Type 2 diabetes is a progressive chronic condition with multiple hormonal and metabolic abnormalities, resulting in elevated blood glucose levels (hyperglycaemia). It is commonly seen in people who are older and those with overweight or obesity, but can also happen in younger people and those with normal body weight. Type 2 diabetes is the commonest form of diabetes globally. Two important features of type 2 diabetes is the presence of multiple hormonal and metabolic abnormalities, as well as its progression over the years.
Given that multiple abnormalities are involved in the disease process of type 2 diabetes, no single treatment can offer complete normalization of these physiological derangements. People with type 2 diabetes often require a combination of treatments, ranging from diet, exercise, weight loss, multiple medications, and insulin. In fact, treatment for type 2 diabetes often work best when combined with lifestyle interventions.
Multiple physiological defects in type 2 diabetes (click on image to zoom).
Over time, type 2 diabetes will progress and people with diabetes may find they need to increase their medications to control their blood glucose. Earlier clinical trial that did not incorporate treatment adjustments (such at the UKPDS) have shown that type 2 diabetes control will inevitably worsen over time. However, newer clinical trials with designs that incorporate treatment adjustments have shown that with good treatment, diabetes control can be kept within target as long as patients receive timely monitoring and treatment adjustments.
After a few years, people who are well controlled with a single medication may gradually lose their glucose control, and will require a combination of medications to control their glucose. Similarly, people who are well controlled on oral medications may find that they will eventually require insulin. However, it is important to mention that progression of diabetes and loss of glucose control over time is a characteristic of type 2 diabetes itself, and is not a sign of personal failure.
HbA1c progression in patients receiving intensive treatment and standard treatment in the UKPDS Trial (click on image to zoom).
HbA1c progression in patients receiving intensive control and standard control in the ADVANCE Trial (click on image to zoom).
Progression of type 2 diabetes applies to people with diabetes remission too. While recent trials have shown that it is possible to normalize blood glucose and be free of diabetes medications with significant weight loss, there are still no data available on the sustainability of this remission. At this point, experts believe that these patients are not "cured", but are in a state of temporary remission, and are still at risk of developing type 2 diabetes again in the future.
The main aim of treatment for type 2 diabetes is to prevent complications and provide the best health outcomes. The most important and most studied complications and health outcomes in people with type 2 diabetes are cardiovascular events (heart attack and stroke) and death. Other complications that have also been extensively studied include heart failure, kidney failure, blindness, and amputations. Currently, the best treatment to prevent these complications is known as "multifactorial intervention" where blood glucose, blood pressure, cholesterol level, and other risk factors are addressed at the same time.