Diabetes mellitus

Diabetes mellitus (DM) also known as simply diabetes, is a group of

metabolic diseases in which there are high blood sugar levels over a prolonged
period This high blood sugar produces the symptoms of frequent urination,
increased thirst, and increased hunger. Untreated, diabetes can cause many
complications. Acute complications include diabetic ketoacidosis and
nonketotic hyperosmolar coma.
Serious long-term complications include heart disease, stroke, kidney failure,
foot ulcers and damage to the eyes.

Diabetes is due to either the pancreas not producing enough insulin, or the
cells of the body not responding properly to the insulin produced. There are
three main types of diabetes mellitus:

 Type 1 DM results from the body's failure to produce enough insulin.

This form was previously referred to as "insulin-dependent diabetes
mellitus" (IDDM) or "juvenile diabetes". The cause is unknown
 Type 2 DM begins with insulin resistance, a condition in which cells fail
to respond to insulin properly. As the disease progresses a lack of
insulin may also develop. This form was previously referred to as "non
insulin-dependent diabetes mellitus" (NIDDM) or "adult-onset
diabetes". The primary cause is excessive body weight and not enough
exercise.
 Gestational diabetes, is the third main form and occurs when pregnant
women without a previous history of diabetes develop a high blood
glucose level.

Prevention and treatment involves a healthy diet, physical exercise, not using
tobacco, and being a normal body weight. Blood pressure control and proper
foot care are also important for people with the disease. Type 1 diabetes must
be managed with insulin injections. Type 2 diabetes may be treated with
medications with or without insulin. Insulin and some oral medications can
cause low blood sugar. Weight loss surgery in those with obesity is an
effective measure in those with type 2 DM. Gestational diabetes usually
resolves after the birth of the baby.

Signs and symptoms:

 The classic symptoms of untreated diabetes are weight loss,

 polyuria (frequent urination),
 polydipsia (increased thirst), and
 polyphagia (increased hunger)
Symptoms may develop rapidly (weeks or months) in type 1 diabetes, while
they usually develop much more slowly and may be subtle or absent in type 2
diabetes.

Several other signs and symptoms can mark the onset of diabetes, although
they are not specific to the disease. In addition to the known ones above, they
include blurry vision, headache, fatigue, slow healing of cuts, and itchy skin.
Prolonged high blood glucose can cause glucose absorption in the lens of the
eye, which leads to changes in its shape, resulting in vision changes. A number
of skin rashes that can occur in diabetes are collectively known as diabetic
dermadromes.

Diabetic emergencies

People (usually with type 1 diabetes) may also experience episodes of diabetic
ketoacidosis, a type of metabolic problems characterized by nausea, vomiting
and abdominal pain, the smell of acetone on the breath, deep breathing known
as Kussmaul breathing, and in severe cases a decreased level of consciousness.

A rare but equally severe possibility is hyperosmolar nonketotic state, which is

more common in type 2 diabetes and is mainly the result of dehydration.

Complications:

All forms of diabetes increase the risk of long-term complications. These

typically develop after many years (10–20), but may be the first symptom in
those who have otherwise not received a diagnosis before that time.

The major long-term complications relate to damage to blood

vessels. Diabetes doubles the risk of cardiovascular disease and about 75% of
deaths in diabetics are due to coronary artery disease. Other "macrovascular"
diseases are stroke, and peripheral vascular disease.

The primary microvascular complications of diabetes include damage to the

eyes, kidneys, and nerves. Damage to the eyes, known as diabetic retinopathy,
is caused by damage to the blood vessels in the retina of the eye, and can result
in gradual vision loss and potentially blindness. Damage to the kidneys,
known as diabetic nephropathy, can lead to tissue scarring, urine protein loss,
and eventually chronic kidney disease, sometimes requiring dialysis or kidney
transplant Damage to the nerves of the body, known as diabetic neuropathy,
is the most common complication of diabetes. The symptoms can include
numbness, tingling, pain, and altered pain sensation, which can lead to damage
to the skin. Diabetes-related foot problems (such as diabetic foot ulcers) may
occur, and can be difficult to treat, occasionally requiring amputation.
Additionally, proximal diabetic neuropathy causes painful muscle wasting
and weakness.
There is a link between cognitive deficit and diabetes. Compared to those
without diabetes, those with the disease have a 1.2 to 1.5-fold greater rate of
decline in cognitive function.
The major long-term complications relate to damage to blood vessels. Diabetes
doubles the risk of cardiovascular disease and about 75% of deaths in
diabetics are due to coronary artery disease. Other "macrovascular" diseases
are stroke, and peripheral vascular disease.

The primary microvascular complications of diabetes include damage to the

eyes, kidneys, and nerves. Damage to the eyes, known as diabetic retinopathy,
is caused by damage to the blood vessels in the retina of the eye, and can result
in gradual vision loss and potentially blindness. Damage to the kidneys,
known as diabetic nephropathy, can lead to tissue scarring, urine protein loss,
and eventually chronic kidney disease, sometimes requiring dialysis or kidney
transplant Damage to the nerves of the body, known as diabetic neuropathy,
is the most common complication of diabetes. The symptoms can include
numbness, tingling, pain, and altered pain sensation, which can lead to damage
to the skin. Diabetes-related foot problems (such as diabetic foot ulcers) may
occur, and can be difficult to treat, occasionally requiring amputation.
Additionally, proximal diabetic neuropathy causes painful muscle wasting
and weakness.

There is a link between cognitive deficit and diabetes. Compared to those

without diabetes, those with the disease have a 1.2 to 1.5-fold greater rate of
decline in cognitive function.

Causes :

Diabetes mellitus is classified into four broad categories: type 1, type 2,

gestational diabetes, and "other specific types". The "other specific types"
are a collection of a few dozen individual causes. The term "diabetes",
without qualification, usually refers to diabetes mellituS
Type 1:

Type 1 diabetes mellitus is characterized by loss of the insulin-producing beta

cells of the islets of Langerhans in the pancreas, leading to insulin deficiency.
This type can be further classified as immune-mediated or idiopathic. The
majority of type 1 diabetes is of the immune-mediated nature, in which a T-
cell-mediated autoimmune attack leads to the loss of beta cells and thus
insulin. It causes approximately 10% of diabetes mellitus cases in North
America and Europe. Most affected people are otherwise healthy and of a
healthy weight when onset occurs. Sensitivity and responsiveness to insulin are
usually normal, especially in the early stages. Type 1 diabetes can affect
children or adults, but was traditionally termed "juvenile diabetes" because a
majority of these diabetes cases were in children.

"Brittle" diabetes, also known as unstable diabetes or labile diabetes, is a

term that was traditionally used to describe the dramatic and recurrent swings
in glucose levels, often occurring for no apparent reason in insulin-dependent
diabetes. This term, however, has no biologic basis and should not be used.
Still, type 1 diabetes can be accompanied by irregular and unpredictable
hyperglycemia, frequently with ketosis, and sometimes with serious
hypoglycemia. Other complications include an impaired counterregulatory
response to hypoglycemia, infection, gastroparesis (which leads to erratic
absorption of dietary carbohydrates), and endocrinopathies (e.g., Addison's
disease).. These phenomena are believed to occur no more frequently than in
1% to 2% of persons with type 1 diabetes.

Type 1 diabetes is partly inherited, with multiple genes, including certain HLA
genotypes, known to influence the risk of diabetes. In genetically susceptible
people, the onset of diabetes can be triggered by one or more environmental
factors, such as a viral infection or diet. There is some evidence that suggests
an association between type 1 diabetes and Coxsackie B4 virus. Unlike type 2
diabetes, the onset of type 1 diabetes is unrelated to lifestyle.
Type 2:

Type 2 diabetes mellitus is characterized by insulin resistance, which may be

combined with relatively reduced insulin secretion. The defective
responsiveness of body tissues to insulin is believed to involve the insulin
receptor. However, the specific defects are not known. Diabetes mellitus cases
due to a known defect are classified separately. Type 2 diabetes is the most
common type.

In the early stage of type 2, the predominant abnormality is reduced insulin

sensitivity. At this stage, hyperglycemia can be reversed by a variety of
measures and medications that improve insulin sensitivity or reduce glucose
production by the liver.

Type 2 diabetes is due primarily to lifestyle factors and genetics. A number of

lifestyle factors are known to be important to the development of type 2
diabetes, including obesity (defined by a body mass index of greater than
thirty), lack of physical activity, poor diet, stress, and urbanization. Excess
body fat is associated with 30% of cases in those of Chinese and Japanese
descent, 60-80% of cases in those of European and African descent, and 100%
of Pima Indians and Pacific Islanders. Those who are not obese often have a
high waist–hip ratio.

Dietary factors also influence the risk of developing type 2 diabetes.

Consumption of sugar-sweetened drinks in excess is associated with an
increased risk.[28][29] The type of fats in the diet is also important, with saturated
fats and trans fatty acids increasing the risk and polyunsaturated and
monounsaturated fat decreasing the risk. Eating lots of white rice appears to
also play a role in increasing risk. A lack of exercise is believed to cause 7% of
cases.

Gestational diabetes:

Gestational diabetes mellitus (GDM) resembles type 2 diabetes in several

respects, involving a combination of relatively inadequate insulin secretion and
responsiveness. It occurs in about 2-10% of all pregnancies and may improve
or disappear after delivery. However, after pregnancy approximately 5-10%
of women with gestational diabetes are found to have diabetes mellitus, most
commonly type 2. Gestational diabetes is fully treatable, but requires careful
medical supervision throughout the pregnancy. Management may include
dietary changes, blood glucose monitoring, and in some cases insulin may be
required.
Though it may be transient, untreated gestational diabetes can damage the
health of the fetus or mother. Risks to the baby include macrosomia (high birth
weight), congenital cardiac and central nervous system anomalies, and skeletal
muscle malformations. Increased fetal insulin may inhibit fetal surfactant
production and cause respiratory distress syndrome. Hyperbilirubinemia may
result from red blood cell destruction. In severe cases, perinatal death may
occur, most commonly as a result of poor placental perfusion due to vascular
impairment. Labor induction may be indicated with decreased placental
function. A Caesarean section may be performed if there is marked fetal
distress or an increased risk of injury associated with macrosomia, such as
shoulder dystocia.

Diagnosis:

Diabetes mellitus is characterized by recurrent or persistent hyperglycemia,

and is diagnosed by demonstrating any one of the following.

 Fasting plasma glucose level ≥ 7.0 mmol/l (126 mg/dl)

 Plasma glucose ≥ 11.1 mmol/l (200 mg/dl) two hours after a 75 g oral
glucose load as in a glucose tolerance test
 Symptoms of hyperglycemia and casual plasma glucose ≥ 11.1
mmol/l (200 mg/dl)
A positive result, in the absence of unequivocal hyperglycemia, should be
confirmed by a repeat of any of the above methods on a different day. It is
preferable to measure a fasting glucose level because of the ease of
measurement and the considerable time commitment of formal glucose
tolerance testing, which takes two hours to complete and offers no prognostic
advantage over the fasting test. According to the current definition, two fasting
glucose measurements above 126 mg/dl (7.0 mmol/l) is considered diagnostic
for diabetes mellitus.

Prevention:

There is no known preventive measure for type 1 diabetes. Type 2 diabetes

can often be prevented by a person being a normal body weight, physical
exercise, and following a healthy diet Dietary changes known to be
effective in helping to prevent diabetes include a diet rich in whole grains
and fiber, and choosing good fats, such as polyunsaturated fats found in
nuts, vegetable oils, and fish. Limiting sugary beverages and eating less red
meat and other sources of saturated fat can also help in the prevention of
diabetes.. Active smoking is also associated with an increased risk of
diabetes, so smoking cessation can be an important preventive measure as
well.

Management:

Diabetes mellitus is a chronic disease, for which there is no known cure except in
very specific situations. Management concentrates on keeping blood sugar
levels as close to normal ("euglycemia") as possible, without causing

hypoglycemia. This can usually be accomplished with diet, exercise, and use
of appropriate medications (insulin in the case of type 1 diabetes; oral
medications, as well as possibly insulin, in type 2 diabetes).

Learning about the disease and actively participating in the treatment

is vital for people with diabetes, since the complications of diabetes are far less
common and less severe in people who have well-managed blood sugar levels.
The goal of treatment is an HbA1C level of 6.5%, but should not be lower
than that, and may be set higher..Attention is also paid to other health problems
that may accelerate the deleterious effects of diabetes. These include smoking,
elevated cholesterol levels, obesity, high blood pressure, and lack of regular
exercise.[52] Specialised footwear is widely used to reduce the risk of ulceration,
or re-ulceration, in at-risk diabetic feet.
Evidence for the efficacy of this remains equivocal, however.

Lifestyle:

People with diabetes can benefit from education about the disease and
treatment, good nutrition to achieve a normal body weight, and sensible
exercise, with the goal of keeping both short-term and long-term blood
glucose levels within acceptable bounds. In addition, given the associated
higher risks of cardiovascular disease, lifestyle modifications are
recommended to control blood pressure

Medications:

Metformin is generally recommended as a first line treatment for type 2

diabetes, as there is good evidence that it decreases mortality. Routine use of
aspirin, however, has not been found to improve outcomes in uncomplicated
diabetes. Angiotensin converting enzyme inhibitors (ACEIs) improve
outcomes in those with DM while the similar medications angiotensin receptor
blockers (ARBs) do not.

Type 1 diabetes is typically treated with a combinations of regular and NPH

insulin, or synthetic insulin analogs. When insulin is used in type 2 diabetes, a
long-acting formulation is usually added initially, while continuing oral
medications. Doses of insulin are then increased to effect

In those with diabetes some recommend blood pressure levels below

120/80 mmHg; however, evidence only supports less than or equal to
somewhere between 140/90 mmHg to 160/100 mmHg.
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