormal value is needed Signup and view all the answers

What is the comparison of diagnosis rates between one-step and two-step testing for gestational diabetes?

One-step testing has a higher diagnosis rate than two-step testing Signup and view all the answers

What is the specificity of the cutoff of 140 mg/dL for diagnosing gestational diabetes?

85% Signup and view all the answers

What is the generally accepted age for defining older adults in diabetes studies?

≥65 years Signup and view all the answers

Which of the following conditions is NOT a secondary cause of diabetes?

Asthma Signup and view all the answers

Which testing method may identify more undiagnosed diabetes cases than HbA1c?

Fasting plasma glucose (FPG) Signup and view all the answers

Why is screening for diabetes in older adults not currently routinely recommended?

Treatment does not affect outcomes. Signup and view all the answers

What is the diagnostic criterion for diabetes from a fasting plasma glucose test?

≥126 mg/dL Signup and view all the answers

When considering the management of diabetes in older patients, which factor is least relevant?

Sex Signup and view all the answers

Which of the following describes Maturity-Onset Diabetes of the Young (MODY) correctly?

Diagnosis is critical for effective management. Signup and view all the answers

Which statement about diabetes in older adults is accurate?

Diabetes can increase the risk for various geriatric conditions. Signup and view all the answers

What recent trend was observed in the prevalence of diabetes in older adults from 1997 to 2010 in the U.S.?

It increased by 62%. Signup and view all the answers

Which of the following is NOT a goal of diabetes screening in older adults?

Diagnose patients at any cost Signup and view all the answers

Study Notes

Subcutaneous Abdominal Fat

Subcutaneous abdominal fat is less correlated with insulin resistance.
"Metabolic obesity" is a term for when patients with Type 2 diabetes have increased visceral fat, but don't have overt obesity

Type 2 Diabetes Epidemiology

Adipocytes release abnormal levels of adipokines such as adiponectin and resistin, which can impair insulin signaling
Adipose tissue activates macrophages and other immune cells, which release TNF-alpha and IL-6 that also impair insulin signaling

Type 2 Diabetes Signs and Symptoms

Many patients are asymptomatic, and are initially diagnosed after glycosuria or hyperglycemia is found on routine lab tests.
At the time of diagnosis, patients may already have neuropathic or cardiovascular complications.
Prevalence of diabetes in the lowest income group is 4.9 times higher than in the highest income group
Prevalence of diabetes in adults who have not completed high school is 5.2 times higher than in adults with a university education
Prevalence of diabetes in adults who are unable to work is 2.9 times higher than in employed adults
Most people with diabetes pay >3% of their income (>$1500) for medications, devices, and supplies out-of-pocket.
33% of Canadians with Type 2 diabetes don't feel comfortable disclosing their disease to others.
Patients with chronic skin conditions are at higher risk for diabetes, such as:
- Vulvovaginal candidiasis in women
- Balanoposthitis in men
- Acanthosis nigricans
- Eruptive xanthomas

Type 2 Diabetes Weight Gain

Many patients are either overweight or obese
Patients often have a centripetal fat distribution
Higher waist circumference is a common issue(>40 inches for men, >35 inches for women)

Type 2 Diabetes Obstetrical Complications

Women who report delivering a baby over 9lb (4.1kg) or have had polyhydramnios, preeclampsia, or unexplained fetal losses should be considered for screening.

Type 2 Diabetes Screening

Screening is highly recommended for Type 2 diabetes.
Early intervention can help reduce disease progression and complications.
Screen asymptomatic adults who are at risk with a body mass index ≥25 kg/m2 and one or more of the following:
- A1c > 5.7%
- Impaired glucose tolerance
- Impaired fasting glucose

Type 1 vs. Type 2 Diabetes

Polyuria and thirst are more common in Type 1 than Type 2 diabetes
Weakness or fatigue seen in both
Polyphagia with weight loss is more common in Type 1, whereas Type 2 patients tend to gain weight
Recurrent blurred vision is more common in Type 2
Vulvovaginitis or pruritis is more common in Type 2
Peripheral neuropathy is seen in both
Nocturnal enuresis is more common in Type 1, it is not common in Type 2
Type 1 diabetes is often symptomatic, while Type 2 is frequently asymptomatic at the time of diagnosis

Metabolic Syndrome

Metabolic syndrome is a cluster of risk factors associated with diabetes and cardiovascular disease
Its usefulness as a diagnostic or management tool is unclear.
There is no clear pathophysiologic basis for metabolic syndrome.
Other measures, such as the Framingham risk score and fasting glucose, are more useful than the use of the "metabolic syndrome" label.

Gestational Diabetes

It comprised 7.8% of all pregnancies in 2020 in the U.S.
Prevalence increases with advancing age and higher pre-pregnancy BMI.
2.5% of women aged 40 years suffer from gestational diabetes.
Only 2 in 5 women in the U.S. had a normal BMI prior to pregnancy.
Screening typically occurs between 24-28 weeks’ gestation with a non-fasting 50g glucose challenge test
- A positive result occurs if blood glucose is >140 mg/dL (7.8 mmol/L). A 3-hour fasting 100g glucose challenge test should then be performed.
- To confirm the diagnosis with this second test, at least one abnormal value should be present (≥180, 155, 140 mg/dL for 1-, 2-, and 3-hour fasting glucose levels, respectively)
A threshold value of 130 mg/dL (7.2 mmol/L) has higher sensitivity (99%) but lower specificity (77%) than a cutoff of 140 mg/dL (85% sensitivity, 86% specificity)
One-step testing uses a single fasting 75g oral glucose tolerance test
Two-step testing uses a non-fasting 50g oral glucose tolerance test followed by a 3-hour fasting 100g glucose tolerance test if the result exceeds 130-140 mg/dL (7.2-7.8 mmol/L)
Diagnosis of gestational diabetes is more common with one-step screening (16.5%) than two-step screening (8.5%), but there are no statistically significant differences in perinatal or maternal complications.
Diagnosis of gestational diabetes is associated with increased psychological and emotional burden.
The two-step testing approach was found to provide equivalent benefits to one-step testing with fewer associated harms, so it is considered more suitable for screening.

Gestational Diabetes Screening Recommendations

Recommended to reduce maternal and fetal complications.
- Complications include preeclampsia, caesarean delivery, congenital malformations, macrosomia, childhood or adolescent obesity, nerve palsy, bone fracture, jaundice, and infant death.
Screen women in the first trimester if any risk factors are present.
- Risk factors include obesity, age >35 years, previous history of gestational diabetes, family history of diabetes, high-risk ethnicity (including black, Hispanic, American Indian, or Asian).
Screen asymptomatic patients at or after 24 weeks’ gestation.

Gestational Diabetes Complications

Gestational Diabetes can result in:
- Gestational hypertension (RR=1.6)
- Preeclampsia (RR=1.5)
- Cesarean delivery (RR=1.3)
- Shoulder dystocia (RR=2.9)
- Macrosomia (RR=1.6)
- Birth defects (RR=1.2)
- 7 times greater maternal risk of developing Type 2 diabetes later in life (RR=7.4)
- 1.5 times greater risk of the child being overweight in childhood/adolescence (RR=1.5)
In high-risk populations, diabetes develops in up to 50% of women with gestational diabetes.

Gestational Diabetes Management

Long-term follow-up is critical.
Screening at 6-12 weeks postpartum with a fasting glucose measurement or a 75g 2-hour glucose tolerance test is recommended.
- Up to 36% of women with gestational diabetes may have persistently abnormal glucose tolerance.
Women with a history of gestational diabetes should be screened every 3 years for overt diabetes.

Diabetes in Children and Adolescents

Types include Type 1 diabetes, Type 2 diabetes, and Maturity-onset diabetes of the young (MODY)
In 2018, an estimated 210,000 children and adolescents in the U.S. had diabetes.
MODY patients generally do not require treatment except in pregnancy.

MODY Screening Recommendations

Consider genetic testing and referral to an endocrinologist and/or a clinical genetics consultant.
Accurate diagnosis of MODY will determine treatment and management plans.
However, there is a lack of evidence from randomized trials to show that early diagnosis and appropriate therapy improve patient outcomes.

Diabetes in Older Adults

Generally considered to be >65 years of age
From 1997-2010, the U.S. prevalence of diabetes in older adults increased by 62%.
21.4% of adults aged ≥65 years in the U.S. have a known diagnosis of diabetes, and 16% aren't aware of their condition.
Older individuals are most commonly affected by Type 2 diabetes.
This population is heterogeneous in regards to race/ethnicity, duration of diabetes, comorbidity, and functional status.
Diabetes increases mortality, cardiovascular and microvascular complications, and other geriatric conditions (cognitive impairment, frailty, unintentional weight loss, polypharmacy, and functional impairment).

Diabetes in Older Adults Screening Recommendations

No current recommendations for routine screening.
Screening is dependent on whether treatment would improve quality of life or life expectancy
- Consider screening to prevent complications that may lead to functional impairment.
Treatment decisions should be made based on age, life expectancy, functional status, and the presence of chronic co-morbid diseases.

Secondary Causes of Diabetes

Causes include:
- Exocrine pancreas diseases
- Endocrinopathies
- Drug- or chemical-induced insulin resistance
- Other genetic diseases
Any disorder that damages the pancreas can result in diabetes.

Secondary Causes of Diabetes - Examples

Exocrine Pancreas Diseases*
Pancreatitis
Cystic Fibrosis
Endocrinopathies*
Somatostatinoma
Pheochromocytoma
Acromegaly
Cushing syndrome
Glucagonomia
Drug or Chemical Induced Insulin Resistance*
Corticosteroids
Sympathomimetics
Niacin
Alpelisib
Sirolimus
Thiazide diuretics
Phenytoin
Atypical antipsychotics
Genetic Syndromes*
Down syndrome
Klinefelter syndrome
Turner syndrome
Wolfram syndrome
Type A insulin resistance
Leprechaunism
Rabson-Mendenhall syndrome
Lipoatrophic diabetes

Diagnostic Testing

Fasting plasma glucose levels (FPG)
Oral glucose tolerance test (OGTT)
Glycated hemoglobin (HbA1c)
Additional tests (urine, self-monitoring, continuous glucose monitoring, autoantibody, and genetic)

Fasting Plasma Glucose (FPG)

100-125 mg/dL (5.6-6.9 mmol/L) is considered impaired fasting glucose tolerance, which increases risk of developing diabetes (“pre-diabetes”)
≥126 mg/dL (7.0 mmol/L) on more than one occasion, after at least 8-hour fasting, is diagnostic of Type 2 Diabetes
Diagnosis may be made with signs and symptoms of hyperglycemia, plus >200 mg/dL (11.1 mmol/L) and repeated testing is required to confirm
Pros: may identify one-third more undiagnosed cases than A1c
Cons: fasting is required

Oral Glucose Tolerance Test (OGTT)

Perform if FPG is:
- 100 mg/dL (5.6 mmol/L) or if there are hyperglycemia signs and symptoms
- If there is a suspicion of diabetes despite a normal FPG
OGTT involves drinking a concentrated glucose drink and blood glucose levels are measured at regular intervals during the test
140-199 mg/dL (7.8-11.0 mmol/L), 2 hours after the glucose drink, suggests impaired glucose tolerance ("pre-diabetes")
≥200 mg/dL (11.1 mmol/L) on two separate occasions is diagnostic of diabetes
Pros: it is a good diagnostic test for diabetes.
Cons: takes a longer time to complete, and requires extra steps for preparation

Glycated Hemoglobin (HbA1c)

It is an accurate measure of average blood glucose levels over the past 2-3 months.
It is a useful tool for monitoring diabetes and assessing glycemic control long term.
≥6.5% is diagnostic of diabetes
5.7-6.4% is considered impaired glucose tolerance ("pre-diabetes")
Pros: doesn't require fasting, can be used to monitor the long term management of diabetes
Cons: patients with a high turnover of red blood cells such as pregnant women or sickle cell anemia may not have accurate results.

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Description

This quiz covers key topics related to Type 2 diabetes, including the role of subcutaneous abdominal fat, epidemiology, and common signs and symptoms. It highlights how adipokines affect insulin signaling and the socioeconomic factors influencing the prevalence of diabetes. Test your knowledge on this critical health issue!