Type 2 Diabetes: What It Is and How to Control It
Type 2 diabetes is a condition in which the body's cells stop responding properly to insulin and the pancreas cannot keep up, so glucose builds up in the blood. It is diagnosed by a fasting blood glucose of 126 mg/dL (7.0 mmol/L) or more, an HbA1c of 6.5 per cent (48 mmol/mol) or more, or a glucose of 200 mg/dL (11.1 mmol/L) or more two hours after a glucose drink or at any time with symptoms. Pakistan has one of the highest rates in the world, with national surveys reporting between one in six and one in four adults affected, and many do not know it because early diabetes often causes no symptoms at all. It is controlled rather than cured, through what you eat, daily movement, weight loss and medicines starting with metformin — but a meaningful number of people who lose 10 to 15 kg early on push it into remission. The damage diabetes causes to eyes, kidneys, nerves, feet, heart and brain is largely preventable, and preventing it depends on a short list of checks done every year and on blood pressure and cholesterol being controlled alongside the sugar.
Diabetologist & General Physician · MBBS
What type 2 diabetes actually is
Every cell in the body runs on glucose, the simple sugar carbohydrate is broken down into. Getting glucose out of the blood and into the cells requires , a hormone made by the pancreas. Insulin works like a key: it unlocks the cells so glucose can enter.
In type 2 diabetes two things go wrong together. The cells become resistant, so the same insulin has less effect — the key still fits but the lock has stiffened. The pancreas compensates by making more, and for years it succeeds: blood sugar stays normal while insulin levels quietly climb. Eventually it cannot keep up. That silent period is why many people are diagnosed only when a complication appears, having had the condition for years. This is a different disease from type 1 diabetes, where the immune system destroys the insulin-producing cells outright, usually in childhood; the two share a name and a symptom list but not a cause, a treatment or a prevention strategy.
How common it is in Pakistan
Pakistan sits at or near the top of every international ranking for diabetes. The International Diabetes Federation's tenth Atlas put the country among the highest in the world, with more than 30 million adults affected. Our two national surveys do not agree on the exact figure — the second National Diabetes Survey of Pakistan reported around 26 per cent of adults, the HbA1c-based Diabetes Prevalence Survey of Pakistan around 17 per cent — but the disagreement is between very high and extremely high. A further one in seven adults has prediabetes, and roughly half of everyone with diabetes here has never been told.
Part of the reason is biological rather than behavioural. South Asians develop insulin resistance at a lower body weight and a younger age than European populations, storing more fat around the organs at any given weight. That is why international guidance sets a lower threshold for us — overweight from about 23 and obesity from about 27.5, rather than 25 and 30 — and why is advised from 25 rather than 40 in anyone with another risk factor. A slim-looking person with a thickening waistline is not exempt.
The symptoms, and why they are unreliable
- Passing urine often, especially at night, because excess glucose pulls water into the urine, and constant thirst, which follows from the fluid loss.
- Losing weight without trying, as the body breaks down fat and muscle for fuel it cannot get from glucose.
- Tiredness that sleep does not fix.
- Blurred vision that comes and goes as sugar levels swing and change the shape of the lens.
- Cuts and boils that heal slowly, repeated skin infections, and genital itching or thrush.
- Tingling, burning or numbness in the feet, which means nerve damage has already begun.
The critical point is that many people with early type 2 diabetes have none of that. Symptoms appear only once glucose has run high for a sustained period, by which stage small blood vessels may already be damaged. That is why testing is advised on the basis of risk rather than symptoms: if you are over 40, or over 25 with a family history, a raised waist, high blood pressure or previous gestational diabetes, ask for it even though you feel perfectly well.
How it is diagnosed
| Test | Normal | Prediabetes | Diabetes |
|---|---|---|---|
| Fasting blood glucose — no food for at least 8 hours | Below 100 mg/dL (5.6 mmol/L) | 100–125 mg/dL (5.6–6.9 mmol/L) | 126 mg/dL (7.0 mmol/L) or above |
| — average sugar over about 3 months | Below 5.7 per cent (39 mmol/mol) | 5.7–6.4 per cent (39–47 mmol/mol) | 6.5 per cent (48 mmol/mol) or above |
| 2 hours after a 75 g glucose drink | Below 140 mg/dL (7.8 mmol/L) | 140–199 mg/dL (7.8–11.0 mmol/L) | 200 mg/dL (11.1 mmol/L) or above |
| Random blood glucose, any time of day | Not used to exclude diabetes | Not used | 200 mg/dL (11.1 mmol/L) or above with symptoms |
One caution about . It measures the proportion of carrying attached sugar, so anything altering the lifespan of red cells alters the result. In , after blood loss or transfusion, in kidney or liver disease, in pregnancy, and in the thalassaemia trait and other haemoglobin variants common here, it can read falsely low or high; a fasting glucose is then more reliable. Our guide to the HbA1c test covers reading the number in more detail.
What good control looks like
For most adults the target is around 7 per cent (53 mmol/mol) or below — tighter for younger people early after diagnosis, looser for older or frailer people in whom a low-sugar episode is more dangerous than a slightly high average. That is a conversation with your doctor, not a universal number.
Sugar is only a third of the job. Blood pressure below about 130/80 mmHg and a low — usually with a , offered to most adults with diabetes over 40 regardless of the starting cholesterol — prevent at least as much heart attack, stroke and kidney damage as glucose control does. If you take one thing from this section: a person with diabetes whose sugar is perfect and whose blood pressure is 160/95 is not well controlled.
Food, on a Pakistani plate
There is no diabetic diet in the sense of a separate cuisine. There is portion size, the balance of the plate, and the drinks. Our guide to healthy eating on a Pakistani plate works through this in more detail, including weddings and dawats; the essentials are these.
- Cut the sugar in chai first. Two cups a day at three teaspoons each is around 90 calories of pure sugar and a sharp glucose rise twice daily. Reduce by half a teaspoon a week and most people stop noticing within a month.
- Fix the ratio, not the food. Roti and rice are not forbidden — the usual problem is four rotis with a little salan. Aim for half the plate as vegetables and salad, a quarter as protein such as daal, chicken, eggs or yoghurt, and a quarter as roti or rice.
- Choose slower carbohydrate — whole-wheat atta rather than maida, brown or parboiled rice, daal and chana. Naan, paratha, white bread and polished-rice biryani raise sugar fastest.
- Drink water, not calories. Soft drinks, bottled juices, sweetened lassi, Rooh Afza and energy drinks deliver a large glucose load with no fullness.
- Keep fruit whole and portioned. Two servings a day is good for you; juice is not, because juicing removes the fibre and leaves the sugar. Mango and banana are fine in a normal portion — the belief that diabetes forbids mango causes more misery than harm.
Movement, weight and remission
The target is at least 150 minutes a week of moderate activity — brisk walking counts, half an hour on five days is the usual route — plus two sessions of muscle work. Activity lowers blood glucose for up to 24 hours afterwards, independently of weight, by making muscle take up glucose without needing much insulin. Walking for ten to fifteen minutes after the largest meal of the day is one of the highest-yield habits available and needs no equipment.
Weight loss is the most powerful intervention of all in the first years after diagnosis. In the DiRECT trial, people who lost around 10 to 15 kg through a supervised programme achieved — normal blood sugars with no diabetes medication — in roughly a third to a half of cases at one to two years. Remission is not cure: the tendency remains and the weight has to stay off. But it is real, achievable for many people diagnosed recently, and worth asking about while the pancreas still has reserve.
The medicines, and what each one does
| Group | Common examples here | What it does | Worth knowing |
|---|---|---|---|
| Biguanide | Metformin | Reduces the glucose the liver releases and helps muscle respond to insulin | Almost always the first medicine. Take with food; loose stools and a metallic taste usually settle in a fortnight. Cheap, and does not cause low sugar on its own. |
| Sulfonylureas | Gliclazide, glimepiride | Push the pancreas to release more insulin | Effective and inexpensive, but can cause low sugar and modest weight gain. Needs care in older people and during Ramadan. |
| DPP-4 inhibitors | Sitagliptin, vildagliptin, linagliptin | Strengthen the body's own after-meal insulin signal | Weight-neutral with a low risk of low sugar. More expensive than the two above. |
| SGLT2 inhibitors | Empagliflozin, dapagliflozin | Make the kidneys pass surplus glucose out in the urine | Also protect the heart and kidneys, so used early where those are affected. Increase genital thrush and urinary infection. |
| GLP-1 receptor agonists | Liraglutide, dulaglutide, semaglutide | Slow stomach emptying, reduce appetite and improve insulin release | The strongest weight and cardiovascular benefits available. Usually injected, costly, and nausea is common at first. |
| Various basal and mixed preparations | Replaces the hormone directly | Needed when other treatments are no longer enough, and sometimes briefly at diagnosis. Starting it is not a failure. |
Two things people are commonly told that are wrong. Insulin does not cause kidney failure — uncontrolled diabetes does, and insulin is often started because the kidneys are already affected, which is where the association comes from. And metformin does not damage the kidneys; the dose is reduced when kidney function falls, as a precaution rather than evidence of harm.
The checks you should be getting every year
This list is the difference between diabetes as a manageable condition and diabetes as a cause of blindness, dialysis and amputation. Keep your own record of the dates; in a busy clinic nobody else will.
- , every three to six months — three-monthly while treatment is changing, six-monthly once stable.
- at every visit, aiming below about 130/80 mmHg, and a once a year to check is controlled.
- Kidneys, once a year — serum with an eGFR, plus a urine albumin-to-creatinine ratio, which detects years before creatinine rises and is the most under-ordered test in diabetes care here.
- Eyes, once a year — a dilated retinal examination or retinal photograph. Diabetic eye damage causes no symptoms until it threatens sight, which is why it is screened for. See our guide to diabetic eye disease.
- Feet, once a year — sensation tested with a monofilament, pulses felt, skin and nails examined. More often if sensation is already reduced.
- Weight and waist at every visit, discussed practically rather than moralistically, and mood once a year — depression is around twice as common in diabetes and makes every other part of self-care harder.
- Vaccination — annual influenza and pneumococcal vaccination, because infection both hits harder and pushes sugars up.
Looking after your feet
Long-standing high sugar damages the small nerves of the feet, so injuries stop hurting, and narrows the small arteries, so they heal slowly. That combination is how an unnoticed blister becomes an ulcer and an ulcer becomes an amputation. Almost all of it is preventable.
- Look at both feet every day, between the toes and underneath. Use a mirror on the floor, or ask someone.
- Do not walk barefoot, indoors or in the courtyard. Hot marble, hot sand and a stray nail all cause injuries a numb foot will not report.
- Check water temperature with your hand or elbow before washing your feet or performing wudu, and dry between the toes.
- Wear shoes that fit, run a hand inside before putting them on, and buy them in the evening when feet are largest.
- Do not cut corns or calluses yourself or use corn plasters. Cut nails straight across, not into the corners.
- Show any new ulcer, blister, colour change, swelling or bad smell to a doctor within 24 hours. Not next week.
Fasting in Ramadan
Most people with well-controlled type 2 diabetes on diet alone or on metformin can fast safely with adjustments. The risks are low blood sugar, very high blood sugar and dehydration in the hot months, and they rise substantially on or a sulfonylurea, with poor control or kidney disease, or after a recent admission for high or low sugars. Islam exempts those for whom fasting would cause harm, and a doctor advising against it is describing a medical risk, not making a religious ruling.
- Have a pre-Ramadan review six to eight weeks beforehand, so doses and timings are adjusted deliberately rather than improvised on day two.
- Expect medication changes. Sulfonylurea and insulin doses are usually reduced and shifted, with the larger dose moved to iftar. Never make these changes yourself, and never simply take the usual morning tablet at sehri.
- Test your sugar during the fast. The widely accepted religious position, reflected in IDF and DAR guidance, is that a finger-prick test does not break the fast.
- Break the fast immediately if your glucose falls below 70 mg/dL (3.9 mmol/L), rises above 300 mg/dL (16.6 mmol/L), or if you develop symptoms of low sugar. This is permitted and it is the correct thing to do.
- Take sehri as late as possible and do not skip it — slow carbohydrate, protein and plenty of water.
- Do not treat iftar as a licence. Dates, pakoras, jalebi and a sweet drink together produce a spike that undoes the day. Dates and water, then pray, then a normal meal, works far better.
- Drink generously between iftar and sehri, and move your walk to after taraweeh rather than the afternoon heat.
When to see a doctor
Ask for a test if you are over 40, or over 25 with a raised waist, a parent or sibling with diabetes, high , polycystic ovary syndrome or a past pregnancy affected by diabetes — regardless of how well you feel. If you already have the diagnosis, see your doctor when readings sit outside the range you agreed, if you are having low-sugar episodes, for any foot problem at all, if your vision changes, or before fasting, travel or a new exercise programme.
Go to hospital, rather than waiting, for drowsiness or confusion, repeated vomiting, deep rapid breathing, chest pressure, sudden one-sided weakness or speech difficulty, sudden loss of vision, or a foot that is hot, swollen, blackened or foul-smelling. The point of that long watch-list is that almost every item on it is treatable when caught early.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
