Diabetes Mellitus

Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst, and hunger. Treatment can include changes in diet, oral medications, and daily injections of insulin, especially with type 1 diabetes.

Diabetes mellitus is a chronic disease that causes serious health complications including renal (kidney) failure, heart disease, stroke, and blindness. Approximately 17 million Americans have diabetes. Unfortunately, as many as one-half are unaware they have it, and rates are expected to continue to increase due to the high prevalence of obesity in the United States.

Every cell in the human body needs energy in order to function. The body's primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches).

Glucose from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin binds to a receptor site on the outside of a cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of the glucose can be converted to concentrated energy sources like glycogen or fatty acids and saved for later use. When there is not enough insulin produced or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather entering the cells.

The body will attempt to dilute the high level of glucose in the blood, a condition called hyperglycemia, by drawing water out of the cells and into the bloodstream in an effort to dilute the sugar and excrete it in the urine. It is not unusual for people with undiagnosed diabetes to be constantly thirsty, drink large quantities of water, and urinate frequently as their bodies try to get rid of the extra glucose. This creates high levels of glucose in the urine.

At the same time that the body is trying to get rid of glucose from the blood, the cells are starving for glucose and sending signals to the body to eat more food, thus making patients extremely hungry. To provide energy for the starving cells, the body also tries to convert fats and proteins to glucose. The breakdown of fats and proteins for energy causes acid compounds called ketones to form in the blood. Ketones also will be excreted in the urine. As ketones build up in the blood, a condition called ketoacidosis can occur. This condition can be life threatening if left untreated, leading to coma and death.

Type 1 diabetes, sometimes called juvenile diabetes, begins most commonly in childhood or adolescence. In this form of diabetes, the body produces little or no insulin. It is characterized by a sudden onset and occurs more frequently in populations descended from Northern European countries (Finland, Scotland, Scandinavia) than in those from Southern European countries, the Middle East, or Asia. In the United States, approximately three people in 1,000 develop type 1 diabetes. This form is also called insulin-dependent diabetes because people who develop this type need to have daily injections of insulin.

The more common form of diabetes, type 2, occurs in approximately 3%–5% of Americans under 50 years of age, and increases to 10%–15% in those over 50. More than 90% of people with diabetes in the United States have type 2. Sometimes called age-onset or adult-onset diabetes, this form of diabetes occurs most often in people who are overweight and who do not exercise. It is also more common in people of Native American, Hispanic, and African-American descent. People who have migrated to Western cultures from East India, Japan, and Australian Aboriginal cultures also are more likely to develop type 2 diabetes than those who remain in their original countries.

Type 2 is considered a milder form of diabetes because of its slow onset (sometimes developing over the course of several years) and because it usually can be controlled with diet and oral medication. The consequences of uncontrolled and untreated type 2 diabetes, however, are just as serious as those for type 1. This form is also called noninsulin-dependent diabetes, a term that is somewhat misleading. Many people with type 2 diabetes can control the condition with diet and oral medications, however, insulin injections are sometimes necessary if treatment with diet and oral medication is not working.

Another form of diabetes called gestational diabetes can develop during pregnancy and generally resolves after the baby is delivered. This diabetic condition develops during the second or third trimester of pregnancy in about 2% of pregnancies. In 2004, incidence of gestational diabetes was reported to have increased 35% in 10 years. Children of women with gestational diabetes are more likely to be born prematurely, have hypoglycemia, or have severe jaundice at birth. The condition usually is treated by diet, however, insulin injections may be required. These women who have diabetes during pregnancy are at higher risk for developing type 2 diabetes within 5–10 years.

Diabetes also can develop as a result of pancreatic disease, alcoholism, malnutrition, or other severe illnesses that stress the body.

While the causes of diabetes mellitus are unclear, there seem to be both hereditary (genetic factors passed on in families) and environmental factors involved. Research has shown that some people who develop diabetes have common genetic markers. In type 1 diabetes, the immune system, the body's defense system against infection, is believed to be triggered by a virus or another microorganism that destroys cells in the pancreas that produce insulin. In type 2 diabetes, age, obesity, and family history of diabetes play a role.

In type 2 diabetes, the pancreas may produce enough insulin, however, cells have become resistant to the insulin produced and it may not work as effectively. Symptoms of type 2 diabetes can begin so gradually that a person may not know that he or she has it. Early signs are lethargy, extreme thirst, and frequent urination. Other symptoms may include sudden weight loss, slow wound healing, urinary tract infections, gum disease, or blurred vision. It is not unusual for type 2 diabetes to be detected while a patient is seeing a doctor about another health concern that is actually being caused by the yet undiagnosed diabetes.

Individuals who are at high risk of developing type 2 diabetes mellitus include people who:

Several common medications can impair the body's use of insulin, causing a condition known as secondary diabetes. These medications include treatments for high blood pressure (furosemide, clonidine, and thiazide diuretics), drugs with hormonal activity (oral contraceptives, thyroid hormone, progestins, and glucocorticoids), and the anti-inflammation drug indomethacin. Several drugs that are used to treat mood disorders (such as anxiety and depression) also can impair glucose absorption. These drugs include haloperidol, lithium carbonate, phenothiazines, tricyclic antidepressants, and adrenergic agonists. Other medications that can cause diabetes symptoms include isoniazid, nicotinic acid, cimetidine, and heparin. A 2004 study found that low levels of the essential mineral chromium in the body may be linked to increased risk for diseases associated with insulin resistance.

Symptoms of diabetes can develop suddenly (over days or weeks) in previously healthy children or adolescents, or can develop gradually (over several years) in overweight adults over the age of 40. The classic symptoms include feeling tired and sick, frequent urination, excessive thirst, excessive hunger, and weight loss.

Ketoacidosis, a condition due to starvation or uncontrolled diabetes, is common in type 1 diabetes. Ketones are acid compounds that form in the blood when the body breaks down fats and proteins. Symptoms include abdominal pain, vomiting, rapid breathing, extreme lethargy, and drowsiness. Patients with ketoacidosis will also have a sweet breath odor. Left untreated, this condition can lead to coma and death.

With type 2 diabetes, the condition may not become evident until the patient presents for medical treatment for some other condition. A patient may have heart disease, chronic infections of the gums and urinary tract, blurred vision, numbness in the feet and legs, or slow-healing wounds. Women may experience genital itching.

Diabetes is suspected based on symptoms. Urine tests and blood tests can be used to confirm a diagnose of diabetes based on the amount of glucose found. Urine tests can also detect ketones and protein that may help diagnose diabetes and assess how well the kidneys are functioning. These tests also can be used to monitor the disease once the patient is on a standardized diet, oral medications, or insulin.

Clinistix and Diastix are paper strips or dipsticks that change color when dipped in urine. The test strip is compared to a chart that shows the amount of glucose in the urine based on the change in color. The level of glucose in the urine lags behind the level of glucose in the blood. Testing the urine with a test stick, paper strip, or tablet that changes color when sugar is present is not as accurate as blood testing, however it can give a fast and simple reading.

Ketones in the urine can be detected using similar types of dipstick tests (Acetest or Ketostix). Ketoacidosis can be a life-threatening situation, so having a quick and simple test to detect ketones can assist in establishing a diagnosis sooner.

Another dipstick test can determine the presence of protein or albumin in the urine. Protein in the urine can indicate problems with kidney function and can be used to track the development of renal failure. A more sensitive test for urine protein uses radioactively tagged chemicals to detect microalbuminuria, small amounts of protein in the urine, that may not show up on dipstick tests.

FASTING GLUCOSE TEST. Blood is drawn from a vein in the patient's arm after a period at least eight hours when the patient has not eaten, usually in the morning before breakfast. The red blood cells are separated from the sample and the amount of glucose is measured in the remaining plasma. A plasma level of 7.8 mmol/L (200 mg/L) or greater can indicate diabetes. The fasting glucose test is usually repeated on another day to confirm the results.

POSTPRANDIAL GLUCOSE TEST. Blood is taken right after the patient has eaten a meal.

ORAL GLUCOSE TOLERANCE TEST. Blood samples are taken from a vein before and after a patient drinks a thick, sweet syrup of glucose and other sugars. In a non-diabetic, the level of glucose in the blood goes up immediately after the drink and then decreases gradually as insulin is used by the body to metabolize, or absorb, the sugar. In a diabetic, the glucose in the blood goes up and stays high after drinking the sweetened liquid. A plasma glucose level of 11.1 mmol/L (200 mg/dL) or higher at two hours after drinking the syrup and at one other point during the two-hour test period confirms the diagnosis of diabetes.

A diagnosis of diabetes is confirmed if there are symptoms of diabetes and a plasma glucose level of at least 11.1 mmol/L, a fasting plasma glucose level of at least 7.8 mmol/L, or a two-hour plasma glucose level of at least 11.1 mmol/L during an oral glucose tolerance test.

Home blood glucose monitoring kits are available so patients with diabetes can monitor their own levels. A small needle or lancet is used to prick the finger and a drop of blood is collected and analyzed by a monitoring device. Some patients may test their blood glucose levels several times during a day and use this information to adjust their doses of insulin.

Diet and moderate exercise are the first treatments implemented in diabetes. For many people with type 2 diabetes, weight loss may be an important goal in helping them to control their diabetes. A well-balanced, nutritious diet provides approximately 50%–60% of calories from carbohydrates, approximately 10%– 20% of calories from protein, and less than 30% of calories from fat. The number of calories required by an individual depends on age, weight, and activity level. The calorie intake also needs to be distributed over the course of the entire day so surges of glucose entering the blood system are kept to a minimum.

Keeping track of the number of calories provided by different foods can become complicated, so patients usually are advised to consult a nutritionist or dietitian. An individualized, easy to manage diet plan can be set up for each patient. Both the American Diabetes Association and the Academy of Nutrition and Dietetics recommend diets based on the use of food exchange lists. Each food exchange contains a known amount of calories in the form of protein, fat, or carbohydrate. A patient's diet plan will consist of a certain number of exchanges from each food category (meat or protein, fruits, breads and starches, vegetables, and fats) to be eaten at meal times and as snacks. Patients have flexibility in choosing which foods they eat as long as they stick with the number of exchanges prescribed.

Oral medications are available to lower blood glucose in people with type 2 diabetes. In 1990, 23.4 million outpatient prescriptions for oral antidiabetic agents were dispensed. By 2001, the number had increased to 91.8 million prescriptions. Oral antidiabetic agents accounted for more than $5 billion dollars in worldwide retail sales per year in the early twenty-first century and were the fastest-growing segment of diabetes drugs. The drugs first prescribed for type 2 diabetes are in a class of compounds called sulfonylureas and include tolbutamide, tolazamide, acetohexamide, and chlorpropamide. Newer drugs in the same class are now available and include glyburide, glimepiride, and glipizide. How these drugs work is not well understood, however, they seem to stimulate cells of the pancreas to produce more insulin. New medications that are available to treat diabetes include metformin, acarbose, and troglitazone. The choice of medication depends in part on the individual patient profile. All drugs have side effects that may make them inappropriate for particular patients. Some, for example, may stimulate weight gain or cause stomach irritation, so they may not be the best treatment for someone who is already overweight or who has stomach ulcers. Others, like metformin, have been shown to have positive effects such as reduced cardiovascular mortality, but increased risk in other situations. While these medications are an important aspect of treatment for type 2 diabetes, they are not a substitute for a well planned diet and moderate exercise. Oral medications have not been shown effective for type 1 diabetes, in which the patient produces little or no insulin.

Constant advances are being made in development of new oral medications for people with diabetes. In 2003, a drug called Metaglip combining glipizide and metformin was approved in a single tablet. Along with diet and exercise, the drug was used as initial therapy for type 2 diabetes. Another drug approved by the U.S. Food and Drug Administration (FDA) combines metformin and rosiglitazone (Avandia), a medication that increases muscle cells' sensitivity to insulin. It is marketed under the name Avandamet. So many new drugs are under development that it is best to stay in touch with a physician for the latest information; physicians can find the best drug, diet, and exercise program to fit an individual patient's need.

Patients with type 1 diabetes need daily injections of insulin to help their bodies use glucose. The amount and type of insulin required depends on the height, weight, age, food intake, and activity level of the individual diabetic patient. Some patients with type 2 diabetes may need to use insulin injections if their diabetes cannot be controlled with diet, exercise, and oral medication. Injections are given subcutaneously, that is, just under the skin, using a small needle and syringe. Injection sites can be anywhere on the body where there is looser skin, including the upper arm, abdomen, or upper thigh.

Regular insulin is fast-acting and starts to work within 15–30 minutes, with its peak glucose-lowering effect about two hours after it is injected. Its effects last for about four to six hours. NPH (neutral protamine Hagedorn) and Lente insulin are intermediate-acting, starting to work within one to three hours and lasting up to 18–26 hours. Ultra-lente is a long-acting form of insulin that starts to work within four to eight hours and lasts 28–36 hours.

Hypoglycemia, or low blood sugar, can be caused by too much insulin, too little food (or eating too late to coincide with the action of the insulin), alcohol consumption, or increased exercise. A patient with symptoms of hypoglycemia may be hungry, cranky, confused, and tired. The patient may become sweaty and shaky. Left untreated, the patient can lose consciousness or have a seizure. This condition is sometimes called an insulin reaction and should be treated by giving the patient something sweet to eat or drink like a candy, sugar cubes, juice, or another high sugar snack.

Transplantation of a healthy pancreas into a diabetic patient is a successful treatment, however, this transplant is usually done only if a kidney transplant is performed at the same time. Although a pancreas transplant is possible, it is not clear if the potential benefits outweigh the risks of the surgery and drug therapy needed.

Since diabetes can be life-threatening if not properly managed, patients should not attempt to treat this condition without medical supervision. A variety of alternative therapies can be helpful in managing the symptoms of diabetes and supporting patients with the disease. Acupuncture can help relieve the pain associated with diabetic neuropathy by stimulation of certain points. A qualified practitioner should be consulted. Herbal remedies also may be helpful in managing diabetes. Although there is no herbal substitute for insulin, some herbs may help adjust blood sugar levels or manage other diabetic symptoms. Some options include:

Any therapy that lowers stress levels also can be useful in treating diabetes by helping to reduce insulin requirements. Among the alternative treatments that aim to lower stress are hypnotherapy, biofeedback, and meditation.

Uncontrolled diabetes is a leading cause of blindness, end-stage renal disease, and limb amputations. It also doubles the risks of heart disease and increases the risk of stroke. Eye problems including cataracts, glaucoma, and diabetic retinopathy also are more common in people with diabetes.

Diabetic peripheral neuropathy is a condition where nerve endings, particularly in the legs and feet, become less sensitive. Diabetic foot ulcers are a particular problem since the patient does not feel the pain of a blister, callous, or other minor injury. Poor blood circulation in the legs and feet contribute to delayed wound healing. The inability to sense pain along with the complications of delayed wound healing can result in minor injuries, blisters, or callouses becoming infected and difficult to treat. In cases of severe infection, the infected tissue begins to break down and rot away. The most serious consequence of this condition is the need for amputation of toes, feet, or legs due to severe infection.

Heart disease and kidney disease are common complications of diabetes. Long-term complications may include the need for kidney dialysis or a kidney transplant due to kidney failure.

Babies born to diabetic mothers have an increased risk of birth defects and distress at birth.

Research continues on diabetes prevention and improved detection of those at risk for developing diabetes. While the onset of type 1 diabetes is unpredictable, the risk of developing type 2 diabetes can be reduced by maintaining ideal weight and exercising regularly. The physical and emotional stress of surgery, illness, pregnancy, and alcoholism can increase the risks of diabetes, so maintaining a healthy lifestyle is critical to preventing the onset of type 2 diabetes and preventing further complications of the disease.

See also American Diabetes Association ; Bariatric surgery ; Bernstein diet ; Childhood obesity ; Children's diets ; Diabetic diet ; Diet and disease prevention ; Gestational diabetes ; Glucosamine ; Hypertriglyceridemia ; Insulin ; Low-sugar diet ; Maternal obesity ; Obesity ; Renal nutrition ; Ulcers .