Definition
A.Relative (rather than absolute) insulin deficiency and peripheral insulin resistance.
B.Previously referred to as non-insulin-dependent diabetes or adult-onset diabetes.
Incidence
A.Accounts for 90% to 95% of all cases of diabetes.
B.According to the 2017 Centers for Disease Control and Prevention’s National Diabetes Statistics Report, an estimated 30.3 million Americans or 9.4% of the population had diabetes in 2015 (see Table 8.2).
C.In 2015, an estimated 1.5 million new cases of diabetes was diagnosed among U.S. adults older than 18 years.
D.Diabetes was the seventh leading cause of death in 2015.
E.Prevalence varies among different ethnicities (see Table 8.3).
Pathogenesis
A.Specific etiologies are not known. There is no autoimmune destruction of beta cells.
B.Excess weight causes insulin resistance. Most patients with type 2 diabetes are overweight or obese.
C.Abdominal obesity contributes to increased risk.
D.Ketoacidosis seldom occurs.
E.Hyperglycemia develops gradually; it is often undiagnosed for years before the official diagnosis is made.
F.Insulin secretion is defective and unable to compensate for increased insulin resistance.
Predisposing Factors
A.Age; risk is higher as age increases.
B.Obesity, with body mass index (BMI) greater than or equal to 25 kg/m².
C.Lack of physical activity.
D.Women with prior gestational diabetes.
E.History of prediabetes.
F.History of metabolic syndrome.
G.Comorbidities of hypertension and dyslipidemia.
H.Higher rates in certain ethnic populations.
1.African Americans.
2.American Indian.
3.Hispanic/Latino.
4.Asian American.
I.Strong genetic predisposition.
J.Medications.
1.Glucocorticoids.
2.Thiazide diuretics.
3.Atypical antipsychotics.
Subjective Data
A.Common complaints/symptoms.
1.Polyuria.
2.Blurred vision.
3.Polydipsia.
4.Malaise/fatigue.
5.Frequent urinary tract infections (UTIs) or vaginal candidiasis.
6.Poor wound healing.
B.Common/typical scenario.
1.Patients frequently complain of fatigue and weakness. They may have muscle cramps, blurred vision, and significant polyuria, polydipsia, and polyphagia.
2.Weight loss occurs over time despite normal or increased appetite.
C.Family and social history.
1.Ask about family history since there is a strong link to family history.
2.Ask about type of occupation, if the person is a shift worker, use of alcohol, smoking, or recreational drug use.
3.Review how much exercise the person gets.
D.Review of symptoms.
1.HEENT.
a.Dental issues. Periodontal disease is associated with diabetes.
2.Psychologic.
a.Depression.
b.Anxiety.
c.Disordered eating.
d.Psychosocial barriers/support.
e.Barriers to self-management.
3.Microvascular complications.
a.Neuropathy.
b.Nephropathy.
c.Retinopathy.
4.Macrovascular complications.
a.Coronary artery disease.
b.Cerebrovascular disease.
c.Peripheral arterial disease.
Physical Examination
A.Height, weight, BMI, waist circumference.
B.Vital signs.
C.Funduscopic examination.
D.Thyroid palpation.
E.Skin examination.
1.Acanthosis nigricans (see Figure 8.1).
2.Lipohypertrophy.
3.Diabetic dermopathy.
4.Skin tags.
F.Foot examination.
1.Inspection, noting mycotic changes to nail or skin.
2.Vascular examination.
a.Hair patterns or lack of hair growth.
b.Pulses (dorsalis pedis and posterior tibial).
c.Temperature/color.
3.Reflexes.
a.Patellar.
b.Achilles.
4.Proprioception, vibration, and monofilament sensation.
Diagnostic Tests
A.Hemoglobin A1C (HgbA1C), fasting glucose, random glucose, or 2-hour glucose tolerance test to diagnose.
1.HgbA1C greater than 6.5%.
2.Fasting glucose greater than 126 mg/dL.
3.Random glucose greater than 200 mg/dL with classic symptoms of hyperglycemia.
4.2-hour glucose tolerance test greater than 200 mg/dL.
B.HgbA1C on admission to hospital if no result available for past 3 months.
C.Yearly lab work for patients with diabetes.
1.Fasting lipid panel.
2.Liver function tests.
3.Urine albumin-to-creatinine ratio.
4.Serum creatinine and glomerular filtration rate (GFR).
Differential Diagnosis
A.Prediabetes.
B.Metabolic syndrome.
C.Stress hyperglycemia.
D.Medication-induced hyperglycemia.
E.Posttransplant diabetes.
F.MODY type diabetes.
G.Latent autoimmune diabetes.
H.Type 1 diabetes.
I.Ketosis-prone diabetes.
J.Pancreatitis.