Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels that result from defects in insulin secretion, or its action, or both. Diabetes mellitus, commonly
referred to as diabetes (as it will be in
this article) was first identified as a
disease associated with “sweet urine,” and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine.Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for example, after eating food), insulin is
released from the pancreas to normalize the glucose level. In patients with diabetes, the absence of insufficient production of, or lack of response to insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.
What is the impact of diabetes?
Over time, diabetes can lead to blindness,kidney kidney failure, and nerve damage. These types of damage are the result of damage to small vessels, referred to as micro vascular disease. Diabetes is also an important factor in accelerating the
hardening and narrowing of the arteries (atherosclerosis), leading to strokes, coronary heart disease, and other large blood vessel diseases. This is referred to as macrovascular disease. Diabetes affects approximately 26 million people in
the United States, while another 79 million have pre-diabetes. An estimated 7 million people in the United States have diabetes
and don’t even know it.
From an economic perspective, the total annual cost of diabetes in 2012 was estimated to be 245 billion dollars in the United States. This included 116 billion in
direct medical costs (healthcare costs) for people with diabetes and another 69 billion in other costs due to disability, premature death, or work loss. Medical expenses for people with diabetes are over two times higher than those for people who do not have diabetes.
Remember, these numbers reflect only the population in the United States. Globally,and the statistics are staggering. Diabetes was the 7th leading cause of death in the United States listed on death certificates
in 2007.
What causes diabetes?
Insufficient production of insulin (either
absolutely or relative to the body’s needs),
production of defective insulin (which is
uncommon), or the inability of cells to use
insulin properly and efficiently leads to
hyperglycemia and diabetes. This latter
condition affects mostly the cells of
muscle and fat tissues, and results in a
condition known as insulin resistance.
This is the primary problem in type 2
diabetes. The absolute lack of insulin,
usually secondary to a destructive process
affecting the insulin-producing beta cells
in the pancreas, is the main disorder in
type 1 diabetes. In type 2 diabetes, there
also is a steady decline of beta cells that
adds to the process of elevated blood
sugars. Essentially, if someone is
resistant to insulin, the body can, to some
degree, increase production of insulin and
overcome the level of resistance. After
time, if production decreases and insulin
cannot be released as vigorously,
hyperglycemia develops.
Glucose is a simple sugar found in food.
Glucose is an essential nutrient that
provides energy for the proper functioning
of the body cells. Carbohydrates are
broken down in the small intestine and
the glucose in digested food is then
absorbed by the intestinal cells into the
bloodstream, and is carried by the
bloodstream to all the cells in the body
where it is utilized. However, glucose
cannot enter the cells alone and needs
insulin to aid in its transport into the
cells. Without insulin, the cells become
starved of glucose energy despite the
presence of abundant glucose in the
bloodstream. In certain types of diabetes,
the cells’ inability to utilize glucose gives
rise to the ironic situation of “starvation
in the midst of plenty”. The abundant,
unutilized glucose is wastefully excreted
in the urine.
Insulin is a hormone that is produced by
specialized cells (beta cells) of the
pancreas. (The pancreas is a deep-seated
organ in the abdomen located behind the
stomach.) In addition to helping glucose
enter the cells, insulin is also important in
tightly regulating the level of glucose in
the blood. After a meal, the blood glucose
level rises. In response to the increased
glucose level, the pancreas normally
releases more insulin into the
bloodstream to help glucose enter the
cells and lower blood glucose levels after
a meal. When the blood glucose levels are
lowered, the insulin release from the
pancreas is turned down. It is important
to note that even in the fasting state
there is a low steady release of insulin
than fluctuates a bit and helps to
maintain a steady blood sugar level
during fasting. In normal individuals, such
a regulatory system helps to keep blood
glucose levels in a tightly controlled
range. As outlined above, in patients with
diabetes, the insulin is either absent,
relatively insufficient for the body’s needs,
or not used properly by the body. All of
these factors cause elevated levels of
blood glucose (hyperglycemia).
What are the different types of diabetes?
There are two major types of diabetes,
called type 1 and type 2. Type 1 diabetes
was also formerly called insulin
dependent diabetes mellitus (IDDM), or
juvenile onset diabetes mellitus. In type 1
diabetes, the pancreas undergoes an
autoimmune attack by the body itself, and
is rendered incapable of making insulin.
Abnormal antibodies have been found in
the majority of patients with type 1
diabetes. Antibodies are proteins in the
blood that are part of the body’s immune
system. The patient with type 1 diabetes
must rely on insulin medication for
survival.
Type 1 diabetes
In autoimmune diseases, such as type 1
diabetes, the immune system mistakenly
manufactures antibodies and
inflammatory cells that are directed
against and cause damage to patients’
own body tissues. In persons with type 1
diabetes, the beta cells of the pancreas,
which are responsible for insulin
production, are attacked by the
misdirected immune system. It is believed
that the tendency to develop abnormal
antibodies in type 1 diabetes is, in part,
genetically inherited, though the details
are not fully understood.
Exposure to certain viral infections
(mumps and Coxsackie viruses) or other
environmental toxins may serve to trigger
abnormal antibody responses that cause
damage to the pancreas cells where
insulin is made. Some of the antibodies
seen in type 1 diabetes include anti-islet
cell antibodies, anti-insulin antibodies and
anti-glutamic decarboxylase antibodies.
These antibodies can be detected in the
majority of patients, and may help
determine which individuals are at risk for
developing type 1 diabetes.
At present, the American Diabetes
Association does not recommend general
screening of the population for type 1
diabetes, though screening of high risk
individuals, such as those with a first
degree relative (sibling or parent) with
type 1 diabetes should be encouraged.
Type 1 diabetes tends to occur in young,
lean individuals, usually before 30 years
of age, however, older patients do present
with this form of diabetes on occasion.
This subgroup is referred to as latent
autoimmune diabetes in adults (LADA).
LADA is a slow, progressive form of type
1 diabetes. Of all the people with
diabetes, only approximately 10% have
type 1 diabetes and the remaining 90%
have type 2 diabetes.
Type 2 diabetes
Type 2 diabetes was also previously
referred to as non-insulin dependent
diabetes mellitus (NIDDM), or adult onset
diabetes mellitus (AODM). In type 2
diabetes, patients can still produce
insulin, but do so relatively inadequately
for their body’s needs, particularly in the
face of insulin resistance as discussed
above. In many cases this actually means
the pancreas produces larger than normal
quantities of insulin. A major feature of
type 2 diabetes is a lack of sensitivity to
insulin by the cells of the body
(particularly fat and muscle cells).
In addition to the problems with an
increase in insulin resistance, the release
of insulin by the pancreas may also be
defective and suboptimal. In fact, there is
a known steady decline in beta cell
production of insulin in type 2 diabetes
that contributes to worsening glucose
control. (This is a major factor for many
patients with type 2 diabetes who
ultimately require insulin therapy.) Finally,
the liver in these patients continues to
produce glucose through a process called
gluconeogenesis despite elevated glucose
levels. The control of gluconeogenesis
becomes compromised.
While it is said that type 2 diabetes
occurs mostly in individuals over 30 years
old and the incidence increases with age,
we are seeing an alarming number
patients with type 2 diabetes who are
barely in their teen years. Most of these
cases are a direct result of poor eating
habits, higher body weight, and lack of
exercise.
While there is a strong genetic component
to developing this form of diabetes, there
are other risk factors – the most
significant of which is obesity. There is a
direct relationship between the degree of
obesity and the risk of developing type 2
diabetes, and this holds true in children
as well as adults. It is estimated that the
chance to develop diabetes doubles for
every 20% increase over desirable body
weight.
Regarding age, data shows that for each
decade after 40 years of age regardless of
weight there is an increase in incidence of
diabetes. The prevalence of diabetes in
persons 65 years of age and older is
around 27%. Type 2 diabetes is also more
common in certain ethnic groups.
Compared with a 7% prevalence in non-
Hispanic Caucasians, the prevalence in
Asian Americans is estimated to be 8%, in
Hispanics 12%, in blacks around 13%, and
in certain Native American communities
20% to 50%. Finally, diabetes occurs
much more frequently in women with a
prior history of diabetes that develops
during pregnancy.
Other types of diabetes
Diabetes can occur temporarily during
pregnancy, and reports suggest that it
occurs in 2% to 10% of all pregnancies.
Significant hormonal changes during
pregnancy can lead to blood sugar
elevation in genetically predisposed
individuals. Blood sugar elevation during
pregnancy is called gestational diabetes.
Gestational diabetes usually resolves once
the baby is born. However, 35% to 60% of
women with gestational diabetes will
eventually develop type 2 diabetes over
the next 10 to 20 years, especially in
those who require insulin during
pregnancy and those who remain
overweight after their delivery. Patients
with gestational diabetes are usually
asked to undergo an oral glucose
tolerance test about six weeks after giving
birth to determine if their diabetes has
persisted beyond the pregnancy, or if any
evidence (such as impaired glucose
tolerance) is present that may be a clue to
the patient’s future risk for developing
diabetes.
“Secondary” diabetes refers to elevated
blood sugar levels from another medical
condition. Secondary diabetes may
develop when the pancreatic tissue
responsible for the production of insulin
is destroyed by disease, such as chronic
pancreatitis (inflammation of the
pancreas by toxins like excessive alcohol),
trauma, or surgical removal of the
pancreas.
Diabetes can also result from other
hormonal disturbances, such as excessive
growth hormone production (acromegaly)
and Cushing’s syndrome. In acromegaly, a
pituitary gland tumor at the base of the
brain causes excessive production of
growth hormone, leading to
hyperglycemia. In Cushing’s syndrome,
the adrenal glands produce an excess of
cortisol, which promotes blood sugar
elevation.
In addition, certain medications may
worsen diabetes control, or “unmask”
latent diabetes. This is seen most
commonly when steroid medications (such
as prednisone) are taken and also with
medications used in the treatment of HIV
infection (AIDS).
What are diabetes symptoms?
• The early symptoms of untreated
diabetes are related to elevated blood
sugar levels, and loss of glucose in the
urine. High amounts of glucose in the
urine can cause increased urine output
and lead to dehydration. Dehydration
causes increased thirst and water
consumption.
• The inability of insulin to perform
normally has effects on protein, fat and
carbohydrate metabolism. Insulin is an
anabolic hormone, that is, one that
encourages storage of fat and protein.
• A relative or absolute insulin deficiency
eventually leads to weight loss despite an increase in appetite.
• Some untreated diabetes patients also
complain of fatigue, nausea and vomiting.
• Patients with diabetes are prone to
developing infections of the bladder, skin, and vaginal areas.
• Fluctuations in blood glucose levels can lead to blurred vision. Extremely elevated glucose levels can lead to lethargy and coma.
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