DIABETES MELLITUS
Diabetes mellitus, or simply diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst), and polyphagia (increased hunger).DIABETES MELLITUS TYPE 1
Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar (glucose) to enter cells to produce energy. The far more common type 2 diabetes occurs when the body becomes resistant to the effects of insulin or doesn't make enough insulin.Various factors may contribute to type 1 diabetes, including genetics and exposure to certain viruses. Although type 1 diabetes typically appears during childhood or adolescence, it also can develop in adults.
Despite active research, type 1 diabetes has no cure, although it can be managed. With proper treatment, people who have type 1 diabetes can expect to live longer, healthier lives than they did in the past.
Signs and symptoms
The most common symptoms of type 1 diabetes mellitus (DM) are polyuria, polydipsia, and polyphagia, along with lassitude, nausea, and blurred vision, all of which result from the hyperglycemia itself.Polyuria is caused by osmotic diuresis secondary to hyperglycemia. Severe nocturnal enuresis secondary to polyuria can be an indication of onset of diabetes in young children. Thirst is a response to the hyperosmolar state and dehydration.
Fatigue and weakness may be caused by muscle wasting from the catabolic state of insulin deficiency, hypovolemia, and hypokalemia. Muscle cramps are caused by electrolyte imbalance. Blurred vision results from the effect of the hyperosmolar state on the lens and vitreous humor. Glucose and its metabolites cause osmotic swelling of the lens, altering its normal focal length.
Symptoms at the time of the first clinical presentation can usually be traced back several days to several weeks. However, beta-cell destruction may have started months, or even years, before the onset of clinical symptoms.
The onset of symptomatic disease may be sudden. It is not unusual for patients with type 1 DM to present with diabetic ketoacidosis (DKA), which may occur de novo or secondary to the stress of
illness or surgery. An explosive onset of symptoms in a young lean patient with ketoacidosis always has been considered diagnostic of type 1 DM.
Over time, patients with new-onset type 1 DM will lose weight, despite normal or increased appetite, because of depletion of water and a catabolic state with reduced glycogen, proteins, and triglycerides. Weight loss may not occur if treatment is initiated promptly after the onset of the disease.
Gastrointestinal (GI) symptoms of type 1 DM are as follows:
• Nausea, abdominal discomfort or pain, and change in bowel movements may accompany acute DKA
• Acute fatty liver may lead to distention of the hepatic capsule, causing right upper quadrant pain
• Persistent abdominal pain may indicate another serious abdominal cause of DKA (eg, pancreatitis
• Chronic GI symptoms in the later stage of DM are caused by visceral autonomic neuropathy
Neuropathy affects up to 50% of patients with type 1 DM, but symptomatic neuropathy is typically a late development, developing after many years of chronic prolonged hyperglycemia. Peripheral neuropathy presents as numbness and tingling in both hands and feet, in a glove-and-stocking pattern; it is bilateral, symmetric, and ascending.
Causes
Type 1 diabetes can occur at any age. It is most often diagnosed in children, adolescents, or young adults.Insulin is a hormone produced in the pancreas by special cells, called beta cells. The pancreas is behind the stomach. Insulin is needed to move blood sugar (glucose) into cells. There, it is stored and later used for energy. In type 1 diabetes, beta cells produce little or no insulin.
Without enough insulin, glucose builds up in the bloodstream instead of going into the cells. The body is unable to use this glucose for energy. This leads to the symptoms of type 1 diabetes.
The exact cause of type 1 diabetes is unknown. Most likely it is an autoimmune disorder. This is a condition that occurs when the immune system mistakenly attacks and destroys healthy body tissue. With type 1 diabetes, an infection or another trigger causes the body to mistakenly attack the cells in the pancreas that make insulin. Type 1 diabetes can be passed down through families.
Risk factors
There aren't many known risk factors for type 1 diabetes, though researchers continue to find new possibilities. Some known risk factors include:• A family history. Anyone with a parent or sibling with type 1 diabetes has a slightly increased risk of developing the condition.
• Genetics. The presence of certain genes indicates an increased risk of developing type 1 diabetes. In some cases — usually through a clinical trial — genetic testing can be done to determine if someone who has a family history of type 1 diabetes is at increased risk of developing the condition.
• Geography. The incidence of type 1 diabetes tends to increase as you travel away from the equator. People living in Finland and Sardinia have the highest incidence of type 1 diabetes — about two to three times higher than rates in the United States and 400 times that of people living in Venezuela.
Possible risk factors for type 1 diabetes include:
• Viral exposure. Exposure to Epstein-Barr virus, coxsackievirus, mumps virus or cytomegalovirus may trigger the autoimmune destruction of the islet cells, or the virus may directly infect the islet cells.
• Early vitamin D. Research suggests that vitamin D may be protective against type 1 diabetes. However, early drinking of cow's milk — a common source of vitamin D — has been linked to an increased risk of type 1 diabetes.
• Other dietary factors. Omega-3 fatty acids may offer some protection against type 1 diabetes. Drinking water that contains nitrates may increase the risk. Consuming dairy products, particularly cow's milk, may increase infants' risk of the disease. Additionally, the timing of the introduction of cereal into a baby's diet may affect risk. One clinical trial found that between ages 3 and 7 months appears to be the optimal time for introducing cereal.
Some other possible risk factors include:
• Having a mother younger than age 25 when she gave birth to you.
• Having a mother who had preeclampsia during pregnancy.
• Being born with jaundice.
• Having a respiratory infection just after birth.
Complications
Type 1 diabetes can affect major organs in your body, including heart, blood vessels, nerves, eyes and kidneys. Keeping your blood sugar level close to normal most of the time can dramatically reduce the risk of many complications. Long-term complications of type 1 diabetes develop gradually, over years. The earlier you develop diabetes — and the less controlled your blood sugar — the higher the risk of complications.Eventually, diabetes complications may be disabling or even life-threatening.
• Heart and blood vessel disease. Diabetes dramatically increases your risk of various cardiovascular problems, including coronary artery disease with chest pain (angina), heart attack, stroke, narrowing of the arteries (atherosclerosis) and high blood pressure.
• Nerve damage (neuropathy). Excess sugar can injure the walls of the tiny blood vessels (capillaries) that nourish your nerves, especially in the legs. This can cause tingling, numbness, burning or pain that usually begins at the tips of the toes or fingers and gradually spreads upward. Poorly controlled blood sugar could cause you to eventually lose all sense of feeling in the affected limbs. Damage to the nerves that affect the gastrointestinal tract can cause problems with nausea, vomiting, diarrhea or constipation. For men, erectile dysfunction may be an issue.
• Kidney damage (nephropathy). The kidneys contain millions of tiny blood vessel clusters that filter waste from your blood. Diabetes can damage this delicate filtering system. Severe damage can lead to kidney failure or irreversible end-stage kidney disease, which requires dialysis or a kidney transplant.
• Eye damage. Diabetes can damage the blood vessels of the retina (diabetic retinopathy), potentially leading to blindness. Diabetes also increases the risk of other serious vision conditions, such as cataracts and glaucoma.
• Foot damage. Nerve damage in the feet or poor blood flow to the feet increases the risk of various foot complications. Left untreated, cuts and blisters can become serious infections. Severe damage might require toe, foot or even leg amputation.
• Skin and mouth conditions. Diabetes may leave you more susceptible to skin problems, including bacterial and fungal infections. Gum infections also may be a concern, especially if you have a history of poor dental hygiene.
• Osteoporosis. Diabetes may lead to lower than normal bone mineral density, increasing your risk of osteoporosis.
• Pregnancy complications. High blood sugar levels can be dangerous for both the mother and the baby. The risk of miscarriage, stillbirth and birth defects are increased when diabetes isn't well controlled. For the mother, diabetes increases the risk of diabetic ketoacidosis, diabetic eye problems (retinopathy), pregnancy-induced high blood pressure and preeclampsia.
• Hearing problems. Hearing impairments occur more often in people with diabetes.
TEST AND DIAGNOSIS
• Glycated hemoglobin (A1C) test. This blood test indicates your average blood sugar level for the past two to three months. It works by measuring the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level of 6.5 percent or higher on two separate tests indicates you have diabetes.• Random blood sugar test. A blood sample will be taken at a random time. Blood sugar values are expressed in milligrams per deciliter (mg/dL) or millimoles per liter (mmol/L). Regardless of when you last ate, a random blood sugar level of 200 mg/dL (11.1 mmol/L) or higher suggests diabetes, especially when coupled with any of the signs and symptoms of diabetes, such as frequent urination and extreme thirst.
• Fasting blood sugar test. A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, you have diabetes.
If you're diagnosed with diabetes, your doctor will also run blood tests to check for autoantibodies that are common in type 1 diabetes. These tests help your doctor distinguish between type 1 and type 2 diabetes. The presence of ketones — byproducts from the breakdown of fat — in your urine also suggests type 1 diabetes, rather than type 2.
Treatment for adults
Type 1 diabetes requires lifelong treatment to keep blood sugar levels within a target range.• Taking several insulin injections every day or using an insulin pump.
• Monitoring blood sugar levels several times a day using a home blood sugar meter.
• Eating a healthful diet that spreads carbohydrate throughout the day, to prevent high blood sugar levels after meals.
• Regular physical activity or exercise, because exercise helps the body to use insulin more efficiently. Exercise may also lower your risk for heart and blood vessel disease.
• Regular medical checkups to monitor and adjust treatment as needed. Screening tests and exams need to be done regularly to watch for signs of complications, such as eye, kidney, heart, blood vessel, and nerve diseases.
• Not smoking.
• Not drinking alcohol if the person is at risk for periods of low blood sugar.
Treatment for children
Treatment for children includes all of the above measures to keep blood sugar levels within the child's target range. Treatment for children should also allow for normal growth and development.Type 2 Diabetes
Type 2 diabetes is previously known as Noninsulin-dependent diabetes and Adult-onset diabetesType 2 diabetes is a lifelong (chronic) disease in which there is a high level of sugar (glucose) in the blood. Type 2 diabetes is the most common form of diabetes.
Causes
Insulin is a hormone produced in the pancreas by special cells, called beta cells. The pancreas is behind the stomach. Insulin is needed to move blood sugar (glucose) into cells. There, it is stored and later used for energy. When you have type 2 diabetes, your fat, liver, and muscle cells do not respond correctly to insulin. This is called insulin resistance. As a result, blood sugar does not get into these cells to be stored for energy. When sugar cannot enter cells, a high level of sugar builds up in the blood. This is called hyperglycemia.Type 2 diabetes usually occurs slowly over time. Most people with the disease are overweight when they are diagnosed. Increased fat makes it harder for your body to use insulin the correct way.
Type 2 diabetes can also develop in people who are thin. This is more common in the elderly. Family history and genes play a role in type 2 diabetes. Low activity level, poor diet, and excess body weight around the waist increase your chance of getting the disease.
Symptoms
People with type 2 diabetes often have no symptoms at first. They may not have symptoms for many years.Early symptoms of diabetes may include:
• Bladder, kidney, skin, or other infections that are more frequent or heal slowly
• Fatigue
• Hunger
• Increased thirst • Increased urination
The first symptom may also be:
• Blurred vision • Erectile dysfunction
• Pain or numbness in the feet or hands
Exams and Tests
You will be suspected to have diabetes if blood sugar level is higher than 200 mg/dL. To confirm the diagnosis, one or more of the following tests must be done.Diabetes blood tests:
• Fasting blood glucose level -- diabetes is diagnosed if it is higher than 126 mg/dL two times
• Hemoglobin A1C test -- Diabetes: 6.5% or higher
• Oral glucose tolerance test -- diabetes is diagnosed if glucose level is higher than 200 mg/dL 2 hours after drinking a special sugar drink
Diabetes screening is recommended for:
• Overweight children who have other risk factors for diabetes, starting at age 10 and repeated every 2 years
• Overweight adults (BMI greater than 25) who have other risk factors
• Adults over age 45 every 3 years
If you have been diagnosed with type 2 diabetes, you need to work closely with your health care provider.
You will likely need to see your provider every 3 months. At these visits, you can expect your provider to do the following:
• Check your blood pressure
• Check the skin and bones on your feet and legs
• Check if your feet are becoming numb
• Examine the back part of the eye with a special lighted instrument
The following tests will help you and your doctor monitor your diabetes and prevent problems:
• Have your blood pressure checked at least every year (blood pressure goals should be 140/80 mm/Hg or lower).
• Have your A1C test (hemoglobin A1C) every 6 months if your diabetes is well controlled; otherwise every 3 months.
• Have your cholesterol and triglyceride levels checked yearly (aim for LDL levels below 70-100 mg/dL).
• Get yearly tests to make sure your kidneys are working well (microalbuminuria and serum creatinine).
• Visit your eye doctor at least once a year, or more often if you have signs of diabetic eye disease.
• See the dentist every 6 months for a thorough dental cleaning and exam. Make sure your dentist and hygienist know that you have diabetes.
Treatment
The goal of treatment at first is to lower your high blood glucose levels. Long-term goals are to prevent problems from diabetes.The most important way to treat and manage type 2 diabetes is activity and nutrition.
LEARN THESE SKILLS
Learning diabetes management skills will help you live well with diabetes. These skills help prevent health problems and the need for medical care. Skills include:
• How to test and record your blood glucose
• What to eat and when
• How to take medications, if needed
• How to recognize and treat low and high blood sugar
• How to handle sick days
• Where to buy diabetes supplies and how to store them
It may take several months to learn these skills. Keep learning about diabetes, its complications, and how to control and live with the disease. Stay up-to-date on new research and treatments. MANAGING YOUR BLOOD SUGAR
Checking your blood sugar levels yourself and writing down the results tells you how well you are managing your diabetes. Talk to your doctor and diabetes educator about how often to check.
To check your blood sugar level, you use a device called a glucose meter. Usually, you prick your finger with a small needle called a lancet. This gives you a tiny drop of blood. You place the blood on a test strip and put the strip into the meter. The meter gives you a reading that tells you the level of your blood sugar.
Your health care provider or diabetes educator will help set up a testing schedule for you. Your doctor will help you set a target range for your blood sugar numbers. Keep these factors in mind:
• Most people with type 2 diabetes only need to check their blood sugar once or twice a day.
• If your blood sugar level is under control, you may only need to check it a few times a week.
• You may test yourself when you wake up, before meals, and at bedtime.
• You may need to test more often when you are sick or under stress.
Keep a record of your blood sugar for yourself and your health care provider. Based on your numbers, changes may need to be made to your meals, activity or medicines to keep your blood sugar level in the right range.
DIET AND WEIGHT CONTROL
Work closely with your doctor, nurse, and dietitian to learn how much fat, protein, and carbohydrates you need in your diet. Your meal plans should fit your lifestyle and habits and should include foods that you like.Managing your weight and having a well-balanced diet are important. Some people with type 2 diabetes can stop taking medicines after losing weight. This does not mean that their diabetes is cured. They still have diabetes.
Very obese patients whose diabetes is not well managed with diet and medicine may consider weight loss (bariatric) surgery.
REGULAR PHYSICAL ACTIVITY Regular activity is important for everyone. It is even more important when you have diabetes. Reasons why exercise is good for your health:
• Lowers your blood sugar level without medicine
• Burns extra calories and fat to help manage your weight
• Improves blood flow and blood pressure
• Increases your energy level
• Improves your ability to handle stress
Talk to your health care provider before starting any exercise program. People with type 2 diabetes may need to take special steps before, during, and after physical activity or exercise.
MEDICATIONS TO TREAT DIABETES
If diet and exercise do not help keep your blood sugar at normal or near-normal levels, your doctor may prescribe medication. Since these drugs help lower your blood sugar levels in different ways, your doctor may have you take more than one drug.
Some of the most common types of medication are listed below. They are taken by mouth or injection.
• Alpha-glucosidase inhibitors
• Biguanides
• DPP IV inhibitors
• Injectable medicines
• Meglitinides
• Sulfonylureas
• Thiazolidinediones
You may need to take insulin if your blood sugar cannot be controlled with any of the above medicines. Insulin must be injected under the skin using a syringe, insulin pen, or pump. It cannot be taken by mouth because the acid in the stomach destroys insulin.
PREVENTING COMPLICATIONS
Your doctor may prescribe medicines or other treatments to reduce your chance of developing eye disease, kidney disease, and other conditions that are common in people with diabetes. These conditions are called complications of diabetes.FOOT CARE
People with diabetes are more likely than those without diabetes to have foot problems. Diabetes damages the nerves. This can make you less able to feel pressure on the foot. You many not notice a foot injury until you get a severe infection.
Diabetes can also damage blood vessels. Small sores or breaks in the skin may become deeper skin sores (ulcers). The affected limb may need to be amputated if these skin ulcers do not heal or become larger, deeper or infected.
To prevent problems with your feet:
• Stop smoking if you smoke.
• Improve control of your blood sugar.
• Get a foot exam by your health care provider at least twice a year and learn if you have nerve damage.
• Check and care for your feet every day. This is very important when you already have nerve or blood vessel damage or foot problems.
• Make sure you wear the right kind of shoes. Ask your health care provider what is right for you.
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Outlook (Prognosis)
Diabetes is a lifelong disease and there is no cure.Some people with type 2 diabetes no longer need medicine if they lose weight and become more active. When they reach their ideal weight, their body's own insulin and a healthy diet can control their blood sugar level.
Possible Complications
After many years, diabetes can lead to serious problems:• could have eye problems, including trouble seeing (especially at night), and light sensitivity and can lead to blindness.
• feet and skin can develop sores and infections. After a long time, your foot or leg may need to be amputated. Infection can also cause pain and itching in other parts of the body.
• Diabetes may make it harder to control your blood pressure and cholesterol. This can lead to a heart attack, stroke, and other problems. It can become harder for blood to flow to your legs and feet. • Nerves in body can get damaged, causing pain, tingling, and numbness.
• have problems digesting the food you eat because of the nerve damage. One could feel weakness or have trouble going to the bathroom. Nerve damage can make it harder for men to have an erection.
• High blood sugar and other problems can lead to kidney damage. The kidneys may not work as well as they used to. They may even stop working so that you need dialysis or a kidney transplant.
When to Contact a Medical Professional
• Chest pain or pressure
• Fainting or unconsciousness
• Seizure
• Shortness of breath
These symptoms can quickly get worse and become emergency conditions (such as convulsions or hypoglycemic coma).
Also call doctor if any of this signs occur :
• Numbness, tingling, or pain in your feet or legs
• Problems with your eyesight
• Sores or infections on your feet
• Symptoms of high blood sugar (being very thirsty, having blurry vision, having dry skin, feeling weak or tired, needing to urinate a lot)
• Symptoms of low blood sugar (feeling weak or tired, trembling, sweating, feeling irritable, having trouble thinking clearly, fast heartbeat, double or blurry vision, feeling uneasy)
