diabetes type 2 patient education

Patient Care & Health Information
Diseases & Conditions
Type 2 diabetes

Type 2 diabetes is usually diagnosed using the glycated hemoglobin (A1C) test. This blood test indicates your average blood sugar level for the past two to three months. Results are interpreted as follows:

Below 5.7% is normal.
5.7% to 6.4% is diagnosed as prediabetes.
6.5% or higher on two separate tests indicates diabetes.

If the A1C test isn't available, or if you have certain conditions that interfere with an A1C test, your health care provider may use the following tests to diagnose diabetes:

Random blood sugar test. Blood sugar values are expressed in milligrams of sugar per deciliter ( mg/dL ) or millimoles of sugar per liter ( mmol/L ) of blood. Regardless of when you last ate, a level of 200 mg/dL (11.1 mmol/L ) or higher suggests diabetes, especially if you also have symptoms of diabetes, such as frequent urination and extreme thirst.

Fasting blood sugar test. A blood sample is taken after you haven't eaten overnight. Results are interpreted as follows:

Less than 100 mg/dL (5.6 mmol/L ) is considered healthy.
100 to 125 mg/dL (5.6 to 6.9 mmol/L ) is diagnosed as prediabetes.
126 mg/dL (7 mmol/L ) or higher on two separate tests is diagnosed as diabetes.

Oral glucose tolerance test. This test is less commonly used than the others, except during pregnancy. You'll need to not eat for a certain amount of time and then drink a sugary liquid at your health care provider's office. Blood sugar levels then are tested periodically for two hours. Results are interpreted as follows:

Less than 140 mg/dL (7.8 mmol/L ) after two hours is considered healthy.
140 to 199 mg/dL (7.8 mmol/L and 11.0 mmol/L ) is diagnosed as prediabetes.
200 mg/dL (11.1 mmol/L ) or higher after two hours suggests diabetes.

Screening. The American Diabetes Association recommends routine screening with diagnostic tests for type 2 diabetes in all adults age 35 or older and in the following groups:

People younger than 35 who are overweight or obese and have one or more risk factors associated with diabetes.
Women who have had gestational diabetes.
People who have been diagnosed with prediabetes.
Children who are overweight or obese and who have a family history of type 2 diabetes or other risk factors.

After a diagnosis

If you're diagnosed with diabetes, your health care provider may do other tests to distinguish between type 1 and type 2 diabetes because the two conditions often require different treatments.

Your health care provider will test A1C levels at least two times a year and when there are any changes in treatment. Target A1C goals vary depending on age and other factors. For most people, the American Diabetes Association recommends an A1C level below 7%.

You also receive tests to screen for complications of diabetes and other medical conditions.

More Information

Glucose tolerance test

Management of type 2 diabetes includes:

Healthy eating.
Regular exercise.
Weight loss.
Possibly, diabetes medication or insulin therapy.
Blood sugar monitoring.

These steps make it more likely that blood sugar will stay in a healthy range. And they may help to delay or prevent complications.

Healthy eating

There's no specific diabetes diet. However, it's important to center your diet around:

A regular schedule for meals and healthy snacks.
Smaller portion sizes.
More high-fiber foods, such as fruits, nonstarchy vegetables and whole grains.
Fewer refined grains, starchy vegetables and sweets.
Modest servings of low-fat dairy, low-fat meats and fish.
Healthy cooking oils, such as olive oil or canola oil.
Fewer calories.

Your health care provider may recommend seeing a registered dietitian, who can help you:

Identify healthy food choices.
Plan well-balanced, nutritional meals.
Develop new habits and address barriers to changing habits.
Monitor carbohydrate intake to keep your blood sugar levels more stable.

Physical activity

Exercise is important for losing weight or maintaining a healthy weight. It also helps with managing blood sugar. Talk to your health care provider before starting or changing your exercise program to ensure that activities are safe for you.

Aerobic exercise. Choose an aerobic exercise that you enjoy, such as walking, swimming, biking or running. Adults should aim for 30 minutes or more of moderate aerobic exercise on most days of the week, or at least 150 minutes a week.
Resistance exercise. Resistance exercise increases your strength, balance and ability to perform activities of daily living more easily. Resistance training includes weightlifting, yoga and calisthenics. Adults living with type 2 diabetes should aim for 2 to 3 sessions of resistance exercise each week.
Limit inactivity. Breaking up long periods of inactivity, such as sitting at the computer, can help control blood sugar levels. Take a few minutes to stand, walk around or do some light activity every 30 minutes.

Weight loss

Weight loss results in better control of blood sugar levels, cholesterol, triglycerides and blood pressure. If you're overweight, you may begin to see improvements in these factors after losing as little as 5% of your body weight. However, the more weight you lose, the greater the benefit to your health. In some cases, losing up to 15% of body weight may be recommended.

Your health care provider or dietitian can help you set appropriate weight-loss goals and encourage lifestyle changes to help you achieve them.

Monitoring your blood sugar

Your health care provider will advise you on how often to check your blood sugar level to make sure you remain within your target range. You may, for example, need to check it once a day and before or after exercise. If you take insulin, you may need to check your blood sugar multiple times a day.

Monitoring is usually done with a small, at-home device called a blood glucose meter, which measures the amount of sugar in a drop of blood. Keep a record of your measurements to share with your health care team.

Continuous glucose monitoring is an electronic system that records glucose levels every few minutes from a sensor placed under the skin. Information can be transmitted to a mobile device such as a phone, and the system can send alerts when levels are too high or too low.

Diabetes medications

If you can't maintain your target blood sugar level with diet and exercise, your health care provider may prescribe diabetes medications that help lower glucose levels, or your provider may suggest insulin therapy. Medicines for type 2 diabetes include the following.

Metformin (Fortamet, Glumetza, others) is generally the first medicine prescribed for type 2 diabetes. It works mainly by lowering glucose production in the liver and improving the body's sensitivity to insulin so it uses insulin more effectively.

Some people experience B-12 deficiency and may need to take supplements. Other possible side effects, which may improve over time, include:

Abdominal pain.

Sulfonylureas help the body secrete more insulin. Examples include glyburide (DiaBeta, Glynase), glipizide (Glucotrol XL) and glimepiride (Amaryl). Possible side effects include:

Low blood sugar.
Weight gain.

Glinides stimulate the pancreas to secrete more insulin. They're faster acting than sulfonylureas. But their effect in the body is shorter. Examples include repaglinide and nateglinide. Possible side effects include:

Thiazolidinediones make the body's tissues more sensitive to insulin. An example of this medicine is pioglitazone (Actos). Possible side effects include:

Risk of congestive heart failure.
Risk of bladder cancer (pioglitazone).
Risk of bone fractures.

DPP-4 inhibitors help reduce blood sugar levels but tend to have a very modest effect. Examples include sitagliptin (Januvia), saxagliptin (Onglyza) and linagliptin (Tradjenta). Possible side effects include:

Risk of pancreatitis.
Joint pain.

GLP-1 receptor agonists are injectable medications that slow digestion and help lower blood sugar levels. Their use is often associated with weight loss, and some may reduce the risk of heart attack and stroke. Examples include exenatide (Byetta, Bydureon Bcise), liraglutide (Saxenda, Victoza) and semaglutide (Rybelsus, Ozempic, Wegovy). Possible side effects include:

SGLT2 inhibitors affect the blood-filtering functions in the kidneys by blocking the return of glucose to the bloodstream. As a result, glucose is removed in the urine. These medicines may reduce the risk of heart attack and stroke in people with a high risk of those conditions. Examples include canagliflozin (Invokana), dapagliflozin (Farxiga) and empagliflozin (Jardiance). Possible side effects include:

Vaginal yeast infections.
Urinary tract infections.
Low blood pressure.
High cholesterol.
Risk of gangrene.
Risk of bone fractures (canagliflozin).
Risk of amputation (canagliflozin).

Other medicines your health care provider might prescribe in addition to diabetes medications include blood pressure and cholesterol-lowering medicines, as well as low-dose aspirin, to help prevent heart and blood vessel disease.

Insulin therapy

Some people who have type 2 diabetes need insulin therapy. In the past, insulin therapy was used as a last resort, but today it may be prescribed sooner if blood sugar targets aren't met with lifestyle changes and other medicines.

Different types of insulin vary on how quickly they begin to work and how long they have an effect. Long-acting insulin, for example, is designed to work overnight or throughout the day to keep blood sugar levels stable. Short-acting insulin generally is used at mealtime.

Your health care provider will determine what type of insulin is right for you and when you should take it. Your insulin type, dosage and schedule may change depending on how stable your blood sugar levels are. Most types of insulin are taken by injection.

Side effects of insulin include the risk of low blood sugar — a condition called hypoglycemia — diabetic ketoacidosis and high triglycerides.

Weight-loss surgery

Weight-loss surgery changes the shape and function of the digestive system. This surgery may help you lose weight and manage type 2 diabetes and other conditions related to obesity. There are several surgical procedures. All of them help people lose weight by limiting how much food they can eat. Some procedures also limit the amount of nutrients the body can absorb.

Weight-loss surgery is only one part of an overall treatment plan. Treatment also includes diet and nutritional supplement guidelines, exercise and mental health care.

Generally, weight-loss surgery may be an option for adults living with type 2 diabetes who have a body mass index (BMI) of 35 or higher. BMI is a formula that uses weight and height to estimate body fat. Depending on the severity of diabetes or the presence of other medical conditions, surgery may be an option for someone with a BMI lower than 35.

Weight-loss surgery requires a lifelong commitment to lifestyle changes. Long-term side effects may include nutritional deficiencies and osteoporosis.

People living with type 2 diabetes often need to change their treatment plan during pregnancy and follow a diet that controls carbohydrates. Many people need insulin therapy during pregnancy. They also may need to stop other treatments, such as blood pressure medicines.

There is an increased risk during pregnancy of developing a condition that affects the eyes called diabetic retinopathy. In some cases, this condition may get worse during pregnancy. If you are pregnant, visit an ophthalmologist during each trimester of your pregnancy and one year after you give birth. Or as often as your health care provider suggests.

Signs of trouble

Regularly monitoring your blood sugar levels is important to avoid severe complications. Also, be aware of symptoms that may suggest irregular blood sugar levels and the need for immediate care:

High blood sugar. This condition also is called hyperglycemia. Eating certain foods or too much food, being sick, or not taking medications at the right time can cause high blood sugar. Symptoms include:

Frequent urination.
Increased thirst.
Blurred vision.

Hyperglycemic hyperosmolar nonketotic syndrome (HHNS). This life-threatening condition includes a blood sugar reading higher than 600 mg/dL (33.3 mmol/L ). HHNS may be more likely if you have an infection, are not taking medicines as prescribed, or take certain steroids or drugs that cause frequent urination. Symptoms include:

Extreme thirst.
Drowsiness.
Dark urine.

Diabetic ketoacidosis. Diabetic ketoacidosis occurs when a lack of insulin results in the body breaking down fat for fuel rather than sugar. This results in a buildup of acids called ketones in the bloodstream. Triggers of diabetic ketoacidosis include certain illnesses, pregnancy, trauma and medicines — including the diabetes medicines called SGLT2 inhibitors.

The toxicity of the acids made by diabetic ketoacidosis can be life-threatening. In addition to the symptoms of hyperglycemia, such as frequent urination and increased thirst, ketoacidosis may cause:

Shortness of breath.
Fruity-smelling breath.

Low blood sugar. If your blood sugar level drops below your target range, it's known as low blood sugar. This condition also is called hypoglycemia. Your blood sugar level can drop for many reasons, including skipping a meal, unintentionally taking more medication than usual or being more physically active than usual. Symptoms include:

Irritability.
Heart palpitations.
Slurred speech.

If you have symptoms of low blood sugar, drink or eat something that will quickly raise your blood sugar level. Examples include fruit juice, glucose tablets, hard candy or another source of sugar. Retest your blood in 15 minutes. If levels are not at your target, eat or drink another source of sugar. Eat a meal after your blood sugar level returns to normal.

If you lose consciousness, you need to be given an emergency injection of glucagon, a hormone that stimulates the release of sugar into the blood.

Medications for type 2 diabetes
GLP-1 agonists: Diabetes drugs and weight loss
Bariatric surgery
Endoscopic sleeve gastroplasty
Gastric bypass (Roux-en-Y)

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Lifestyle and home remedies

Careful management of type 2 diabetes can reduce the risk of serious — even life-threatening — complications. Consider these tips:

Commit to managing your diabetes. Learn all you can about type 2 diabetes. Make healthy eating and physical activity part of your daily routine.
Work with your team. Establish a relationship with a certified diabetes education specialist, and ask your diabetes treatment team for help when you need it.
Identify yourself. Wear a necklace or bracelet that says you are living with diabetes, especially if you take insulin or other blood sugar-lowering medicine.
Schedule a yearly physical exam and regular eye exams. Your diabetes checkups aren't meant to replace regular physicals or routine eye exams.
Keep your vaccinations up to date. High blood sugar can weaken your immune system. Get a flu shot every year. Your health care provider also may recommend the pneumonia vaccine. The Centers for Disease Control and Prevention (CDC) also recommends the hepatitis B vaccination if you haven't previously received this vaccine and you're 19 to 59 years old. Talk to your health care provider about other vaccinations you may need.
Take care of your teeth. Diabetes may leave you prone to more-serious gum infections. Brush and floss your teeth regularly and schedule recommended dental exams. Contact your dentist right away if your gums bleed or look red or swollen.
Pay attention to your feet. Wash your feet daily in lukewarm water, dry them gently, especially between the toes, and moisturize them with lotion. Check your feet every day for blisters, cuts, sores, redness and swelling. Contact your health care provider if you have a sore or other foot problem that isn't healing.
Keep your blood pressure and cholesterol under control. Eating healthy foods and exercising regularly can go a long way toward controlling high blood pressure and cholesterol. Take medication as prescribed.
If you smoke or use other types of tobacco, ask your health care provider to help you quit. Smoking increases your risk of diabetes complications. Talk to your health care provider about ways to stop using tobacco.
Use alcohol sparingly. Depending on the type of drink, alcohol may lower or raise blood sugar levels. If you choose to drink alcohol, only do so with a meal. The recommendation is no more than one drink daily for women and no more than two drinks daily for men. Check your blood sugar frequently after drinking alcohol.
Make healthy sleep a priority. Many people with type 2 diabetes have sleep problems. And not getting enough sleep may make it harder to keep blood sugar levels in a healthy range. If you have trouble sleeping, talk to your health care provider about treatment options.
Caffeine: Does it affect blood sugar?

Alternative medicine

Many alternative medicine treatments claim to help people living with diabetes. According to the National Center for Complementary and Integrative Health, studies haven't provided enough evidence to recommend any alternative therapies for blood sugar management. Research has shown the following results about popular supplements for type 2 diabetes:

Chromium supplements have been shown to have few or no benefits. Large doses can result in kidney damage, muscle problems and skin reactions.
Magnesium supplements have shown benefits for blood sugar control in some but not all studies. Side effects include diarrhea and cramping. Very large doses — more than 5,000 mg a day — can be fatal.
Cinnamon, in some studies, has lowered fasting glucose levels but not A1C levels. Therefore, there's no evidence of overall improved glucose management.

Talk to your health care provider before starting a dietary supplement or natural remedy. Do not replace your prescribed diabetes medicines with alternative medicines.

Coping and support

Type 2 diabetes is a serious disease, and following your diabetes treatment plan takes commitment. To effectively manage diabetes, you may need a good support network.

Anxiety and depression are common in people living with diabetes. Talking to a counselor or therapist may help you cope with the lifestyle changes and stress that come with a type 2 diabetes diagnosis.

Support groups can be good sources of diabetes education, emotional support and helpful information, such as how to find local resources or where to find carbohydrate counts for a favorite restaurant. If you're interested, your health care provider may be able to recommend a group in your area.

You can visit the American Diabetes Association website to check out local activities and support groups for people living with type 2 diabetes. The American Diabetes Association also offers online information and online forums where you can chat with others who are living with diabetes. You also can call the organization at 800-DIABETES ( 800-342-2383 ).

Preparing for your appointment

At your annual wellness visit, your health care provider can screen for diabetes and monitor and treat conditions that increase your risk of diabetes, such as high blood pressure, high cholesterol or a high BMI .

If you are seeing your health care provider because of symptoms that may be related to diabetes, you can prepare for your appointment by being ready to answer the following questions:

When did your symptoms begin?
Does anything improve the symptoms or worsen the symptoms?
What medicines do you take regularly, including dietary supplements and herbal remedies?
What are your typical daily meals? Do you eat between meals or before bedtime?
How much alcohol do you drink?
How much daily exercise do you get?
Is there a history of diabetes in your family?

If you are diagnosed with diabetes, your health care provider may begin a treatment plan. Or you may be referred to a doctor who specializes in hormonal disorders, called an endocrinologist. Your care team also may include the following specialists:

Certified diabetes education specialist.
Foot doctor, also called a podiatrist.
Doctor who specializes in eye care, called an ophthalmologist.

Talk to your health care provider about referrals to other specialists who may be providing care.

Questions for ongoing appointments

Before any appointment with a member of your treatment team, make sure you know whether there are any restrictions, such as not eating or drinking before taking a test. Questions that you should regularly talk about with your health care provider or other members of the team include:

How often do I need to monitor my blood sugar, and what is my target range?
What changes in my diet would help me better manage my blood sugar?
What is the right dosage for prescribed medications?
When do I take the medications? Do I take them with food?
How does management of diabetes affect treatment for other conditions? How can I better coordinate treatments or care?
When do I need to make a follow-up appointment?
Under what conditions should I call you or seek emergency care?
Are there brochures or online sources you recommend?
Are there resources available if I'm having trouble paying for diabetes supplies?

What to expect from your doctor

Your health care provider is likely to ask you questions at your appointments. Those questions may include:

Do you understand your treatment plan and feel confident you can follow it?
How are you coping with diabetes?
Have you had any low blood sugar?
Do you know what to do if your blood sugar is too low or too high?
What's a typical day's diet like?
Are you exercising? If so, what type of exercise? How often?
Do you sit for long periods of time?
What challenges are you experiencing in managing your diabetes?
Professional Practice Committee: Standards of Medical Care in Diabetes — 2020. Diabetes Care. 2020; doi:10.2337/dc20-Sppc.
Diabetes mellitus. Merck Manual Professional Version. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/diabetes-mellitus-dm. Accessed Dec. 7, 2020.
Melmed S, et al. Williams Textbook of Endocrinology. 14th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Dec. 3, 2020.
Diabetes overview. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes/overview/all-content. Accessed Dec. 4, 2020.
AskMayoExpert. Type 2 diabetes. Mayo Clinic; 2018.
Feldman M, et al., eds. Surgical and endoscopic treatment of obesity. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed Oct. 20, 2020.
Hypersmolar hyperglycemic state (HHS). Merck Manual Professional Version. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/hyperosmolar-hyperglycemic-state-hhs. Accessed Dec. 11, 2020.
Diabetic ketoacidosis (DKA). Merck Manual Professional Version. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/diabetic-ketoacidosis-dka. Accessed Dec. 11, 2020.
Hypoglycemia. Merck Manual Professional Version. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/hypoglycemia. Accessed Dec. 11, 2020.
6 things to know about diabetes and dietary supplements. National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/tips/things-to-know-about-type-diabetes-and-dietary-supplements. Accessed Dec. 11, 2020.
Type 2 diabetes and dietary supplements: What the science says. National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/providers/digest/type-2-diabetes-and-dietary-supplements-science. Accessed Dec. 11, 2020.
Preventing diabetes problems. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/all-content. Accessed Dec. 3, 2020.
Schillie S, et al. Prevention of hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recommendations and Reports. 2018; doi:10.15585/mmwr.rr6701a1.
Diabetes prevention: 5 tips for taking control
Hyperinsulinemia: Is it diabetes?

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Diabetes self management patient education materials, table of contents.

Click on any of the links below to access helpful materials on managing all aspects of diabetes that can be printed and given to your patients .

Introductory Information

Diabetes Mellitus Type 1 : Symptoms, diagnosis, prevention, and treatment (e.g., insulin)
Diabetes Mellitus Type 2 : Symptoms, diagnosis, prevention, and treatment (e.g., medications)
Women and Diabetes: Eating and weight, pregnancy, and heart disease
Men and Diabetes: Sexual Issues and employment concerns
Diabetes and Your Lifestyle : Exercise, traveling, employment, sexual issues, and special considerations for the elderly

General Self-Care (e.g., Blood Glucose, Foot Care)

Blood glucose.

Pass This Test : Testing blood glucose levels
Tool: Blood Sugar Monitoring Log (Oral Meds): Patient log to record levels
Tool: Blood Sugar Monitoring Log (Insulin Meds): Patient log to monitor levels
Tool: Foot Care Log : Patient log to record self-inspections and any problem areas
Tool: Injection Sites : Patient log to help rotate injection sites
Tool: Planning Your Exercise: Guide to help patients design an exercise program
Tool: Physical Activity Log : Patient log to record physical activity
Exercise in Disguise: Finding ways to exercise at home and outside of the gym
Exercising Like Your Life Depends on It: Health benefits to exercising
Hot Weather Exercise: Taking extra care when exercising in hot weather

Nutrition/Health

Diet/weight loss.

Managing Type 2 Diabetes through Diet : Suggestions for balancing your diet
Losing Weight When You Have Diabetes: Weight loss benefits, suggestions to start, and a brief discussion of weight loss drugs
The Skinny on Visceral Fat : Dangers of visceral fat and exercise tips to reduce visceral fat

Meal Planning

Tool: Shopping Guide and Nutrition Tips: Shopping list and money-saving tips
Tool: Meal Planning Guides: Plate diagrams demonstrating appropriate portions
Tool: Food Log : Patient log to record food and drink
No More Carb Confusion : Understanding carbs and their effect on blood sugar

Smoking and Alcohol

Mixing Alcohol with Diabetes: What drinking does to your body, and when it is ok
Tool: Sick Day Guidelines: Tips, suggested foods, and patient log to record intake
Diabetes and Stress : Immediate and long-term affects, and tips to manage stress

Medical Care Topics / Relation to Other Illnesses

Infections and Diabetes: Explains increased chance for infections
Make the DASH to Lower Your Blood Pressure : Nutrition tips to lower hypertension

Heart Smart

Diabetes and Your Heart : "ABC" numbers and their link to heart disease
Heart Smart Medications : Types of medications to prevent heart problems
Young at Heart : Suggestions to reverse heart disease and tips for heart health

Vascular Disease

Microvascular Disease Due to Diabetes: Discusses increased risk for eye and kidney problems
Macrovascular Disease Due to Diabetes: Discusses increased risk for heart attack and stroke
Preserving Kidney Function : Preserving Kidney function, especially when damage has already occurred
Keeping Kidneys Healthy: Tips for kidney health and some "kidney-protective" meds
Nine Ways to Avoid Diabetes Complications : Overview of tips to manage diabetes (healthy eating, activity, checking feet, etc.)

Patient Education Library

Types of Physical Activity

nutrition for life: diabetes plate method

Plan Your Plate

Best Foods For You: Making Healthy Food Choices

Your Mental Health and Diabetes

Fact Sheets

At A Glance
Diabetes and Prediabetes Fact Sheet
On Your Way to Preventing Type 2 Diabetes
Take Charge of Your Diabetes: Your Medicines
Take Charge of Your Diabetes: Healthy Eyes
Take Charge of Your Diabetes: Healthy Feet
Take Charge of Your Diabetes: Healthy Teeth
Take Charge of Your Diabetes: Healthy Ears
Take Care of Your Kidneys and They Will Take Care of You
How to Help a Loved One With Diabetes When You Live Far Apart
Choosing Healthy Foods on Holidays and Special Occasions
Tasty Recipes for People with Diabetes [PDF - 9 MB]
Steps to Help You Stay Healthy With Diabetes
5 Questions to Ask Your Health Care Team
Managing Diabetes: Medicare Coverage and Resources [PDF - 1 MB]
Road to Health Toolkit (English) This collection of tools is tailored to African Americans and can be used to counsel and motivate those at high risk for type 2 diabetes.
Road to Health Toolkit (Spanish)/Kit El camino hacia la buena salud This collection of tools can be used to counsel and motivate those at high risk for type 2 diabetes.
Road to Health: Blaze Your Own Trail to Healthy Living [PDF – 6.91MB] This flipchart is culturally adapted to counsel and motivate American Indian people who are at risk for type 2 diabetes.

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National Diabetes Prevention Program
Native Diabetes Wellness Program
Chronic Kidney Disease
Vision Health Initiative
Heart Disease and Stroke
Overweight & Obesity

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Type 2 diabetes

Peer reviewed by Dr Krishna Vakharia, MRCGP Last updated by Dr Colin Tidy, MRCGP Last updated 26 Apr 2023

Meets Patient’s editorial guidelines

In this series: Type 2 diabetes treatment Type 2 diabetes diet

Type 2 diabetes can occur at any age, including during childhood, but it occurs mainly in people aged over 40. The first-line treatment is diet, weight control and physical activity.

The good news is that many people can stay well using these lifestyle measures. However if the blood sugar (glucose) level remains high then tablets to reduce the blood glucose level are usually advised. Insulin injections are needed in some cases. Other treatments include reducing blood pressure if it is high, lowering high cholesterol levels, and also other measures to reduce the risk of complications.

What is type 2 diabetes, how common is type 2 diabetes, type 2 diabetes symptoms, type 2 diabetes diagnosis, type 2 diabetes complications, what are the aims of type 2 diabetes treatment, treatment aim 1 - keeping your blood sugar (glucose) level at normal levels, treatment aim 2 - to reduce other risk factors, treatment aim 3 - monitoring to detect and treat any complications promptly, immunisation.

Continue reading below

Playlist: What is Diabetes?

Dr. Partha Kar, FRCP

How do you explain type 2 diabetes to your child?

Type 2 diabetes and its symptoms tend to develop gradually (over weeks or months). This is because in type 2 diabetes you still make insulin (unlike in type 1 diabetes ). However, you develop type 2 diabetes because:

You do not make enough insulin for your body's needs; or

The cells in your body do not use insulin properly. This is called insulin resistance. The cells in your body become resistant to normal levels of insulin. This means that you need more insulin than you normally make to keep the blood sugar (glucose) level down; or

A combination of the above two reasons.

You can learn more about insulin and blood glucose from our separate leaflet called Diabetes (Diabetes Mellitus) .

Type 2 diabetes is much more common than type 1 diabetes.

Type 2 diabetes develops mainly in people older than the age of 40 but type 2 diabetes is now becoming far more common in children and in young people.

The number of people with type 2 diabetes is increasing in the UK, as it is more common in people who are overweight or obese. It also tends to run in families. Type 2 diabetes is around five times more common in South Asian and African-Caribbean people (often developing before the age of 40 in this group). It is estimated that by 2025 more than 5 million people in the UK will be diagnosed with diabetes.

Playlist: Risks of Diabetes

Who is most at risk from type 2 diabetes.

Is type 2 diabetes hereditary?

How can I avoid getting a hypo?

Dr. Sarah Jarvis MBE, FRCGP

What can someone with type 1 diabetes do to stop their blood glucose going too high?

Other risk factors.

Having a first-degree relative with type 2 diabetes. (A first-degree relative is a parent, brother, sister, or child.)

Being overweight or obese .

Having a waist measuring more than 31.5 inches (80 cm) if you are a woman or more than 37 inches (94 cm) if you are a man. Where in your body you store excess weight is important. Central obesity (a big tummy) probably happens because of the effect of insulin pushing excess sugar into abdominal fat cells over the years.

Having pre-diabetes (impaired glucose tolerance) . Impaired glucose tolerance means that your blood sugar (glucose) levels are higher than normal but not high enough to have diabetes. People with impaired glucose tolerance have a high risk of developing diabetes and so impaired glucose tolerance is often called pre-diabetes.

Having diabetes or pre-diabetes when you were pregnant .

How do you know if you have type 2 diabetes?

As already mentioned, type 2 diabetes symptoms often come on gradually and can be quite vague at first. Many people have type 2 diabetes for a long period of time before their diagnosis is made.

The most common type 2 diabetes symptoms are:

Being thirsty a lot of the time.

Passing large amounts of urine.

Tiredness, which may be worse after meals.

The reason why you make a lot of urine and become thirsty is that if your blood sugar (glucose) rises too high (because insulin is not doing its job) the excess sugar leaks into your urine. This pulls out extra water through the kidneys.

As the type 2 diabetes symptoms may develop gradually, you can become used to being thirsty and tired and you may not recognise for some time that you are ill. Some people also develop blurred vision and frequent infections, such as recurring thrush.

However, some people with type 2 diabetes do not have any symptoms if the glucose level is not too high. But, even if you do not have symptoms, you should still have treatment to reduce the risk of developing complications.

Patient picks for Type 2 diabetes

Video: How do you know if you have type 2 diabetes?

Type 2 diabetes diet

How do you get tested for type 2 diabetes.

A simple dipstick test may detect sugar (glucose) in a sample of urine. However, this is not enough to make a definite diagnosis of type 2 diabetes. Therefore, a blood test called HbA1c is needed to make the diagnosis. The blood test detects the level of glucose in your blood . If the glucose level is high then it will confirm that you have type 2 diabetes.

Some people have to have two samples of blood taken and may be asked to fast. (Fasting means having nothing to eat or drink, other than water, from midnight before the blood test is performed.)

It is now recommended that the blood test for HbA1c can also be used as a test to diagnose type 2 diabetes. An HbA1c value of 48 mmol/mol (6.5%) or above is recommended as the blood level for diagnosing type 2 diabetes. An HbA1c blood test gives an average of how high your blood glucose levels have been over the preceding few months.

In many cases type 2 diabetes is diagnosed during a routine medical or when tests are done for an unrelated medical condition.

Short-term complication - a very high glucose level

This is rare with type 2 diabetes. It is more common in untreated type 1 diabetes when a very high level of blood sugar (glucose) can develop quickly. However, a very high glucose level develops in some people with untreated type 2 diabetes. A very high blood level of glucose can cause lack of fluid in the body (dehydration), drowsiness and serious illness which can be life-threatening.

Long-term complications

If your blood glucose level is higher than normal over a long period of time, it can gradually damage your blood vessels. This can occur even if the glucose level is not very high above the normal level. This may lead to some of the following complications (often years after you first develop type 2 diabetes):

Furring, or 'hardening', of the arteries (atheroma) . This can cause problems such as angina , heart attacks, stroke and poor circulation.

Kidney damage which sometimes develops into chronic kidney disease .

Eye problems which can affect vision (due to damage to the small arteries of the retina at the back of the eye).

Nerve damage .

Foot problems (due to poor circulation and nerve damage).

Impotence (again due to poor circulation and nerve damage).

Complications of type 2 diabetes treatment

Medications for type 2 diabetes, like most other medications, can cause side-effects in some people. You can find out more about diabetes medications and their side-effects from our separate leaflet called Type 2 Diabetes Treatment .

However, one important side-effect which can affect people taking insulin and/or certain diabetes tablets is hypoglycaemia (often called a 'hypo'). This occurs when the level of glucose becomes too low, usually under 4 mmol/L. Not all tablet medicines used for diabetes can cause a hypo - for example, metformin does not cause this.

A hypo may occur if you have too much diabetes medication, have delayed or missed a meal or snack, or have taken part in unplanned exercise or physical activity. You can find out more about the symptoms and treatments of hypos from our separate leaflet called Hypoglycaemia (Low Blood Sugar) .

Until about 20 years ago, the medication options for treatment of type 2 diabetes were fairly limited. Insulin, along with a group of medicines called the sulfonylureas, can cause hypos (as well as weight gain). In the last 20 years, as newer medication has been developed, many people do not need to take sulfonylureas. In fact, more and more people never need to take insulin as newer agents offer more options for type 2 diabetes treatment.

Note: hypoglycaemia does not occur if you are treated with diet alone .

If you have type 2 diabetes, you may think that keeping your blood sugar (glucose) at normal levels is all that matters. In fact, while that's important, there's more to treatment than this.

Lifestyle changes are an essential part of treatment for all people with type 2 diabetes, regardless of whether or not they take medication.

Many people with type 2 diabetes can reduce their blood glucose (and HbA1c) to a target level with changes to their diet, weight and exercise levels. However, if the blood sugar (or HbA1c) level remains too high after a trial of these measures for a few months, then medication is usually advised.

Diet, weight control and physical activity

Diet. What you eat is absolutely central to your blood glucose control, as well as your general health. Please read our separate leaflet called Type 2 Diabetes Diet for more information. Your practice nurse or dietician can give you more information and support.

Lose weight if you are overweight. Getting to a perfect weight is unrealistic for many people. However, losing some weight if you are obese or overweight will help to reduce your blood glucose and blood pressure levels (and have other health benefits too). Recent evidence from Professor Taylor, Newcastle University, has shown that weight loss alone can put diabetes into drug-free remission in at least a third of patients.

Do some physical activity regularly. If you are able, a minimum of 30 minutes' brisk walking at least five times a week is advised. Anything more vigorous and more often is even better - for example, swimming, cycling, jogging, dancing. Ideally, you should do an activity that gets you at least mildly out of breath and mildly sweaty. You can spread the activity over the day - for example, two fifteen-minute spells per day of brisk walking, cycling, dancing, etc. Regular physical activity also reduces your risk of having a heart attack or stroke.

Medication is not used instead of a healthy diet, weight control and physical activity - you should still do these things as well as take medication. See our separate leaflet called Type 2 Diabetes Treatment for more details .

How is the blood glucose level monitored?

The blood test that is mainly used to keep a check on your blood glucose level is called the HbA1c test . This test is commonly done every 2-6 months by your doctor or nurse.

The HbA1c test measures a part of the red blood cells. Glucose in the blood attaches to part of the red blood cells. This part can be measured and gives a good indication of your average blood glucose level over the preceding 1-3 months.

Type 2 diabetes treatment aims to lower your HbA1c to below a target level. Ideally, it is best to maintain HbA1c to less than 48 mmol/mol (6.5%). However, this may not always be possible to achieve and your target level of HbA1c should be agreed between you and your doctor.

If your HbA1c is above your target level then you may be advised to step up treatment (for example, to increase a dose of medication) to keep your blood glucose level down.

Some people with diabetes check their actual blood glucose level regularly with a blood glucose monitor. If you are advised to do this then your doctor or nurse will give you instructions on how to do it.

Continuous glucose monitoring (CGM) The National Institute for Health and Care Excellence (NICE) has recommended that CGM should be offered to some people using insulin several times a day. They recommend that your specialist team should offer this if:

You have repeated or severe episodes of hypoglycaemia ('hypos').

You have impaired hypoglycaemia awareness, where you don't recognise the early symptoms of hypos.

You have a condition or disability for which you can't use regular finger-prick testing.

You need to measure your blood glucose at least eight times a day.

You are less likely to develop complications of type 2 diabetes if you reduce any other risk factors. These are briefly mentioned below - see the separate leaflet called Cardiovascular Disease (Atheroma) for more details . Although everyone should aim to cut out preventable risk factors, people with diabetes have even more of a reason to do so.

Keep your blood pressure down

It is very important to have your blood pressure checked regularly. The combination of high blood pressure and diabetes is a particularly high risk factor for complications. Even mildly raised blood pressure should be treated if you have type 2 diabetes. Medication, often with two or even three different medicines, may be needed to keep your blood pressure down but remember weight loss and exercise can really help with this too.

See the separate leaflet called Diabetes and High Blood Pressure for more details.

If you smoke - now is the time to stop

Smoking is a major risk factor for complications . You should consult your practice nurse or attend a smoking cessation clinic - it's much easier to quit with support. As well as expert help and advice, medication or nicotine replacement therapy (nicotine gum, etc) may help you to stop.

Other medication

You will usually be advised to take a medicine to lower your cholesterol level . This will help to lower the risk of developing some complications such as heart disease , peripheral arterial disease and stroke .

Protect your kidneys

Keeping your blood glucose well controlled can reduce your risk of kidney damage. But a group of medications first developed to treat type 2 diabetes can provide added protection against developing and worsening chronic kidney disease.

These medicines, called SGLT-2 inhibitors, are now recommended for everyone with type 2 diabetes who has chronic kidney disease with protein in the urine. This is one of the reasons getting regular kidney checks (see below) is so important.

In fact, some medicines in this class are now used to protect the kidneys in people who have chronic kidney disease but who do not have diabetes.

You can find out more about the SGLT-2 inhibitors in our leaflet on type 2 diabetes treatment .

Most GP surgeries and hospitals have special diabetes clinics. Doctors, nurses, dieticians, specialists in foot care (podiatrists - previously called chiropodists), specialists in eye health (optometrists) and other healthcare workers all play a role in giving advice and checking on progress. Regular checks may include:

Checking levels of blood sugar (glucose), HbA1c, cholesterol and blood pressure.

Ongoing advice on diet and lifestyle.

Checking for early signs of complications - for example:

Eye checks - see more detail below.

Urine tests - which include testing for protein in the urine, which may indicate early kidney problems.

Foot checks - to help prevent foot ulcers .

Other blood tests - these include checks on kidney function and other general tests.

It is important to have regular checks, as some complications, particularly if detected early, can be treated or prevented from becoming worse.

Eye screening

Regular (at least yearly) eye checks can detect problems with the retina (a possible complication of diabetes), which can often be prevented from becoming worse. Increased pressure in the eye ( glaucoma ) is more common in people with diabetes and can usually be treated.

The National Institute for Health and Care Excellence (NICE) has updated its recommendations on eye screening and treatment in an update of its guidance on type 2 diabetes.

Eye checks usually include taking photographs of the back of your eye (retinal photography) to see whether there are any problems. This needs to be done at a specialist eye screening clinic.

The guidance recommends that:

You should be referred to a specialist local eye screening service as soon as you are diagnosed with type 2 diabetes.

If your eyesight suddenly deteriorates significantly without any obvious explanation, you should be referred to a specialist eye doctor (an ophthalmologist). How urgently you are referred will depend on your symptoms and personal circumstances.

You should be immunised against flu (each autumn) and also against pneumococcal germs (bacteria) - a vaccination just given once. These infections can be particularly unpleasant if you have diabetes.

Article History

The information on this page is written and peer reviewed by qualified clinicians.

Next review due: 24 Mar 2028

26 apr 2023 | latest version.

Last updated by

Peer reviewed by

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Type 2 Diabetes Patient Case Simulation

Case Simulation 1

CLINIC- Sim : Simulating a Patient-Centered Approach to Optimize Early Glycemic and Weight Control in Type 2 Diabetes

Learn more about glycemic control and weight management in type 2 diabetes

Shared decision-making resources, watch an expert video on shared decision-making and download the conversation starter to aid in your patient interactions.

These videos were commissioned by Lilly and are intended to be used by HCPs who treat diabetes for medical, scientific and educational purposes. Video content is not approved for continuing education credit. Disclosures: Dr. Matt Capehorn

Board member of the Association for the Study of Obesity (ASO)
Faculty member of the Primary care Academy of Diabetes Specialists (PCADS)
Expert Advisor to NICE
Professional Advisor to the Obesity Empowerment Network (OEN)
Director – RIO Weight management Limited
Medical Director – Lighterlife (commercial VLCD company)
Ad-hoc Medical Advisor – McDonalds UK

Advisory Boards: Lilly, Boehringer Ingelheim, Novo Nordisk; Speaker fees/travel: Lilly, Boehringer Ingelheim, Novo Nordisk; Research income (RIO): Lilly, Boehringer Ingelheim, Novo Nordisk

Patient Information

Expand accordion Patient Profile

47-year-old African American female
Diagnosed with T2D 9 months ago
HbA 1c since diagnosis: 8.7%
Current treatment: 1000 mg metformin daily at diagnosis
Followed by registered dietitian/nurse educator

Expand accordion Medical History

Prediabetes for 2 years preceding diagnosis, tried to manage with diet and exercise
Gestational diabetes with her second child
Hypertension
Mixed dyslipidemia

Expand accordion Family History

T2D in father, maternal aunt
CAD in father
Hypertension in mother and father

Expand accordion Social History

Married, has 2 children ages 10 and 15
Never smoked or vaped, no illicit substances, rarely drinks alcohol
High school math teacher

Expand accordion Physical Exam and Labs

Normal eGFR, normal urine microalbumin
BMI: 33 kg/m 2 (195 lbs)
Blood pressure: 145/90 mmHg
Total cholesterol: 210 mg/dL
LDL cholesterol: 109 mg/dL
HDL cholesterol: 44 mg/dL
Triglycerides: 290 mg/dL

9 months since diagnosis The patient was diagnosed with type 2 diabetes, and her HbA 1c was 8.7% at the time. She was started on 1000 mg metformin daily. During that visit, she was advised on lifestyle modifications, including dietary changes to help both her diabetes and hypertension management, as well as recommendations to incorporate exercise. She was encouraged to start a statin for dyslipidemia but was too overwhelmed by her diabetes and declined statin therapy. At visit 2, her HbA 1c decreased to 7.9%. She again declined a statin and agreed to start an ACE inhibitor. Her metformin was titrated to 1500 mg total daily dose.

13 months since diagnosis (4-month follow-up)

She returns 4 months later.
She is taking a dose of 1500 mg metformin daily (500 mg in the morning and 1000 mg in the evening) without missing doses. She was not able to tolerate a dose of 1000 mg twice daily. Her HbA 1c has decreased to 7.7% from 7.9%, and her body weight remained stable.
Blood pressure: 130/85 mmHg
Total cholesterol: 205 mg/dL
LDL cholesterol: 110 mg/dL
HDL cholesterol: 43 mg/dL
Triglycerides: 260 mg/dL
She increased her physical activity by parking farther and trying to walk more, but often struggles to find the time to get more exercise in.
She tries to eat more balanced meals with protein, vegetables and fewer carbohydrates; she finds it difficult to make multiple meals for her family members who prefer to keep to their old dietary routine.
She is motivated to continue working on lifestyle changes and has agreed to start a statin.

Question #1

In addition to continuing metformin 1500 mg daily, which of the following may be the next best step.

Continue lifestyle modifications – she is very motivated and prefers not to start another medication

Start a sulfonylurea and continue lifestyle modifications

Start an incretin receptor agonist and continue lifestyle modifications

Start a DPP-4 inhibitor

Related Resources

Hear from Dr. Capehorn on collaborating with patients to individualize care.

VV-MED-145674

Patient-Physician Conversation Starter (PDF)

Tips and tricks to initiate patient centric conversations.

VV-MED-145677

Shared Decision-Making (PDF)

Support early glycemic control and weight management through shared decision-making.

VV-MED-148828

VV-MED-144376

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ACP Guideline on Pharmacologic Treatments for Diabetes: Key Points

The following are key points to remember about a clinical guideline from the American College of Physicians (ACP) on newer pharmacologic treatments in adults with type 2 diabetes:

Type 2 diabetes is associated with higher risk for mortality and morbidity, greater health care use, and greater costs when adults with diabetes are compared with those without diabetes.
Major treatment goals for patients with type 2 diabetes include adequate glycemic control and primary and secondary prevention of atherosclerotic cardiovascular and kidney diseases, which account for nearly one half of all deaths among adults with type 2 diabetes.
This guideline addresses effectiveness and harms of newer pharmacologic treatments to reduce the risk for all-cause mortality, cardiovascular morbidity, and progression of chronic kidney disease (CKD) in adults with type 2 diabetes.
Newer pharmacologic treatments include glucagon-like peptide-1 (GLP-1) agonists (dulaglutide, exenatide, liraglutide, lixisenatide, and semaglutide), a GLP-1 agonist and glucose-dependent insulinotropic polypeptide agonist (tirzepatide), sodium–glucose cotransporter-2 (SGLT-2) inhibitors (canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin), dipeptidyl peptidase-4 (DPP-4) inhibitors (alogliptin, linagliptin, saxagliptin, and sitagliptin), and long-acting insulins (insulin glargine and insulin degludec).
The ACP recommends adding an SGLT-2 inhibitor or GLP-1 agonist to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control (strong recommendation; high-certainty evidence).
Use of an SGLT-2 inhibitor is recommended to reduce the risk for all-cause mortality, major adverse cardiovascular events (MACE), progression of CKD, and hospitalization due to congestive heart failure [CHF]. Clinicians should prioritize adding SGLT-2 inhibitors in patients with type 2 diabetes and CHF or CKD.
Use of a GLP-1 agonist is recommended to reduce the risk for all-cause mortality, MACE, and stroke. Clinicians should prioritize adding GLP-1 agonists in patients with type 2 diabetes and an increased risk for stroke or for whom total body weight loss is an important treatment goal.
The ACP recommends against adding a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control to reduce morbidity and all-cause mortality (strong recommendation; high-certainty evidence).
Metformin (unless contraindicated) and lifestyle modifications are the first steps in managing type 2 diabetes in most patients. When selecting an additional therapy, clinicians should consider the evidence of benefits, harms, patient burden, and cost of medications in addition to performing an individualized assessment of each patient’s preferences, glycemic control target, comorbid conditions, and risk for symptomatic hypoglycemia.
Overall, clinicians should aim to achieve glycated hemoglobin (HbA 1c ) levels between 7% and 8% in most adults with type 2 diabetes and deintensify pharmacologic treatments in adults with HbA 1c levels <6.5%. An individualized glycemic goal should be based on risk for hypoglycemia, life expectancy, diabetes duration, established vascular complications, major comorbidities, patient preferences and access to resources, capacity for adequate monitoring of hypoglycemia, and other harms.
Finally, type 2 diabetes management should be based on collaborative communication and goal setting among all team members, including clinical pharmacists, to reduce the risk for polypharmacy and associated harms.

Clinical Topics: Diabetes and Cardiometabolic Disease, Prevention

Keywords: Diabetes Mellitus, Type 2, Pharmaceutical Preparations

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Atypical Diabetes

Approach to the patient with atypical diabetes, atypical diabetes and precision medicine, article information, atypical diabetes: what have we learned and what does the future hold.

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Stephen I. Stone , Ashok Balasubramanyam , Jennifer E. Posey; Atypical Diabetes: What Have We Learned and What Does the Future Hold?. Diabetes Care 19 April 2024; 47 (5): 770–781. https://doi.org/10.2337/dci23-0038

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Ris (Zotero)
Reference Manager

As our understanding of the pathophysiology of diabetes evolves, we increasingly recognize that many patients may have a form of diabetes that does not neatly fit with a diagnosis of either type 1 or type 2 diabetes. The discovery and description of these forms of “atypical diabetes” have led to major contributions to our collective understanding of the basic biology that drives insulin secretion, insulin resistance, and islet autoimmunity. These discoveries now pave the way to a better classification of diabetes based on distinct endotypes. In this review, we highlight the key biological and clinical insights that can be gained from studying known forms of atypical diabetes. Additionally, we provide a framework for identification of patients with atypical diabetes based on their clinical, metabolic, and molecular features. Helpful clinical and genetic resources for evaluating patients suspected of having atypical diabetes are provided. Therefore, appreciating the various endotypes associated with atypical diabetes will enhance diagnostic accuracy and facilitate targeted treatment decisions.

Graphical Abstract

It is now generally recognized that the binary categorization of diabetes into type 1 and type 2 is insufficient to capture the range of metabolic and clinical phenotypes, molecular mechanisms, and disease pathogenesis that lead to the final common end point of hyperglycemia. The frequency of non–type 1, non–type 2 diabetes—now referred to as “atypical diabetes”—is likely underestimated, and the proportion varies considerably (from 5% to 11%) depending on the ethnic and other characteristics of the population studied ( 1 ).

In this review, we seek to provide an overview of some of the characteristic features of well-described forms of atypical diabetes, including examples of those for which the etiological basis is known and others for which the etiological basis is not yet fully understood. Atypical diabetes is suspected in individuals who do not fit clearly into currently accepted criteria that define type 1 diabetes (T1D), type 2 diabetes (T2D), or secondary diabetes ( 1 , 2 ). We introduce the concept of endotypes, in which patients with diabetes can be clustered based on similar clinical or molecular/genetic mechanisms.

Below, we discuss several examples of atypical diabetes, their etiological or mechanistic bases, and their characteristic clinical features. We provide this section as a framework for approaching patients who do not fit accepted criteria of T1D or T2D—rather than as a comprehensive review of all forms of atypical diabetes ( Fig. 1 ).

Conceptualization of diabetes subtypes within three axes: insulin sensitivity, insulin secretion, and islet autoimmunity. The green area represents the normal inverse relationship between insulin sensitivity and insulin secretion. As an individual develops insulin resistance, there is an eventual loss of compensatory insulin secretion. This can result in impaired fasting glucose (pink) and insulin-resistant diabetes (type 2), as shown in dark blue. Autoimmune diabetes (T1D) is featured by overall insulin sensitivity, with near-absolute loss of insulin secretion and a high degree of islet autoimmunity. Individuals with LADA also manifest islet autoimmunity but retain insulin secretory capacity and remain insulin sensitive. Conversely, those with insulin resistance syndromes and lipodystrophies tend to have a high degree of insulin resistance and secrete high levels of insulin. Individuals with many monogenic and mitochondrial forms of diabetes secrete very low levels of insulin and remain insulin sensitive, but lack evidence of islet autoimmunity. KPD, defined according to presentation with DKA, includes four subtypes, each shown in light blue. Patients with A+β+ present with similar metabolic features compared to LADA. A+β− patients metabolically resemble T1D. A − β − individuals have near-complete insulin deficiency but lack evidence for islet autoimmunity. A − β+ patients often manifest insulin resistance with sustained insulin secretory reserve despite presentation with DKA.

Monogenic Diabetes

The term “monogenic diabetes” is typically used to describe nonsyndromic forms of diabetes with demonstration of Mendelian inheritance driven by damaging variants in a single gene. Maturity-onset diabetes of the young (MODY) and neonatal diabetes are the two most well-described forms of monogenic diabetes. Many genes responsible for these disorders are pivotal to β-cell development or function ( 3 ). Importantly, some forms of MODY have proven to be amenable to sulfonylureas, demonstrating an early opportunity for precision medicine in diabetes ( 4 ).

A strong family history of diabetes that typically follows an autosomal dominant pattern of inheritance, with multiple affected generations, is a common hallmark of monogenic diabetes. Affected relatives may be misdiagnosed with T1D or T2D ( 5 ). Distinctive presenting features for some subtypes of MODY may also provide an index of suspicion. A comprehensive review of all forms of MODY is outside of the scope of this review. However, below, we use GCK-MODY, HNF1A-MODY, and neonatal diabetes to illustrate some of the unique etiological and clinical features of monogenic forms of diabetes. Table 1 includes a review of several well-described forms of monogenic and neonatal diabetes, for which a genetic cause has been identified, defining clinical features, and microvascular complications ( 6 ).

Genetic causes of monogenic and neonatal diabetes

GCK-MODY (MODY 2)

GCK-MODY is the most common form of MODY, with demonstration of an autosomal dominant pattern of inheritance ( 7 ). It results from heterozygous pathogenic variants in GCK , the gene encoding glucokinase. Glucokinase performs the rate-limiting step in the conversion of glucose to glucose-6-phosphate within the pancreatic β-cell. Glucose-6-phosphate then enters the tricarboxylic acid cycle, and generates ATP, which triggers a cascade resulting in insulin secretion ( 8 ). Thus, GCK serves as the “glucostat” of the β-cell, regulating insulin secretion. Heterozygous inactivating GCK mutations result in a higher set point of glucose at which insulin is secreted ( 9 ).

Clinically, GCK-MODY presents as mild hyperglycemia in an individual lacking common metabolic risk factors for T2D ( 9 ). Patients often have a history of hemoglobin A 1c (HbA 1c ) levels that oscillate between prediabetes and mild diabetes levels. Importantly, patients with GCK-MODY are not at increased risk for micro- or macrovascular complications of hyperglycemia ( 10 ) and thus do not require pharmacotherapy. Rather, treatment of their diabetes is often frustrating to patients as it results in either no improvement in their blood glucose or significant hypoglycemia ( 11 ). Accurate diagnosis of this condition prevents unnecessary treatment, as microvascular complications of GCK-MODY–related diabetes are exceedingly rare ( 6 ).

HNF1A-MODY (MODY 3)

The second most common form of MODY is HNF1A-MODY. With HNF1A-MODY there is also demonstration of an autosomal dominant pattern of inheritance, and HNF1A-MODY results from heterozygous pathogenic variants in hepatocyte nuclear factor 1α ( HNF1A ) ( 12 ). HNF1A is an important β-cell transcription factor; thus, patients with HNF1A-MODY often develop insulin-deficient diabetes in the second to third decade of life ( 3 ). Microvascular complications of hyperglycemia are common in individuals with HNF1A-MODY without appropriate treatment ( 6 ).

Importantly, HNF1A-MODY is often successfully treated with sulfonylureas, particularly if recognized early in the course of disease ( 13 ). Often, recognition of one family member with HNF1A-MODY can inform cascade testing in family members, with substantial therapeutic impact.

Neonatal Diabetes

Most commonly, neonatal diabetes is caused by loss-of-function variants in the K ATP channel, composed of two subunits encoded by KCNJ11 ( Kir6.2 ) and ABCC8 ( SUR1 ) ( 14 ). Neonatal diabetes is typically diagnosed in the first 6 months of life, and where neonatal diabetes is not recognized early, infants may present with severe hyperglycemia and ketoacidosis ( 14 ). The severity and course of neonatal diabetes are quite variable, with some experiencing only transient metabolic dysregulation and others a more permanent form of diabetes. The most severe form of neonatal diabetes, which occurs in <1 in 1 million live births, is characterized by developmental Delay, Epilepsy, and Neonatal Diabetes (DEND). DEND typically will occur in the setting of KCNJ11 or ABCC8 mutations ( 15 ).

Oligogenic Forms of Diabetes

Initially the field of genetics and diabetes focused on highly penetrant, inherited forms of diabetes that resulted from mutations in a single gene (monogenic diabetes). However, with the explosion of genomic data becoming available over the last several years, attention is increasingly directed toward conditions in which two (digenic) or a few (oligogenic) genes with variant alleles contribute to an inherited form of diabetes. Often, these genes cluster in shared pathways, compounding the effect of multiple genes that individually would not result in significant disease ( 16 ). Examples include a case of digenic MODY with variants in HNF1A and HNF1B ( 17 ) or severe insulin resistance due to heterozygous variants in the PPARG and PPP1R3A genes ( 18 ). In other cases, additional genetic variation can explain variable or incomplete penetrance of the diabetes phenotype ( 19 ). Aided by recent advances in DNA-sequencing technology, increased ascertainment and deeper understanding of digenic and oligogenic models of atypical diabetes will continue to move the field of precision diabetes forward. Additionally, the field of genetics and diabetes has made significant progress in determining the polygenic (tens to hundreds of genes) risk for both T1D and T2D; however, this is outside of the scope of this review ( 20 ).

Syndromic Diabetes

Patients with syndromic forms of diabetes typically present with a range of atypical clinical features in addition to hyperglycemia. Unique combinations of syndromic features may arise from a single molecular defect and can provide a rationale for evaluation by an expert in medical genetics. As with monogenic diabetes, a positive family history may suggest a genetic etiology, although more severe conditions may result from de novo mutational events, thus appearing to be sporadic rather than familial. Similar to MODY, the genes responsible for syndromic forms of diabetes often encode proteins important for β-cell development, function, or survival. However, their expression in other tissues can lead to multiorgan involvement, with common examples including neurological involvement (microcephaly with simplified gyral pattern, epilepsy, and permanent neonatal diabetes syndrome, IER31P1 variants [ 21 ]), other endocrine features (neonatal diabetes mellitus with congenital hypothyroidism syndrome, GLIS3 variants [ 22 ]), skeletal involvement (Wolcott-Rallison syndrome, EIF2AK3 variants [ 21 ]), gastrointestinal involvement (Mitchell-Riley syndrome, RFX6 variants [ 23 ]), or immunological involvement (immunodysregulation, polyendocrinopathy, enteropathy X-linked syndrome, FOXP3 variants [ 24 ]). Below, we detail the characteristic features of Wolfram syndrome as one well-studied example of syndromic diabetes.

Wolfram Syndrome

Wolfram syndrome, also known as diabetes insipidus, diabetes mellitus, optic atrophy, deafness syndrome (DIDMOAD) ( 25 ), is caused by biallelic pathogenic variants in WFS1 or CISD2 and segregates in families in an autosomal recessive pattern. WFS1 encodes wolframin, a transmembrane protein in the endoplasmic reticulum. Aberrant wolframin function leads to endoplasmic reticulum stress and dysregulation of the unfolded protein response on which mature insulin synthesis relies. As such, Wolfram syndrome is considered one of the prototypical endoplasmic reticulum stress disorders ( 21 ).

Patients with classic Wolfram syndrome often present before 16 years of age with antibody-negative, insulin-deficient diabetes. They soon develop optic atrophy and can have additional features of sensorineural hearing impairment, diabetes insipidus, urinary tract abnormalities, progressive neurodegeneration, and psychiatric disorders ( 25 , 26 ). Individuals with Wolfram syndrome due to CISD2 variants tend to be more severely affected and may additionally develop gastrointestinal bleeding ( 27 ).

Mitochondrial Diabetes

Subtypes of mitochondrial diabetes result from mitochondrial dysfunction. The presenting features of mitochondrial disorders can be variable, with organ systems such as the pancreas (particularly β-cells) that require high levels of aerobic metabolism the most likely to be affected. A positive family history is often observed, manifesting as a strictly maternal inheritance pattern in conditions that are caused by variants encoded in the mitochondrial genome or as autosomal recessive inheritance in conditions caused by variants encoded in the nuclear genome. Proper diagnosis of mitochondrial forms of diabetes is paramount, as treatment with metformin, often a first-line medication for T2D, is contraindicated in mitochondrial diabetes due to the increased risk of provoking lactic acidosis ( 28 ).

Clinically, mitochondrial disorders display tremendous clinical and prognostic heterogeneity which is driven in part by the identity of the etiologic variant, its degree of heteroplasmy or homoplasmy (the fraction of mitochondrial genomes in which the variant is present) if encoded in the mitochondrial genome, and cell-to-cell and tissue-to-tissue heterogeneity that is observed in these conditions. The heteroplasmic mitochondrial genome variant c.3243A>G MT-TL1 illustrates some of this complexity: individuals with this variant may develop maternally inherited diabetes-deafness syndrome (MIDD), mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS), Leigh syndrome, or a combination of other features observed in individuals with mitochondrial dysfunction. Diabetes, when it develops, may respond well to sulfonylureas or may be characterized by insulinopenia. Age of onset can range from early childhood to ≥40 years of age, although up to 9% of individuals will remain unaffected ( 29 ).

Lipodystrophic Forms of Diabetes

Lipodystrophic forms of diabetes are clinically characterized by loss of body fat, which may be generalized or involve limited areas of the body (“partial lipodystrophy”). Accompanying clinical characteristics include prominent musculature, phlebomegaly, severe hypertriglyceridemia, and profound hepatomegaly resulting from steatohepatitis ( 30 ). The hyperglycemia is driven by insulin resistance, which can manifest with severe acanthosis nigricans ( 30 ). Investigation of lipodystrophic syndromes has shed light on the key role of adipose tissue on metabolism and insulin sensitivity. One such adipokine, leptin, has multiple effects including the promotion of satiety ( 31 ). Another, adipokine, adiponectin, plays a key role in glucose regulation and fatty acid oxidation. Thus, together these hormones prevent complications of obesity and metabolic syndrome ( 31 ). Major categories of lipodystrophy ( 31 ) are summarized below and in Table 2 .

Major categories of lipodystrophies

Distribution limited under REMS program, a program to ensure that prescriptions are being used in accord with FDA-approved indications.

Congenital Generalized Lipodystrophy

Congenital generalized lipodystrophy (CGL) (Berardinelli-Seip syndrome) is characterized by near-complete lack of adipose tissue first diagnosed in infancy ( 32 ). Multiple autosomal recessive forms have been identified, associated with AGPAT2 , BSCL2 , CAV1 , PTRF , PCYT1A , and PPARG ( 30 ). Treatment for diabetes includes metformin and insulin. Notably, extremely high doses of insulin are often required ( 31 ). Fibric acid derivatives and/or statins may be needed to lower severe hypertriglyceridemia ( 31 ). Metreleptin, a recombinant human leptin analog, is approved by the U.S. Food and Drug Administration (FDA) for the treatment of CGL. Notably, metreleptin’s distribution is limited under a risk evaluation and mitigation strategy (REMS) program ( 31 ).

Familial Partial Lipodystrophy

Familial partial lipodystrophy (FPLD) is characterized by localized loss of fat in the limbs, buttocks, and hips. There is a concurrent accumulation of fat in other areas, often resulting in a cushingoid appearance ( 32 ). Unlike with CGL, patients with FPLD typically first present during adolescence ( 31 ). Most forms of FPLD are autosomal dominant and result from heterozygous variants in LMNA , PPARG , AKT2 , or PLIN1 ( 30 ). However, autosomal recessive FPLD also occurs, resulting from biallelic variants in CIDEC , LIPE , or PCYT1A ( 30 ). Diabetes can be treated with metformin, thiazolidinediones, and high-dose insulin. Patients with FPLD often require aggressive management for hypertension and hyperlipidemia ( 31 ).

Progeroid Syndromes

Progeroid syndromes mimic physiological aging. This can include features of premature wrinkles, greying and loss of hair, osteoarthritis, loss of muscle mass, and increased risk of cancer and heart disease ( 33 ). These conditions can result in partial or generalized loss of body fat, and present during childhood ( 31 ). Genes implicated in progeroid lipodystrophy include LMNA , ZMPSTE24 , SPRTN , WRN , BANF1 , FBN1 , CAV1 , POLD1 , and KCNJ6 ( 30 ). Many progeroid forms of lipodystrophy result in relatively mild to moderate diabetes and severe hypertriglyceridemia. Similar to other lipodystrophy syndromes, metformin, thiazolidinediones, and insulin are used in treatment ( 31 ).

Acquired Generalized Lipodystrophy

Acquired generalized lipodystrophy (AGL) (Lawrence syndrome) usually occurs before adolescence and results in progressive loss of whole-body fat ( 34 ). It is often associated with autoimmune diseases and thus is more common in females ( 34 ). Similar to CGL, AGL can be treated with metformin, sulfonylureas, thiazolidinediones, and high-dose insulin. Metreleptin is also FDA approved for the treatment of AGL under the REMS program ( 31 ).

Latent Autoimmune Diabetes

Latent autoimmune diabetes (LADA) is defined by the presence of islet autoantibodies but absence of insulin dependency for at least 6 months after initial diagnosis of diabetes in adults. Often, LADA patients are initially classified as having “T2D.” The frequency of LADA in cohorts of T2D patients varies between 5% and 13% ( 35 – 42 ) depending on geographic location, patient demographics, the numbers of autoantibodies tested, and the sensitivity and cutoffs of the autoantibody assays. Both clinical features and genetic associations suggest that LADA represents a pathophysiologic overlap between T1D and T2D. Genome-wide association studies of European patients diagnosed with LADA compared with both control subjects without diabetes and subjects with T1D and T2D showed genetic correlations with both T1D and T2D ( 43 ). In a subsequent study investigating the genetic etiology of LADA and childhood-onset T1D, both LADA and T1D were associated with MHC class II. However, only T1D was associated with MHC class I. These findings support the possibility that LADA and childhood-onset T1D indeed have distinct genetic bases ( 44 ). Endotypic heterogeneity in LADA could influence the natural history of β-cell dysfunction as well as treatment approaches in these patients ( 41 ). LADA is likely underdiagnosed in clinical practice, since physicians infrequently measure islet autoantibodies in adult patients who do not appear to require insulin therapy at the time of diagnosis. Widespread autoantibody testing in patients (especially nonobese patients) with “T2D” could improve the diagnostic yield, but this conclusion must be tempered with the understanding that true “positivity” in autoantibody assays may depend on the assays used, variable titers for determining cutoffs, the transient nature of some autoantibodies at lower titer, and ethnicity ( 38 , 45 – 49 ).

Ketosis-Prone Diabetes

The defining characteristic of ketosis-prone diabetes (KPD) is diabetic ketoacidosis (DKA) at presentation, in the absence of characteristic features of autoimmune T1D ( 50 ). Strikingly, this class of atypical diabetes is both clinically and etiologically heterogeneous. Four distinct subtypes of KPD have been defined based on quantitative measurements of antibody positivity (A+) or negativity (A−) and presence (β+) or absence (β−) of β-cell functional reserve ( 51 ). Within this classification, A+β− KPD most closely aligns with features of traditional, autoimmune T1D. A−β− KPD also resembles T1D, but does not have detectable islet autoantibodies. Additionally, A−β− KPD harbors a lower frequency of T1D-associated HLA susceptibility alleles ( 51 , 52 ), and demonstrates a lower T1D genetic risk score ( 53 ). Importantly, many patients with A−β− KPD either harbor pathogenic variants in essential β-cell transcription factors or demonstrate occult (T cell–mediated) islet autoimmunity ( 54 , 55 ). Individuals with A+β+ KPD are older and overweight at initial presentation with DKA and tend to have GAD65 autoantibodies with DPD epitope specificity ( 56 ) (which is associated with a milder form of islet autoimmunity) and to possess HLA alleles that are protective against islet autoimmunity ( 52 ). Patients with A−β+ KPD, specifically the subset termed “unprovoked” A−β+ KPD, superficially resemble patients with T2D but present with DKA despite adequate β-cell functional reserve ( 57 ). These patients are able to discontinue insulin therapy within 1–2 months after the initial index episode of DKA and may remain off insulin for several years, maintaining excellent glycemic control on oral therapy alone ( 57 ). Some patients with A−β+ KPD display hypercatabolism of the branched chain amino acid leucine, that explains in part their proclivity to developing ketoacidosis ( 58 ). Others have a defect in intracellular availability of arginine during periods of hyperglycemia, which severely blunts insulin secretory capacity during hyperglycemic crises ( 58 ). Studies in West African patients have suggested a role for herpesvirus 8 infection ( 59 ), and a report from Japan implicates insulin peptide–specific interferon-γ responses in the pathogenesis of KPD ( 60 ). The Aβ classification scheme for KPD has high accuracy in predicting glycemic control and insulin dependence among the different phenotypes of patients presenting with DKA, and pathophysiologic studies based on comparison of the different phenotypic subtypes have demonstrated its value as an endotypic classification ( 61 ).

Fulminant Diabetes

Fulminant diabetes has been described predominantly in patients living in Far Eastern countries. It is characterized by very sudden onset, with patients presenting usually with DKA but with normal or near-normal HbA 1c at diagnosis. Although fulminant diabetes is reported frequently as a subtype of T1D, the patients often lack the typical T1D-associated islet autoantibodies, and the HLA alleles and haplotypes associated with fulminant diabetes are different from those associated with typical autoimmune T1D. Unlike LADA, patients experience a rapid destruction of β-cells within weeks. This results in a discrepancy between their current blood glucose state and their HbA 1c ( 62 ).

Severe Insulin Resistance Syndromes

The etiology of many severe insulin resistance syndromes is not yet fully understood. However, early steps toward elucidation of critical mechanisms underlying disease pathogenesis have been made. Individuals with disorders of severe insulin resistance display features of hyperinsulinemia, such as severe acanthosis nigricans, and differ from those with lipodystrophy syndromes in that they do not manifest adipose tissue loss ( 63 ). Additional features may include hirsutism, polycystic ovary syndrome, impaired growth, and irregular menses. They often require substantial amounts of exogenous insulin to approach glucose homeostasis, and in some cases, hyperglycemia may be preceded by a period of hypoglycemia.

Abnormal function of the insulin signaling pathway drives a subset of severe insulin resistance syndromes, with loss-of-function variants in the gene encoding the insulin receptor ( INSR ). Notably, complete loss-of-function variants in INSR lead to an earlier-onset and more severe presentation of insulin resistance (Donohue syndrome) than with partial loss-of-function variants (Rabson-Mendenhall syndrome), providing a functional rationale for the molecular pathogenesis.

Early evidence suggests that severe insulin resistance syndromes may be amenable to precision therapeutics. For example, insulin sensitizers such as metformin and pioglitazone have shown efficacy in Rabson-Mendenhall syndrome ( 64 ). Other proposed treatment strategies exploit the shared structural homology and interrelated signaling pathways of insulin and insulin-like growth factor-1 (IGF-1); e.g., recombinant IGF-1 treatment can improve glucose control and overall life span in Donohue syndrome ( 65 ).

Type A insulin resistance syndrome results from heterozygous or mild homozygous mutations in INSR . It presents later in life, and women often struggle with menometrorrhagia, ovarian cysts, and subfertility ( 66 ). Type B insulin resistance syndrome, conversely, occurs due to polyclonal antibodies against the insulin receptor. It typically presents in adulthood, primarily in middle-aged women. Patients with type B insulin resistance syndrome will experience both hypo- and hyperglycemia based on antibody-mediated activation and subsequent downregulation of the insulin receptor ( 66 ). Often, type B insulin resistance is diagnosed in the setting of other autoimmune conditions or as part of a paraneoplastic syndrome ( 66 ). Insulin autoimmune syndrome (Hirata disease) is characterized by spontaneous episodes of hypoglycemia due to the presence of high titers of insulin autoantibodies ( 67 ).

Insulin-mediated pseudoacromegaly (IMPA) is an example of severe insulin resistance characterized by accelerated rather than impaired growth. First recognized in 1993, its etiology remained elusive until exome sequencing (ES) was applied for a female proband and sister sharing features of IMPA and their unaffected parents in 2020 ( 68 ). Variant analysis revealed a maternally inherited FGFR1 variant and a paternally inherited KLB variant in both the proband and her sister. Functional studies showed that these variants combined to reduce the insulin-sensitizing impact of FGF21, supporting a digenic model of inheritance in this family and providing the first molecular etiology of IMPA ( 68 ). These findings suggest the enticing possibility that treatment with FGF21 analogs or thiazolidinediones, which induce hepatic FGF21 expression, may be efficacious in this form of atypical diabetes ( 69 , 70 ).

Diabetes Secondary to Pancreatic Disease

Some forms of atypical diabetes are associated with exocrine pancreatic disease, and these are typically referred to as pancreatogenic diabetes, classified by the American Diabetes Association as type 3c diabetes. This class of atypical diabetes comprises a heterogeneous group of conditions that may be inherited or acquired, including cystic fibrosis, hemochromatosis, chronic pancreatitis, fibrocalculous pancreatopathy, pancreatic cancer, pancreatectomy, and congenital pancreatic agenesis ( 71 , 72 ). In many cases, the pathogenesis underlying diabetes development in these conditions is incompletely understood.

Additional Forms of Atypical Diabetes

The representative forms of atypical diabetes described above do not encompass all reported forms of this heterogeneous condition. In Table 3 , we provide a summary of the major forms of atypical diabetes currently known, with their key features manifested as presence or absence of insulin sensitivity, insulin secretion, and autoimmunity, as well as other distinctive clinical characteristics.

Key characteristics of major forms of atypical diabetes

The number of plus (+) and minus (−) signs indicates the degree of difference.

A summary of the approach to a patient with atypical diabetes is outlined in Fig. 2 .

Approach to the patient with atypical diabetes. Features including the aspects of the clinical disease course, family history, and physical exam, as well as informative diagnostic tools, are outlined. When clinical investigation does not yield a definitive atypical diabetes diagnosis, research options may be considered. Image created with BioRender.com .

When to Suspect Atypical Diabetes?

As described above and in Table 3 , atypical diabetes in patients can present in a multitude of ways; hence, a thorough family history is very important. For example, many forms of monogenic diabetes are transmitted in an autosomal dominant manner ( 73 ). A family history of individuals presenting with similar features along multiple generations can be an important clue that prompts the clinician to perform further testing.

The presentation and progression of a patient’s illness can be another important distinguishing feature. For example, syndromic forms of diabetes will present with manifestations in specific affected organ systems. Patients with mitochondrial diabetes often present with deafness or lactic acidosis ( 28 ). A careful medical history can point to a diagnosis of pancreatogenic, fulminant, and slowly progressive forms of diabetes. Conversely, patients with the A−β+ and A+β+ subtypes of KPD will have a striking history of initial presentation with DKA, followed by insulin-free remission within 4–6 months ( 74 ).

Physical examination must be thorough, with specific attention paid to manifestations of insulin resistance, adipose tissue disorders, and the syndromes noted above. It is paramount to diagnose lipodystrophy, as identifying areas and patterns of adipose tissue loss can inform the diagnosis ( 30 ). Patients with lipodystrophic forms of diabetes will often have extremely elevated triglyceride and low HDL cholesterol levels. Patients with insulin resistance syndromes will have characteristic physical findings including severe acanthosis nigricans and hirsutism ( 63 ).

Clinical Tests That Help Identify and Classify Forms of Atypical Diabetes

It is very helpful to measure clinically reliable markers of islet autoimmunity, β-cell function, insulin sensitivity, and genetic variants underlying known forms of monogenic diabetes in patients suspected of having atypical diabetes.

Islet Autoimmunity

The four most common autoantibodies in people with autoimmune diabetes are autoantibodies against GAD (GAD65), islet antigen 2 (IA-2), insulin, and zinc transporter 8 (ZnT8) ( 49 ). Autoantibodies against insulin may be unreliable for patients already treated with exogenous insulin ( 75 ). Autoantibody positivity may wane with time ( 76 , 77 ); hence, it is important to try to measure these when a patient is first diagnosed with diabetes. Identification of patients with high titers of multiple islet autoantibodies strongly suggests autoimmune form of diabetes such as T1D, LADA, or an “A+” subtype of KPD ( 49 , 55 ). The significance of a low titer of a single diabetes autoantibody is not clear ( 78 – 80 ).

It is useful to measure serum insulin or C-peptide levels as a marker of the patient’s endogenous insulin secretory capacity ( 81 ). C-peptide is cleaved from proinsulin as it is processed into mature insulin and is not a component of therapeutic insulin preparations; hence, its serum level can reflect residual β-cell capacity ( 82 ). Different cutoffs of fasting C-peptide levels have been derived in different patient cohorts with varying clinical conditions for determination of whether a patient has adequate β-cell functional reserve ( 83 , 84 ).

For evaluation of insulin secretion in a dynamic fashion, patients can be evaluated with an oral glucose tolerance test (OGTT) ( 85 , 86 ). Glucose and insulin/C-peptide can be drawn at baseline and every 30 min over the course of 120 min after consumption of 75 g (or, in children, 1.75 g/kg) oral glucose solution ( 87 ). Insulin, C-peptide, and glucose data from an OGTT allow the endocrinologist to calculate a range of indices of insulin secretory capacity such as the C-peptide index (CPI): (C-peptide 30min − C-peptide 0min ) / (glucose 30min − glucose 0min ). CPI <0.245 is suggestive of insulin deficiency ( 88 ). Compared with an OGTT, the mixed-meal tolerance test (MMTT) generates a stronger β-cell response as incretin hormones are modulated by ingestion of glucose, protein, and fat ( 89 , 90 ). In the U.S., BOOST High Protein (Nestle Health Science) is commonly used as the “mixed meal,” at a dose of 6 mL/kg with a maximum dose of 360 mL in older children and adults ( 91 ). The OGTT and MMTT can also provide indirect evidence of insulin resistance if the stimulated C-peptide levels remain high throughout the 2-h test in the presence of sustained hyperglycemia ( 92 ).

When performing an OGTT or MMTT is not feasible, the insulin dose–adjusted HbA 1c (IDAA 1c ) measurement can be a helpful surrogate. The IDAA 1c is calculated as follows: HbA 1c (%) + [4 × insulin dose (units/kg/24 h)]. IDAA 1c ≤9 corresponds to a predicted stimulated C-peptide >0.9 ng/mL and partial recovery of β-cell function ( 93 ).

In considering a diagnosis of monogenic diabetes, online probability calculators are available to aid in clinical decision-making. By entering readily available demographic and clinical information such as age at diagnosis, BMI, insulin requirement, and HbA 1c into the calculator, the clinician can obtain a value that indicates the patient’s likelihood of having monogenic diabetes ( 94 ). Such tools provide decision support to order genetic testing and to convince third-party payers to approve such testing. Some literature suggests a cutoff of 36% probability with a positive predictive value of 74.4% in using the Exeter MODY probability calculator ( https://www.diabetesgenes.org/exeter-diabetes-app/ModyCalculator ) ( 87 ).

In the case of pancreatic diabetes, patients may have elevated fecal elastase ( 95 ). For patients with insulin-resistant forms of diabetes it may important to rule out Cushing disease by measuring 24-h urine free cortisol, measuring midnight salivary cortisol, or performing a low-dose dexamethasone suppression test ( 96 ). In the case of overgrowth syndromes, such as IMPA, it is important to rule out growth hormone excess by measuring IGF-1 and growth hormone or by performing a growth hormone suppression test ( 97 ).

Ordering and Interpreting Genetic Testing

Molecular genetic testing is a powerful tool to secure a diagnosis of single-gene atypical diabetes disorders and identify relatives at risk. Until recently, there were limited clinical guidelines regarding when to consider genetic testing for atypical diabetes. The International Society for Pediatric and Adolescent Diabetes (ISPAD) now provides a framework for consideration of testing for well-defined monogenic forms of atypical diabetes, including MODY and neonatal diabetes ( 98 ). Risk calculators, such as the Exeter MODY risk calculator, can provide a more objective approach to assessment of risk and stratification of patients who are most likely to benefit from molecular testing.

Genetic testing approaches have evolved in recent years, with broad-based molecular tests (exome sequencing [ES], array comparative genomic hybridization) demonstrating an increased diagnostic utility in comparisons with targeted gene panels that require a clinician to accurately presuppose the molecular diagnosis. Despite this evolution, some unique variants are most sensitively detected by methodologies other than ES or array comparative genomic hybridization, and the choice of testing should be informed by the sensitivity and specificity of available tests for the suspected diagnosis ( 99 ). From a practical standpoint in the clinic, gene panels and focused testing remain more accessible to many patients, due to high out-of-pocket costs and in some cases limited insurance coverage of ES testing. While the implementation of next-generation sequencing methods has had a tremendous impact on clinical diagnostics in rare disease, implicit bias remains a barrier to equitable access to testing and should be recognized and minimized ( 100 ).

Results of genetic testing can be complex. Pretest counseling of patients is important to address possible results and review the risks, benefits, and potential limitations of testing. Current American College of Medical Genetics and Genomics practice guidelines recommend that diagnostic laboratories follow a standardized interpretation process to classify variants along a spectrum from “benign” to “pathogenic” to describe their functional impact ( 101 ). Within this classification scheme are variants of uncertain significance, for which there is limited evidence to support a classification of “pathogenic/likely pathogenic” or “benign/likely benign.” Variants of uncertain significance can often present a challenge to the clinical interpretation and actionability of results. Fortunately, as new information comes to light about a variant, reanalysis of the patient’s genetic data can lead to more unequivocal reclassification of the variant as benign or pathogenic.

We characterize current precision medicine approaches to atypical diabetes in Table 4 . The future dream of precision diabetes is that all patients will receive a diagnosis of a specific form of diabetes based on an extensive, endotypic classification, with genome sequencing, transcriptomic, and metabolomic data available to clinicians to inform individualized management plans. Currently, such a classification does not exist and the clinical utility of such data in diabetes care is limited. The Rare and Atypical Diabetes Network (RADIANT) exemplifies this approach and research focus needed to elucidate all forms of atypical diabetes, their clinical characteristics, and their molecular and pathophysiological etiologies ( 2 ). This work will inform implementation of omics tools for diagnostic and therapeutic purposes and enable a more complete cataloging and classification of atypical diabetes. Such advances informing diabetes care at an individualized level will be truly transformative when achieved at scale, and current research in atypical diabetes is positioned to establish new standards for the implementation of multiomics in routine clinical care.

Precision approaches to atypical diabetes

SU, sulfonylureas; GLP-1 RA, glucagon-like peptide 1 receptor agonists; HTN, hypertension; IPEX syndrome, immunodysregulation, polyendocrinopathy, enteropathy X-linked syndrome; MEDS, microcephaly with simplified gyral pattern, epilepsy, and permanent neonatal diabetes syndrome; NDH, neonatal diabetes mellitus with congenital hypothyroidism; PCOS, polycystic ovary syndrome; SGLT-2i, sodium–glucose cotransporter 2 inhibitors; TG, triglycerides; TZDs, thiazolidinediones.

This article is featured in podcasts available at diabetesjournals.org/care/pages/diabetes_care_on_air .

Note Added in Proof. Between initial publication of this article online and its final publication online and in print, the genes KLF11 , PAX4 , and BLK were removed from Table 1 due to a recent refutation of their roles in monogenic diabetes.

Acknowledgments. J.E.P. is an editor of Diabetes Care but was not involved in any of the decisions regarding review of the manuscript or its acceptance.

Funding. S.I.S. is supported by a K08 grant from the National Institutes of Health (NIH) (DK124574). The authors are also supported by the RADIANT study, funded by the National Institute of Diabetes and Digestive and Kidney Diseases.

Duality of Interest. No potential conflicts of interest relevant to this article were reported.

Author Contributions. S.I.S. researched and authored sections pertaining to monogenic, syndromic, mitochondrial, severe insulin resistance lipodystrophic, and pancreatic diabetes. S.I.S. also researched and authored the section on the approach to the patient with atypical diabetes. A.B. researched and authored sections on LADA, KPD, and fulminant diabetes. J.E.P. researched and authored sections on defining atypical diabetes, ordering and interpreting genetic testing, and atypical diabetes and precision medicine. All authors reviewed and edited the manuscript in its entirety.

Handling Editors. The journal editors responsible for overseeing the review of the manuscript were Steven E. Kahn and Adrian Vella.

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BRIEF RESEARCH REPORT article

Usability evaluation of the educational website “understanding my diabetes” for mexican patients with type 2 diabetes.

1 Unidad de Investigación en Epidemiología Clínica, Hospital General Regional No. 1 “Dr. Carlos Mac Gregor Sánchez Navarro” Instituto Mexicano del Seguro Social, Ciudad de México, Mexico
2 Unidad de Medicina Familiar Número 7, Coordinación de Educación e Investigación en Salud, Instituto Mexicano del Seguro Social, Ciudad de México, Mexico
3 Departamento de Salud Publica, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, Mexico

Background: Diabetes education is an integral part of the treatment for the metabolic control of patients with diabetes. The use of the Internet as a tool for diabetes education, as well as its acceptance, is still under study.

Aim: To assess the usability of the educational website “I understand my diabetes” designed for patients with type 2 diabetes attending primary care clinics.

Material and method: A cross-sectional study was done in 110 patients with type 2 diabetes from two family medicine clinics, each of whom was assigned a user account on the educational website “Entiendo mi diabetes.” The web site assigned a user name and password to each patient. They were able to access the educational website at home. After a 15-day review period, participants were asked to evaluate usability using the Computer System Usability Questionnaire. Additionally, we developed an eight-item questionnaire usability focusing on diabetes care. Sociodemographic data, blood pressure, and anthropometric measurements were recorded. Glucose levels and lipid profiles were also measured.

Results: The patients with diabetes had a mean age of 52.7 years and a median of 5 years since they were diagnosed with diabetes. The website received a good usability rating from 89.1% of participants, with favorable assessments in all three dimensions: 87.3% for information, 85.5% for quality, and 88.2% for interface. Regarding usability specifically for diabetes care, 98.2% rated it as having good usability.

Conclusion: The website for education about the disease in patients “I understand my diabetes” had an adequate usability evaluation by patients, so they also considered it very useful for diabetes care. The diabetes care instrument had adequate usability and reliability.

Introduction

Type 2 diabetes (T2D) is defined as a group of metabolic disorders characterized by chronic hyperglycemia. It is the result of impaired insulin secretion, deficient effectiveness, or both conditions ( 1 ). Globally, in 2019, its estimated prevalence was 9.3%, affecting 463 million people, and it is projected to increase to 700 million by 2045. Moreover, it is estimated that approximately 50.1% of individuals with T2D are unaware of their condition ( 2 ).

In Mexico, the prevalence of T2D was 9.5% in 2016, and 18.3% (5.8% were new diagnosis) in 2022 ( 3 ). The objectives of comprehensive treatment are to achieve glycemic control with a glycated hemoglobin (HbA1c) level < 7%, with a primary focus on reducing long-term micro and macrovascular complications ( 4 ).

In the 2016 National Health and Nutrition Survey (Ensanut 2016) the researchers reported that 68.2% of the population diagnosed with diabetes in Mexico has poor metabolic control (HbA1c ≥ 7%) ( 5 ). Since this persistent poor glycemic control, the increase in the prevalence of T2D and the late diagnosis of the disease, it is necessary to promote strategies to adopting a healthy lifestyle and disease care. Metabolic control in patients with diabetes must have a comprehensive approach, according to the physician care, pharmacological treatment, and initiatives to promote a healthy lifestyle.

Diabetes education is a crucial component for instilling knowledge about the disease, promoting self-care, and encouraging positive lifestyle changes ( 6 , 7 ). Furthermore, evidence suggests that providing diabetes education reduces the risk of condition related mortality ( 8 ).

Over the past two decades, there has been a growing use of Health Information and Communication Technologies (ICTs) for providing diabetes education and monitoring indicators ( 9 ). It has been demonstrated that these tools can contribute to improving HbA1c levels, body composition, knowledge of the disease, and the adoption of a healthy lifestyle ( 9 , 10 ).

Nevertheless, it has been reported that educational websites lack validated information, have accessibility issues, and exhibit variability with regard to the quality of the information, its updating, ease of use and comprehension ( 11 , 12 ).

The term “usability” is defined as the degree to which users can perform tasks accurately and efficiently ( 13 ). According to the International Organization for Standardization (ISO 9241), usability refers to the efficiency, effectiveness, and satisfaction of users in a specific context ( 14 ). Usability reports exist for developments involving the use of ICTs in diabetes, indicating a range from 38 to 80% ( 15 , 16 ). Limitations include difficulty completing multiple steps to achieve an objective, limited functionality and interaction, navigation challenges, as well as a high abandonment rate. In addition, patient difficulties in accessing and experiencing educational websites have been documented ( 17 ).

The persistent increase of patients with diabetes makes it difficult to provide education about the disease in primary care; therefore, implementing strategies with the use of ICTs, designed by clinicians with experience in diabetes, as well as in the culture, educational level and social environment of the patients, becomes an imperative need. In this sense, it is required to have digital tools adapted to the end user, which are easy to use and understand, as well as useful to improve the knowledge of T2D and promote its care.

In Mexico, the usability of systems designed to provide diabetes education is even more limited than that reported in other countries. In this sense, our research group developed an educational site called “Understanding my diabetes” which was built by physicians, nutritionists, and diabetes educators with more than 10 years of experience. The diabetes web site was validated by a consensus of experts ( 18 ).

Therefore, the aim of this study is to measure the usability of the educational website “Understanding my diabetes” for ease awareness of the condition and improve self-management in patients with T2D, attending primary clinics care.

Materials and methods

Study design and population.

A descriptive cross-sectional study was conducted among patients affiliated with two family medicine clinics of the Instituto Mexicano del Seguro Social (Mexican Institute of Social Security, IMSS) in Mexico City from September 2021 to May 2022.

The study was approved by the Ethics and Research Committee at IMSS with registration number R-2021-3609-025. Patients were invited to participate in the study during their clinic appointments. The participating researchers provided information about the study to the patients, answered their questions and, once they decided to participate voluntarily, their consent was requested by signing the informed consent form.

The sample size was calculated based on the assessment of the usability of the educational program and findings reported in a similar study ( 19 ). A formula was used for proportion, with a confidence level of 95%, an expected proportion of 1.21, and a margin of error of 0.10, resulting in a total of 92 participants. To account for a 20% potential loss (participants cannot completing the assessment), 110 patients were included in the study.

Selection criteria

The study included patients who were previously diagnosed with T2D by their treating physician, aged 18 or older, and who had been diagnosed less than 10 years ago. Participants needed to be literate, to have access to a home computer or smartphone, and possess internet connectivity. Patients with severe complications of the disease, such as chronic kidney disease requiring replacement therapy, blindness, amputation, or any condition that hindered the evaluation of the educational website (visual impairment, or psychological conditions), were excluded.

Patients with severe complications of the disease, such as chronic kidney disease (patients that requiring replacement therapy), blindness, amputation, or any condition that hindered the evaluation of the educational website (visual impairment, or psychological conditions) were excluded ( Figure 1 ).

Figure 1 . Selection criteria.

Sociodemographic and clinical measurements

The collection of sociodemographic and clinical data was conducted by participating medical and nutrition staff. Blood pressure readings were recorded, measured by a healthcare professional on two occasions using a mercury sphygmomanometer, with a five-minute interval between each reading. Patients were requested to remain seated for more than 5 min before the readings. The recorded blood pressure value was the average of the two measurements.

Socioeconomic status

The socioeconomic status was assessed using the INEGI questionnaire known as AMAI, comprising 7 levels. To categorize participants into three socioeconomic classes, a scoring system defined by the authors of the instrument was employed: a score between 0 and 111 points indicated a low socioeconomic level, 112–204 points indicated a medium level, and a score of ≥205 indicated a high socioeconomic level ( 20 ).

Anthropometric measurements

Anthropometric measurements were recorded by two nutritionists who received prior training and standardization through a training course.

Two nutritionists took a training course for the standardization of measurements. They recorded the anthropometric measurements of the sample. They followed the Habitch method, adhering to the specifications recommended by Lohman and colleagues ( 21 , 22 ). Body weight was measured on a calibrated SECA ® model 813 scale, with participants wearing light clothing. Height was measured using a SECA ® model 220 stadiometer, with the patient positioned with their back to the scale following the Frankfort plane. The body mass index (BMI) was calculated.

Waist circumference (WC) was measured with a SECA® measuring tape, with the reference point at the midpoint between the lowest rib and the upper edge of the iliac crest on the right side. Both measurements were assessed at three different times, and the mean value of the second and third measurements was used for recording and analysis.

Biochemical measurements

Biochemical indicators were measured in venous blood after a 10-h fasting period. High-Performance Liquid Chromatography (HPLC) was employed. Automated photometry (Roche Cobas 800 c701) was used for the measurement of glucose, total cholesterol levels, and triglycerides.

Educational Website “Entiendo mi diabetes” in Spanish language. Este sitio web educativo fue desarrollado por el equipo investigador, compuesto de medicos especialistas de familia, de medicina interna, nutriólogos, epidemiologos, educadores en diabetes, informáticos, que participan con el equipo de investigación. The educational course was implemented on the Moodle platform at the website www.entiendomidiabetes.com by a team of web developers. The course comprises modules on understanding diabetes, pharmacological treatment, control indicators, nutrition, myths surrounding diabetes, complications related to the disease, depression, and family support. These modules are designed in a straightforward manner, incorporating visual resources and minimal text. The use of videos facilitates easy comprehension. Each module includes didactic or reinforcing activities with the aim of motivating patients to actively manage their health.

These educational modules were validated through an expert consensus, including physicians, nutritionists, psychologists, and diabetes educators. The validation process was conducted blindly and in pairs, assessing the content validity of the educational modules, which has been previously reported ( 18 ).

This course is managed over Moodle, the free open- source Learning Platform and can be visited at: http://entiendomidiabetes.com/moodle28/login/index.php .

Usability measurement instrument

The level of usability was assessed using the Computer System Usability Questionnaire (CSUQ), validated in the Mexican population ( 23 ).

The instrument comprises 16 items that evaluate three main domains: system quality (items 1–6), information quality (items 7–12), and interface quality (items 13–16). The instrument utilizes a 7-level Likert scale, ranging from completely disagree “1“to completely agree “7.” In order to assess usability, a total of 112 points were used, categorized into tercile: low usability (<37 points), moderate (38–74 points), and high usability (>75 points). Regarding the dimensions, for a maximum quality score of 42 points, (low quality ≤14 points, moderate 15 to 28 points, and high quality ≥29 points). Patients created their username and password for the educational site, and after interacting with the site, from login to the complete review of one of the modules, they were asked to complete the usability questionnaire.

Diabetes care instrument

A research team consisting of two-family physicians, two nutritionists, and two diabetes educators designed a 10-item questionnaire aimed at measuring usability for diabetes care. Following a second content analysis review, two items were eliminated as they were deemed repetitive. Eight items were included, focusing on measuring understanding of content (items 1 and 2), items directed toward positive changes in disease care (items 3–7), and likelihood to recommend the educational site to others (item 8). A Likert scale ranging from 1 to 7 was used. A score of 8–24 was considered low usability in diabetes care, 25–40 as moderate, and ≥41 as high usability.

Statistical analysis

The data were analyzed using the statistical package SPSS, version 25. Qualitative variables characterizing the population and the type of usability of the educational program are presented in frequencies and proportions. The Kolmogorov–Smirnov normality test was employed to identify the distribution of quantitative variables. For variables with a parametric distribution, mean and standard deviation were used, while for those with a non-parametric distribution, median and interquartile range were utilized.

The usability of each item in the instrument was measured through the mean and standard deviation.

To assess the scale reliability of the diabetes usability instrument CSUQ and the instrument of diabetes care, Cronbach’s alpha was calculated.

To identify the association between usability and qualitative variables with sociodemographic and clinical variables, the chi-square test was employed. A statistically significant difference was considered with a p -value < 0.05.

The sociodemographic characteristics and data of the studied population are presented in Table 1 .

Table 1 . Sociodemographic characteristics of the studied population with diabetes.

A total of 110 patients were included, 66% were female. The average age of the study population was 52.7 ± 10.2 years, with a median diabetes diagnosis duration of 5 years. The most frequently reported level of education was higher education (39%), while the most frequently identified socioeconomic level was middle class, (67%). Thirteen percent received diabetic education and 32% of the patients studied received nutritional therapy previously.

Thirteen percent received diabetic education and 32% of the sample received nutritional therapy previously. The median BMI was 29 kg/m 2 , and fasting glucose was 145 mg/dL.

Table 2 displays the rating for each item in the usability instrument of the educational site. The highest average rating was 6.47 for the item addressing assistance in completing tasks, whereas the lowest was 6.03, pertaining to resolving issues on the website. The mean of usability of the educational website was 94.76 ± 15.48 and the reliability test was 0.97 ( Table 3 ). The usability of the website using the diabetes instrument shows that 98.2% of patients rated it as high and 1.2% as regular.

Table 2 . Usability rating of the educational website “Entiendo mi diabetes.”

Table 3 . Usability level of the educational site related to aspects of diabetes care.

The usability description is presented in Figure 2 , revealing that 89.1% of the patients rated it as high usability, 9.1% as moderate, and 1.8% as low usability. In Figure 3 , the three dimensions of usability from the instrument are illustrated, indicating high usability across all three dimensions: 87.3% for information, 85.5% for quality, and 88.2% for the interface.

Figure 2 . Usability level of the educational website “Entiendo mi diabetes”.

Figure 3 . Usability in the dimensions of the website “Entiendo mi diabetes”.

Regarding the average rating of the 8 items in the instrument aimed at measuring usability in diabetes care, 98.2% rated it as having high usability. The highest average rating was related to understanding the behavior of diabetes (6.79), while the lowest was motivation for physical exercise (6.70). The overall mean usability of the diabetes care instrument was 54.37 ± 3.94 and the reliability value was 0.93.

Low, moderate, and high usability were compared with sociodemographic variables, prior diabetes education, socioeconomic level, education level, and marital status, with no statistically significant differences found among them. There was no difference between glycemic control and type of usability; the data are presented in Table 4 .

Table 4 . Usability level and its association with sociodemographic and clinical variables.

Diabetes education is a fundamental component of comprehensive patient care and is essential for achieving metabolic control, as well as reducing or preventing the complications associated with the disease. Information and Communication Technologies (ICTs) are valuable tools, especially in healthcare areas where there is a high demand for medical care.

In the present study, the usability of an educational website on diabetes is reported, with 89% of patients rating the educational tool as highly usable. Nine out of ten patients found it useful, easy to use, and of adequate quality. Authors who have assessed usability in patients with diabetes using an app have consistently rated ease of use and learning highly, while the lowest ratings were for trust and quality of interaction with the app. Additionally, those with a lower educational level tended to rate it more favorably ( 19 ). It has been reported that with the implementation of web-based educational programs, patients with lower diabetes education have a higher perception of the risk of complications. In this study, however, no differences in the usability of the educational program were found when comparing it with the level of education or socioeconomic status ( 24 ). This could be explained by the fact that the website “Entiendo mi diabetes” included simple, easily understandable information presented interactively to facilitate patient understanding and action in caring for their health. Even though age could be a limiting factor for the use of educational tools with ICTs, no differences in usability were observed.

When considering the dimensions of the usability instrument, more than 85% of the studied patients believed that the educational program met, provided adequate information, and was easy to use. It is important to highlight aspects of quality that the educational content was designed by nutritionists and clinical doctors specializing in diabetes care in primary care clinics. Moreover, it underwent a validation process by clinical experts.

Other authors have assessed usability using the CSUQ program, and this study is one of the few that has demonstrated the level of usability of an educational program, finding a higher rating than what other authors have reported ( 25 , 26 ).

It was observed that patients perceive an adequate system quality, meeting expectations, and the interface quality proves to be intuitive, generating user satisfaction. These results align with findings from other authors, suggesting that usability improves when a multidisciplinary team is involved in creating educational programs for patients. However, it becomes more valuable when patients are involved in the evaluation process ( 27 ).

It is essential to highlight that only 29% of the population had received in-person diabetes education at their clinic. Therefore, continuing the development of web-focused educational materials can be of significant value, enabling patients to receive diabetes education remotely. Additionally, it can serve as a motivating factor for them to manage their condition effectively from the time they receive a diagnosis.

In this regard, healthcare professionals are typically the ones evaluating educational programs. Therefore, it becomes necessary for the system’s quality to meet user expectations, to assess the quality of information and its comprehension, and ensure that the interface is intuitive for the user. Other authors have reported the usability of an app prototype for diabetic foot self-care in end-users, identifying high usability due to the fact that the tool was centered around user needs and requirements ( 28 ).

Prior to implementing an educational program using ICTs, evaluation by experts in the medical, nutrition, and diabetes education fields, as well as by software developers for its implementation, is crucial. Finally, the development should undergo assessment by end users. One of the strengths of this study was the design of an instrument to measure usability focused on aspects of diabetes care. The instrument developed had adequate reliability, with a Cronbach’s Alpha value of 0.93. It was found that 98% of participants considered the educational program useful for understanding the disease, for promoting diabetes care and adherence to diet and exercise. To date, there is limited information on patient satisfaction for diabetes management websites in Mexico.

Among the limitations of the present study is the cross-sectional design. Future studies should assess the usability at various stages throughout the duration of an educational program. Additionally, there should be increased participation of women in the study, as they are the ones who most frequently seek medical attention.

It is crucial that healthcare professionals become guides in the use of technologies as new methods of learning. It has been reported that this approach increases patient trust, a better adherence to treatment and motivation in health education can be achieved ( 29 , 30 ). When the patients become acquainted with an education web site it is necessary and very important the follow-up by healthcare professionals. This contributes to assessing the long-term effectiveness of interventions of ICTs.

On the other hand, in patients with type 2 diabetes in Mexico, poor glycemic control has been reported in 2016 National Health and Nutrition Survey (Ensanut 2016). This survey showed that 68.2% of patients do not achieve metabolic control, furthermore they present a late diagnosis, and high prevalence of overweight and obesity. Then, with this conditions, the sample have a higher risk of developing complications of the disease, such as kidney or cardiovascular disease ( 5 ).

There is a high demand for health services for patients with type 2 diabetes in primary care units in Mexico. By the year 2022, it was estimated that the IMSS would care for 4.2 million patients with diabetes. 64% of the care in primary care clinics at the IMSS was for diabetes ( 31 ).

According to this high demand for health care, provide diabetes education becomes a complex task. Therefore, digital tools to provide pharmacological treatment and diabetes education at a distance could contribute to improve metabolic control, promove a healthy lifestyle and acquire knowledge of diabetes to avoid complications of the disease. In addition, providing diabetes education through ICTs could reduce the costs of the disease in patients with type 2 diabetes, as well as improve the perception of their quality of life, as previously reported ( 32 ).

The educational diabetes website received a high usability rating from nine out of ten patients. Furthermore, the study revealed that the educational program was deemed useful and easily comprehensible, addressing key aspects to inform and motivate self-care in diabetes. User interaction and satisfaction remained unaffected by factors such as age, education, or socioeconomic status. Assessing usability is crucial for enhancing the end-user experience, with significant implications for adherence and motivation in utilizing digital tools for health education. There is an emphasis on the importance of granting patients access to new knowledge through simple and user-friendly tools, underscoring the need for reinforcement by healthcare professionals.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by COMITE DE ETICA E INVESTIGACIÓN, INSTITUTO MEXICANO DEL SEGURO SOCIAL. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

GO: Investigation, Validation, Writing – original draft. SV: Investigation, Writing – original draft. CI: Investigation, Writing – original draft, Methodology. AM: Writing – original draft, Conceptualization, Formal analysis. LV: Conceptualization, Formal analysis, Investigation, Methodology, Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article. This study received funding from the Instituto Mexicano del Seguro Social, in the call for priority projects, with a number in the Fund FIS/IMSS/PROT/PRIO/18/O84.

Acknowledgments

The authors would like to thank the authorities of the participating clinics for the facilities granted to carry out this study.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: type 2 diabetes, health information technology, usability, website, diabetes education

Citation: Ortíz GO, Vega García S, Islas Salinas C, Muñoz Torres AV and Velázquez López L (2024) Usability evaluation of the educational website “understanding my diabetes” for Mexican patients with type 2 diabetes. Front. Public Health . 12:1394066. doi: 10.3389/fpubh.2024.1394066

Received: 29 February 2024; Accepted: 23 April 2024; Published: 10 May 2024.

Reviewed by:

Copyright © 2024 Ortíz, Vega García, Islas Salinas, Muñoz Torres and Velázquez López. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Lubia Velázquez López, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Original Article
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Cite this article

Cheng Ji 1 , 2 na1 ,
Jie Ma 3 na1 ,
Lingjun Sun 4 na1 ,
Lijuan Liu 3 ,
Lijun Wang 3 ,
Weihong Ge 1 &

Considering the prevalence of type 2 diabetes (T2D), osteoporosis should be considered a serious complication. However, an effective tool for the assessment of low bone mass mineral density (BMD) in T2D patients is not currently available. Therefore, the aim of our study was to establish a simple-to-use risk assessment tool by exploring risk factors for low BMD in T2D patients.

This study included 436 patients with a low BMD and 381 patients with a normal BMD. Multiple logistic regression analysis was performed to evaluate risk factors for low BMD in T2D patients. A nomogram was then developed from these results. A receiver operating characteristic (ROC) curve, calibration plot, and goodness-of-fit test were used to validate the nomogram. The clinical utility of the nomogram was also assessed.

Multivariate logistic regression indicated that age, sex, education, body mass index (BMI), fasting C-peptide, high-density cholesterol (HDL), alkaline phosphatase (ALP), estimated glomerular filtration rate (eGFR), and type I collagen carboxy terminal peptide (S-CTX) were independent predictors for low BMD in T2D patients. The nomogram was developed from these variables using both the unadjusted area under the curve (AUC) and the bootstrap-corrected AUC (0.828). Calibration plots and the goodness-of-fit test demonstrated that the nomogram was well calibrated.

Conclusions

The nomogram-illustrated model can be used by clinicians to easily predict the risk of low BMD in T2D patients. Our study also revealed that common factors are independent predictors of low BMD risk. Our results provide a new strategy for the prediction, investigation, and facilitation of low BMD in T2D patients.

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The datasets generated and/or analysed during the current study are not publicly available but are available from the corresponding author on reasonable request.

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Acknowledgements

The authors thank Daphne Liao, Pharm.D. and Lei Zou, Pharm.D of MCPHS University for linguistic review of the manuscript.

This work was supported by the Pharmacy Scientific Research Project of Zhengda Tianqing Hospital of Jiangsu Pharmaceutical Association (grant numbers:TQ2021006) and the Clinical Research Special Fund Cultivation Project of Nanjing Drum Tower Hospital (grant numbers:2021-LCYJ-PY-33).

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These authors contributed equally: Cheng Ji, Jie Ma, Lingjun Sun

Authors and Affiliations

Department of Pharmacy, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, Jiangsu, China

Cheng Ji & Weihong Ge

Nanjing Medical Center for Clinical Pharmacy, Nanjing, Jiangsu, China

Department of Pharmacy, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China

Jie Ma, Lijuan Liu & Lijun Wang

Department of Endocrinology, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China

Lingjun Sun

Department of Pharmacy, The First Hospital Affiliated to China Pharmaceutical University, Nanjing, Jiangsu, China

Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, Jiangsu, China

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Correspondence to Weihong Ge or Yan Bi .

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All procedures of the research were performed in accordance with ethical principles for medical research involving human subjects of the 1964 Helsinki Declaration and its later amendments. The study was approved by the Clinical Research Ethics Committee of the Nanjing drum tower hospital. All participants had signed the informed consent form.

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Ji, C., Ma, J., Sun, L. et al. Prediction model for low bone mass mineral density in type 2 diabetes: an observational cross-sectional study. Endocrine (2024). https://doi.org/10.1007/s12020-023-03500-w

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