What is diabetes?

Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels,
which result from defects in insulin secretion, or 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 or insufficient production
of 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 failure, and nerve damage. These types of damage
are the result of damage to small vessels, referred to as microvascular 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 17 million people (about 8% of the population) in
the United States. In addition, an estimated additional 12 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
1997 was estimated to be 98 billion dollars in the United States. The per capita cost resulting from
diabetes in 1997 amounted to $10,071.00; while healthcare costs for people without diabetes incurred a
per capita cost of $2,699.00. During this same year, 13.9 million days of hospital stay were attributed to
diabetes, while 30.3 million physician office visits were diabetes related. Remember, these numbers
reflect only the population in the United States. Globally, the statistics are staggering.

Diabetes is the third leading cause of death in the United States after heart disease and cancer.

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. For more, please read
the Insulin Resistance article. 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 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.

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. These antibodies can be measured 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 patients with diabetes, only
approximately 10% of the patients have type 1 diabetes and the remaining 90% have type 2 diabetes.

Type 2 diabetes was also 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. In fact, for the first time in the history of humans, type 2 diabetes is now more common
than type 1 diabetes in childhood. 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 to 74 years of age is nearly
20%. Type 2 diabetes is also more common in certain ethnic groups. Compared with a 6% prevalence in
Caucasians, the prevalence in African Americans and Asian Americans is estimated to be 10%, in
Hispanics 15%, 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 (gestational
diabetes - see below).

Diabetes can occur temporarily during pregnancy. 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, 25-50% of women with gestational diabetes will eventually develop Type 2 diabetes later in
life, 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 6 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.

How is diabetes diagnosed?

The fasting blood glucose (sugar) test is the preferred way to diagnose diabetes. It is easy to perform
and convenient. After the person has fasted overnight (at least 8 hours), a single sample of blood is
drawn and sent to the laboratory for analysis. This can also be done accurately in a doctor’s office using
a glucose meter.

Normal fasting plasma glucose levels are less than 100 milligrams per deciliter (mg/dl). Fasting plasma
glucose levels of more than 126 mg/dl on two or more tests on different days indicate diabetes. A
random blood glucose test can also be used to diagnose diabetes A blood glucose level of 200 mg/dl or
higher indicates diabetes.

When fasting blood glucose stays above 100mg/dl, but in the range of 100-126mg/dl, this is known as
impaired fasting glucose (IFG). While patients with IFG do not have the diagnosis of diabetes, this
condition carries with it its own risks and concerns, and is addressed elsewhere.

The oral glucose tolerance test

Though not routinely used anymore, the oral glucose tolerance test (OGTT) is a gold standard for
making the diagnosis of type 2 diabetes. It is still commonly used for diagnosing gestational diabetes.
With an oral glucose tolerance test, the person fasts overnight (at least eight but not more than 16
hours). Then first, the fasting plasma glucose is tested. After this test, the person receives 75 grams of
glucose (100 grams for pregnant women). There are several methods employed by obstetricians to do
this test, but the one described here is standard. Usually, the glucose is in a sweet-tasting liquid that the
person drinks. Blood samples are taken at specific intervals to measure the blood glucose.

For the test to give reliable results, the person must be in good health (not have any other illnesses, not
even a cold). Also, the person should be normally active (not lying down, for example, as an inpatient in
a hospital) and should not be taking medicines that could affect the blood glucose. For three days before
the test, the person should have eaten a diet high in carbohydrates (150- 200 grams per day). The
morning of the test, the person should not smoke or drink coffee.

The classic oral glucose tolerance test measures blood glucose levels five times over a period of three
hours. Some physicians simply get a baseline blood sample followed by a sample two hours after
drinking the glucose solution. In a person without diabetes, the glucose levels rise and then fall quickly.
In someone with diabetes, glucose levels rise higher than normal and fail to come back down as fast.

People with glucose levels between normal and diabetic have impaired glucose tolerance (IGT). People
with impaired glucose tolerance do not have diabetes, but are at high risk for progressing to diabetes.
Each year, 1-5% of people whose test results show impaired glucose tolerance actually eventually
develop diabetes. Weight loss and exercise may help people with impaired glucose tolerance return
their glucose levels to normal. In addition, some physicians advocate the use of medications, such as
metformin (Glucophage), to help prevent/delay the onset of overt diabetes. Recent studies have shown
that impaired glucose tolerance itself may be a risk factor for the development of heart disease. In the
medical community, most physicians are now understanding that impaired glucose tolerance is nor
simply a precursor of diabetes, but is its own clinical disease entity that requires treatment and
monitoring.

Evaluating the results of the oral glucose tolerance test

Glucose tolerance tests may lead to one of the following diagnoses:

← Normal response: A person is said to have a normal response when the 2-hour glucose level
is less than 140 mg/dl, and all values between 0 and 2 hours are less than 200 mg/dl.
← Impaired glucose tolerance: A person is said to have impaired glucose tolerance when the
fasting plasma glucose is less than 126 mg/dl and the 2-hour glucose level is between 140 and
199 mg/dl.
← Diabetes: A person has diabetes when two diagnostic tests done on different days show that
the blood glucose level is high.
← Gestational diabetes: A woman has gestational diabetes when she has any two of the
following: a 100g OGTT, a fasting plasma glucose of more than 95 mg/dl, a 1-hour glucose
level of more than 180 mg/dl, a 2-hour glucose level of more than 155 mg/dl, or a 3-hour
glucose level of more than 140 mg/dl.

Why is blood sugar checked at home?

Home blood sugar (glucose) testing is an important part of controlling blood sugar. One important goal
of diabetes treatment is to keep the blood glucose levels near the normal range of 70 to 120 mg/dl
before meals and under 140 mg/dl at two hours after eating. Blood glucose levels are usually tested
before and after meals, and at bedtime. The blood sugar level is typically determined by pricking a
fingertip with a lancing device and applying the blood to a glucose meter, which reads the value. There
are many meters on the market, for example, Accu-Check Advantage, One Touch Ultra, Sure Step and
Freestyle. Each meter has its own advantages and disadvantages (some use less blood, some have a
larger digital readout, some take a shorter time to give you results, etc). The test results are then used to
help patients make adjustments in medications, diets, and physical activities.

There are some interesting developments in blood glucose monitoring. Currently, at least three
continuous glucose sensors are being considered for approval in the United States (Dexcom, Medtronic
and Navigator). The new continuous glucose sensor systems involve an implantable cannula placed just
under the skin in the abdomen or in the arm. This cannula allows for frequent sampling of blood glucose
levels. Attached to this is a transmitter that sends the data to a pager-like device. This device has a
visual screen that allows the wearer to see, not only the current glucose reading, but also the graphic
trends. In some devices, the rate of change of blood sugar is also shown. There are alarms for low and
high sugar levels. Certain models will alarm if the rate of change indicates the wearer is at risk for
dropping or rising blood glucose too rapidly. The Medtronic version is specifically designed to interface
with their insulin pumps. However, at this time the patient still must manually approve any insulin dose
(the pump cannot blindly respond to the glucose information it receives, it can only give a calculated
suggestion as to whether the wearer should give insulin, and if so, how much). All of these devices need
to be correlated to fingersticks for a few hours before they can function independently. The devices can
then provide readings for 3-5 days.
Diabetes experts feel that these blood glucose monitoring devices give patients a significant amount of
independence to manage their disease process; and they are a great tool for education as well. It is also
important to remember that these devices can be used intermittently with fingersticks. For example, a
well-controlled patient with diabetes can rely on fingerstick glucose checks a few times a day and do
well. If they become ill, if they decide to embark on a new exercise regimen, if they change their diet and
so on, they can use the sensor to supplement their fingerstick regimen, providing more information on
how they are responding to new lifestyle changes or stressors. This kind of system takes us one step
closer to closing the loop, and to the development of an artifical pancreas that senses insulin
requirements based on glucose levels and the body’s needs and releases insulin accordingly - the
ultimate goal.

Hemoglobin A1c (A1c)

To explain what an A1c is, think in simple terms. Sugar sticks, and when it's around for a long time, it's
harder to get it off. In the body, sugar sticks too, particularly to proteins. The red blood cells that circulate
in the body live for about three months before they die off. When sugar sticks to these cells, it gives us
an idea of how much sugar is around for the preceding three months. In most labs, the normal range is
4-5.9 %. In poorly controlled diabetes, its 8.0% or above, and in well controlled patients it's less than
7.0% (optimal is <6.5%). The benefits of measuring A1c is that is gives a more reasonable and stable
view of what's happening over the course of time (three months), and the value does not bounce as
much as finger stick blood sugar measurements. There is a direct correlation between A1c levels and
average blood sugar levels as follows.

While there are no guidelines to use A1c as a screening tool, it gives a physician a good idea that
someone is diabetic if the value is elevated. Right now, it is used as a standard tool to determine blood
sugar control in patients known to have diabetes.

A1c(%) Mean blood sugar (mg/dl)

6 135
7 170
8 205
9 240
10 275
11 310
12 345

The American Diabetes Association currently recommends an A1c goal of less than 7.0%. Other Groups
such as the American Association of Clinical Endocrinologists feel that an A1c of < 6.5% should be the
goal.

Of interest, studies have shown that there is about a 10% decrease in relative risk for microvascular
disease for every 1 % reduction in A1c. So, if a patient starts off with an A1c of 10.7 and drops to 8.2,
though there are not yet at goal, they have managed to decrease their risk of microvascular
complications by about 20%. The closer to normal the A1c, the lower the absolute risk for microvascular
complications. Data also suggests that the risk of macrovascular disease decreases by about 24% for
every 1% reduction in A1c values.

It should be mentioned here that there are a number of conditions in which an A1c value may not be
accurate. For example, with significant anemia, the red blood cell count is low, and thus the A1c is
falsely low as is similarly in cases of sickle cell disease and other hemoglobinopathies. For more, please
read the Hemoglobin A1c article.

What are the acute complications of diabetes?

1. Severely elevated blood sugar levels due to an actual lack of insulin or a relative deficiency of
insulin.
2. Abnormally low blood sugar levels due to too much insulin or other glucose-lowering
medications.
Insulin is vital to patients with type 1 diabetes - they cannot live with out a source of exogenous insulin.
Without insulin, patients with type 1 diabetes develop severely elevated blood sugar levels. This leads to
increased urine glucose, which in turn leads to excessive loss of fluid and electrolytes in the urine. Lack
of insulin also causes the inability to store fat and protein along with breakdown of existing fat and
protein stores. This dysregulation, results in the process of ketosis and the release of ketones into the
blood. Ketones turn the blood acidic, a condition called diabetic ketoacidosis (DKA). Symptoms of
diabetic ketoacidosis include nausea, vomiting, and abdominal pain. Without prompt medical treatment,
patients with diabetic ketoacidosis can rapidly go into shock, coma, and even death.

Diabetic ketoacidosis can be caused by infections, stress, or trauma all which may increase insulin
requirements. In addition, missing doses of insulin is also an obvious risk factor for developing diabetic
ketoacidosis. Urgent treatment of diabetic ketoacidosis involves the intravenous administration of fluid,
electrolytes, and insulin, usually in a hospital intensive care unit. Dehydration can be very severe, and it
is not unusual to need to replace 6-7 liters of fluid when a person presents in diabetic ketoacidosis.
Antibiotics are given for infections. With treatment, abnormal blood sugar levels, ketone production,
acidosis, and dehydration can be reversed rapidly, and patients can recover remarkably well.

In patients with type 2 diabetes, stress, infection, and medications (such as corticosteroids) can also
lead to severely elevated blood sugar levels. Accompanied by dehydration, severe blood sugar
elevation in patients with type 2 diabetes can lead to an increase in blood osmolality (hyperosmolar
state). This condition can lead to coma (hyperosmolar coma). A hyperosmolar coma usually occurs in
elderly patients with type 2 diabetes. Like diabetic ketoacidosis, a hyperosmolar coma is a medical
emergency. Immediate treatment with intravenous fluid and insulin is important in reversing the
hyperosmolar state. Unlike patients with type 1 diabetes, patients with type 2 diabetes do not generally
develop ketoacidosis solely on the basis of their diabetes. Since in general, type 2 diabetes occurs in an
older population, concomitant medical conditions are more likely to exist, and these patients may
actually be sicker overall. The complication and death rates from hyperosmolar coma is thus higher than
in DKA.

Hypoglycemia means abnormally low blood sugar (glucose). In patients with diabetes, the most
common cause of low blood sugar is excessive use of insulin or other glucose-lowering medications, to
lower the blood sugar level in diabetic patients in the presence of a delayed or absent meal. When low
blood sugar levels occur because of too much insulin, it is called an insulin reaction. Sometimes, low
blood sugar can be the result of an insufficient caloric intake or sudden excessive physical exertion.

Blood glucose is essential for the proper functioning of brain cells. Therefore, low blood sugar can lead
to central nervous system symptoms such as dizziness, confusion, weakness, and tremors. The actual
level of blood sugar at which these symptoms occur varies with each person, but usually it occurs when
blood sugars are less than 65 mg/dl. Untreated, severely low blood sugar levels can lead to coma,
seizures, and, in the worse case scenario, irreversible brain death. At this point, the brain is suffering
from a lack of sugar, and this usually occurs somewhere around levels of <40 mg/dl.

The treatment of low blood sugar consists of administering a quickly absorbed glucose source. These
include glucose containing drinks, such as orange juice, soft drinks (not sugar-free), or glucose tablets
in doses of 15-20 grams at a time (for example, the equivalent of half a glass of juice). Even cake
frosting applied inside the cheeks can work in a pinch if patient cooperation is difficult. If the individual
becomes unconscious, glucagon can be given by intramuscular injection.

Glucagon causes the release of glucose from the liver (i.e., it promotes gluconeogenesis). Glucagon
can be lifesaving and every patient with diabetes who has a history of hypoglycemia (particularly those
on insulin) should have a glucagon kit. Families and friends of those with diabetes need to be taught
how to administer glucagon, since obviously the patients will not be able to do it themselves in an
emergency situation. Another lifesaving device that should be mentioned is very simple; a medic alert
bracelet should be worn by all patients with diabetes.

What are the chronic complications of diabetes?

These diabetes complications are related to blood vessel diseases and are generally classified into
small vessel disease, such as those involving the eyes, kidneys and nerves (microvascular disease),
and large vessel disease involving the heart and blood vessels (macrovascular disease). Diabetes
accelerates hardening of the arteries (atherosclerosis) of the larger blood vessels, leading to coronary
heart disease (angina or heart attack), strokes, and pain in the lower extremities because of lack of
blood supply (claudication). For more information, please read the following articles: Stroke, Angina, and
Heart Attack.
Eye Complications

The major eye complication of diabetes is called diabetic retinopathy. Diabetic retinopathy occurs in
patients who have had diabetes for at least five years. Diseased small blood vessels in the back of the
eye cause the leakage of protein and blood in the retina. Disease in these blood vessels also causes
the formation of small aneurysms (microaneurysms), and new but brittle blood vessels
(neovascularization). Spontaneous bleeding from the new and brittle blood vessels can lead to retinal
scarring and retinal detachment, thus impairing vision.

To treat diabetic retinopathy a laser is used to destroy and prevent the recurrence of the development of
these small aneurysms and brittle blood vessels. Approximately 50% of patients with diabetes will
develop some degree of diabetic retinopathy after 10 years of diabetes, and 80% of diabetics have
retinopathy after 15 years of the disease. Poor control of blood sugar and blood pressure further
aggravates eye disease in diabetes. For more, please read the Diabetic Eye Disease article.

Cataracts and glaucoma are also more common among diabetics. It is also important to note that since
the lens of the eye lets water through, if blood sugar concentrations vary a lot, the lens of the eye will
shrink and swell with fluid accordingly. As a result, blurry vision is very common in poorly controlled
diabetes. Patients are usually discouraged from getting a new eyeglass prescription until their blood
sugar is controlled. This allows for a more accurate assessment of what kind of glasses prescription is
required.

Kidney damage

Kidney damage from diabetes is called diabetic nephropathy. The onset of kidney disease and its
progression is extremely variable. Initially, diseased small blood vessels in the kidneys cause the
leakage of protein in the urine. Later on, the kidneys lose their ability to cleanse and filter blood. The
accumulation of toxic waste products in the blood leads to the need for dialysis. Dialysis involves using
a machine that serves the function of the kidney by filtering and cleaning the blood. In patients who do
not want to undergo chronic dialysis, kidney transplantation can be considered. For more about dialysis,
please read the Kidney Dialysis article.

The progression of nephropathy in patients can be significantly slowed by controlling high blood
pressure, and by aggressively treating high blood sugar levels. Angiotensin converting enzyme inhibitors
(ACE inhibitors) or angiotensin receptor blockers (ARBs) used in treating high blood pressure may also
benefit kidney disease in diabetic patients.

Nerve damage

Nerve damage in diabetes is called diabetic neuropathy and is also caused by disease of small blood
vessels. In essence, the blood flow to the nerves is limited, leaving the nerves without blood flow, and
they get damaged or die as a result (a term known as ischemia). Symptoms of diabetic nerve damage
include numbness, burning, and aching of the feet and lower extremities. When the nerve disease
causes a complete loss of sensation in the feet, patients may not be aware of injuries to the feet, and fail
to properly protect them. Shoes or other protection should be worn as much as possible. Seemingly
minor skin injuries should be attended to promptly to avoid serious infections. Because of poor blood
circulation, diabetic foot injuries may not heal. Sometimes, minor foot injuries can lead to serious
infection, ulcers, and even gangrene, necessitating surgical amputation of toes, feet, and other infected
parts.

Diabetic nerve damage can affect the nerves that are important for penile erection, causing erectile
dysfunction (ED, impotence). Erectile dysfunction can also be caused by poor blood flow to the penis
from diabetic blood vessel disease.

Diabetic neuropathy can also affect nerves to the stomach and intestines, causing nausea, weight loss,
diarrhea, and other symptoms of gastroparesis (delayed emptying of food contents from the stomach
into the intestines, due to ineffective contraction of the stomach muscles).

The pain of diabetic nerve damage may respond to traditional treatments with gabapentin (Neurontin),
phenytoin (Dilantin), carbamazepine (Tegretol), desipramine (Norpraminine), amitriptyline (Elavil), or
with topically-applied capsaicin (an extract of pepper). Neurontin, Dilantin and Tegretol are medications
that are traditionally used in the treatment of seizure disorders. Elavil and Norpraminine are medications
that are traditionally used for depression. While many of these medications are not FDA indicated
specifically for the treatment of diabetes related nerve pain, they are used by physicians commonly. The
pain of diabetic nerve damage may also improve with better blood sugar control, though unfortunately
blood glucose control and the course of neuropathy do not always go hand in hand. Newer medications
for nerve pain have recently come to market in the US. Pregabalin (Lyrica) which has an indication for
diabetic neuropathic pain and duloxetine (Cymbalta) are newer agents used in the treatment of diabetic
neuropathy. For more, please read the Diabetic Neuropathy article.

What can be done to slow diabetes complications?

Findings from the Diabetes Control and Complications Trial (DCCT) and the United Kingdom
Prospective Diabetes Study (UKPDS) have clearly shown that aggressive and intensive control of
elevated levels of blood sugar in patients with type 1 and type 2 diabetes decreases the complications
of nephropathy, neuropathy, retinopathy, and may reduce the occurrence and severity of large blood
vessel diseases. Aggressive control with intensive therapy means achieving fasting glucose levels
between 70-120 mg/dl; glucose levels of less than 160 mg/dl after meals; and a near normal
hemoglobin A1C levels (see below).

Studies in type 1 patients have shown that in intensively treated patients, diabetic eye disease
decreased by 76%, kidney disease decreased by 54%, and nerve disease decreased by 60%. More
recently the EDIC trial has shown that type 1 diabetes is also associated with increased heart disease,
similar to type 2 diabetes. However, the price for aggressive blood sugar control is a two to three fold
increase in the incidence of abnormally low blood sugar levels (caused by the diabetes medications).
For this reason, tight control of diabetes to achieve glucose levels between 70-120 mg/dl is not
recommended for children under 13 years of age, patients with severe recurrent hypoglycemia, patients
unaware of their hypoglycemia, and patients with far advanced diabetes complications. To achieve
optimal glucose control without an undue risk of abnormally lowering blood sugar levels, patients with
type 1 diabetes must monitor their blood glucose at least four times a day and administer insulin at least
three times per day. In patients with type 2 diabetes, aggressive blood sugar control has similar
beneficial effects on the eyes, kidneys, nerves and blood vessels.

How is diabetes treated?

Please see the Diabetes Treatment article.

Diabetes At A Glance
← Diabetes is a chronic condition associated with abnormally high levels of sugar (glucose) in the
blood.
← Insulin produced by the pancreas lowers blood glucose.
← Absence or insufficient production of insulin causes diabetes.
← The two types of diabetes are referred to as type 1 (insulin dependent) and type 2 (non-insulin
dependent).
← Symptoms of diabetes include increased urine output, thirst and hunger as well as fatigue.
← Diabetes is diagnosed by blood sugar (glucose) testing.
← The major complications of diabetes are both acute and chronic.
← Acutely: dangerously elevated blood sugar, abnormally low blood sugar due to
diabetes medications may occur.
← Chronically: disease of the blood vessels (both small and large) which can damage
the eye, kidneys, nerves, and heart may occur
← Diabetes treatment depends on the type and severity of the diabetes. Type 1 diabetes is
treated with insulin, exercise, and a diabetic diet. Type 2 diabetes is first treated with weight
reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood
sugars, oral medications are used. If oral medications are still insufficient, insulin medications
are considered.

http://www.medicinenet.com/diabetes_mellitus/page8.htm
 Diabetes
(READING TIPS: For fast reading, scan through the topic headings in BOLD BLACK, important
conclusions in BOLD BLUE, and " Must Know " in BOLD RED. To jump to specific
sections in this article, click on the respective LINKS in the Contents.)

Before You Begin

Information presented here is for general educational purposes only.

Each one of us is biochemically and metabolically different. If you
have a specific health concern and wish my personalized nutritional
recommendation, write to me by clicking here.

Contents
Introduction
What is Diabetes?
Two Types of Diabetes Mellitus
Symptoms of NIDDM
Diagnosis of Diabetes
Complications of Diabetes
Importance of Tight Blood Sugar Control
Type II Diabetes - Curable?
Diabetes Protocol
1. Key Nutritional Supplements
A. Chromium
B. VITAMIN C
C. VITAMIN E
D. Digestive enzymes
E. Magnesium
2. Auxiliary Supporting nutrients
3. Diabetic Low Glycemic Index Diet
Anti-Aging Food Pyramid for Diabetes
Diet Tips for Diabetes Mellitus
4 . Exercise
5. Prescription Medications
Summary

Introduction
Of the 15 million Americans who have Type II diabetes, more than a
third are unaware of it. Another 21 million Americans have a
greater than 50/50 chance of developing the disease because
they have impaired blood-sugar metabolism. This year alone more than
187,000 people will die of Type II diabetes, also called non-insulin-dependent diabetes mellitus
(NIDDM), making it the sixth leading cause of death by disease. Each day, over 2,200 people are
diagnosed with this chronic life debilitating, expansive, and pro-aging disease.

What is Diabetes?
Glucose is a simple sugar found in food. It is an essential nutrient that provides energy for the proper
functioning of the body cells. After meals, food is digested in the stomach and the intestines into glucose
and other nutrients. The glucose in digested food is absorbed by the intestinal cells into the
bloodstream, and is carried by blood to all the cells in the body. However, glucose cannot enter the
cells alone. It needs assistance from insulin in order to penetrate the cell walls. Insulin therefore
acts as a regulator of glucose metabolism in the body.

Insulin is called the "hunger hormone". As the blood sugar level increases following a carbohydrate
rich meal, the corresponding insulin level rises with the eventual lowering of the blood sugar level and
glucose is transported from the blood into the cell for energy. When the blood glucose levels are
lowered, the insulin release from the pancreas is turned off. When the blood sugar level drops below a
certain level, hunger is felt. This often occurs a few hours after the meal. In normal individuals, such a
regulatory system helps to keep blood glucose levels in a tightly controlled range. Cravings for sweets
frequently form part of this cycle, which can lead to snacking, often for more carbohydrates. If the
cravings are not fulfilled, sensations such as hunger, dizziness, moodiness, and a state of "collapse" can
result.

This system of auto regulation and homeostasis is the function of the pancreas and it works around the
clock. Dysfunction of this auto regulation system - either inability of the pancreas to secrete any or
insufficient insulin, or pancreas overload from too much sugar ingested over a long period of time, or
over compensatory mechanism, or a combination of these, results in the lack of insulin, and hence
high blood sugar. This is the hallmark of diabetes mellitus (commonly called diabetes)

Two Types of Diabetes Mellitus

 Type I diabetes mellitus is also called insulin dependent
diabetes mellitus (IDDM), or juvenile onset diabetes
mellitus. It is an autoimmune disease in which the pancreas produces no insulin at all,
and the patient relies on insulin medication for survival. Type I diabetes tends to occur in
young, lean individuals, usually before 30 years of age. Approximately 10% of the patients with
diabetes mellitus have IDDM. There is no cure for this type.

 Type II diabetes mellitus is also referred to as non-insulin

dependent diabetes mellitus (NIDDM), or adult onset
diabetes mellitus (AODM). It is a metabolic disorder resulting from the body's
inability to make enough, or properly use, insulin. 90% of all Diabetes Mellitus are of Type II.
Type II diabetes mellitus occurs mostly in individuals over 40 years old. The incidence of type
II diabetes increases with age. Unlike type I diabetes mellitus, 80% of type II
diabetic patients are obese. Type II diabetes mellitus also has a strong
genetic tendency.

It is nearing epidemic proportions, due to an increased number of elderly people, a greater

prevalence of obesity and a sedentary lifestyle. In type II diabetes, patients can still produce
insulin, but do so inadequately. The pancreas in these patients not only produces an
insufficient amount of insulin, but also releases insulin late in response to increased glucose
levels. Some type II diabetics have body cells that are resistant to the action of insulin (Insulin
Resistance). Finally, the liver in these patients continues to produce glucose despite elevated
glucose levels.

Type II diabetes once hardly ever struck before middle age, and the older you are the
more at risk you are. Now it is striking younger people.

Symptoms of NIDDM
The early symptoms of untreated diabetes mellitus are related to elevated blood sugar
levels, and excretion of it to 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. Some untreated diabetic 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 (diabetic coma).
The most unrecognized symptom of NIDDM is weight gain. High
insulin levels prohibit the release of serotonin, a neurotransmitter in the brain that informs the body to
slow down eating. Without serotonin, there is a tendency to overeat, which then leads to a spiral of
excessive sugar intake. A viscous cycle of hyper-insulinemia resulting in insulin resistance is set up. This
in turn creates a "carbohydrate addict" whose craving for a higher sugar intake continues
to increase. The same dietary factors that cause NIDDM lead to obesity. Eating refined carbohydrates
such as sugar, or carbohydrates that easily converts into sugar such as yam, potato, or rice, creates
more glucose than the body can handle. Excess glucose then gets stored as fat. As diabetes sets in, so
does lethargy and inactivity, contributing further to the vicious cycle of weight gain and worsening of
diabetes.

Diagnosis of Diabetes
The fasting plasma glucose test is the standard and preferred way to diagnose diabetes. Normal fasting
plasma glucose levels are less than 110 milligrams per deciliter (mg/dl). If the overnight fasting
blood glucose is greater than 126 mg/dl on two different tests on different
days, the diagnosis of diabetes mellitus is made. Random blood glucose alone is seldom used because
it is not reliable.

Fasting blood sugar can be performed using a simple home blood sugar (glucose) testing kit. Many
doctors also take the hemoglobin A1C level. This is a test to measure of the overall effectiveness of
blood glucose control over a period of time (two months). Elevated
hemoglobin A1C
levels indicate a poor overall control of blood sugar.

Complications of Diabetes
Type 1 Diabetes:
Insulin is vital to patients with type I diabetes. Without insulin, patients with type I diabetes can develop
severely elevated blood sugar levels. This leads to increased urine glucose, which in turn leads to
excessive loss of fluid and electrolytes in the urine. Lack of insulin also causes the breakdown of fat
cells, with the release of ketones into the blood. Symptoms of diabetic ketoacidosis include nausea,
vomiting, and abdominal pain. Without prompt medical treatment, patients with diabetic acidosis can
rapidly go into shock, coma, and even death. With proper treatment, the symptoms can be reversed
rapidly, and patients can recover remarkably well.

Type 2 Diabetes:

Short term complications are normally due imbalance of sugar level in the body as a
result of:

A. Severely high blood sugar levels due to a lack of insulin.

Symptoms are similar to that of Type 1 Diabetes described above.

B. Abnormally low blood sugar levels due to too much insulin or

other glucose-lowering medications. Low blood sugar can lead to nervous
system symptoms such as dizziness, confusion, weakness, and tremors. Untreated, severely low blood
sugar levels can lead to coma and irreversible brain death.

Long-term complications are related to blood vessel diseases. Diabetes causes

diseases of the small vessels, which can damage the eyes, kidneys, nerves, and heart. Four major
areas are involved:
A. EYE. Each year about 24,000 people lose their sight because of diabetes. Diabetes is the
main cause of blindness in adult. Eye complications of diabetes (diabetic retinopathy) occur in patients
who have had diabetes for at least 5 years. Disease in these blood vessels also causes the formation of
small aneurysms (micro aneurysms), and new but brittle blood vessels (neovascularization).
Spontaneous bleeding from the new and brittle blood vessels can lead to retinal scarring and retinal
detachment, thus impairing vision. Approximately 50% of patients with diabetes will develop some
degree of diabetic retinopathy after 10 years of diabetes, and 80% of diabetics have retinopathy
after 15 years of the disease.

B. Kidney damage from diabetes is called diabetic nephropathy. Kidney disease usually
occurs approximately 10 years after the onset of diabetes. Each year, about 28,000 people initiated
treatment for end stage renal disease (kidney failure) because of diabetes. The progression of
nephropathy in patients can be significantly slowed by controlling high blood pressure, and by
aggressively treating high blood sugar levels.

C. Nerve damage in diabetes (diabetic neuropathy) is also caused by small blood vessel
disease. Symptoms of diabetic nerve damage include numbness, burning, and aching of the feet and
lower extremities. Seemingly minor skin injuries should be attended to promptly to avoid serious
infections. Diabetic nerve damage can affect the nerves, which are important for penile erection, causing
impotence. Diabetic neuropathy can also affect nerves to the intestines, causing nausea, weight loss,
About 60-70% of people with diabetes have mild to
and diarrhea.
sever form of diabetic nerve damage. The risk of a leg amputation is 15-40 times
greater for a person with diabetes. Each year, more than 56,000 amputations are performed among
people with diabetes.

D. Heart Disease and Strokes. Patients with diabetes are 2-4 times more likely to
have heart disease, which is present in 75 percent of diabetes-related death (more than 75,000 deaths
due to heart disease annually). Diabetic patients are also 2 to 4 times more likely to suffer a stroke.
Diabetes also accelerates the hardening of the arteries (atherosclerosis) of the larger blood vessels,
leading to coronary heart disease (angina or heart attack), strokes, and pain in the lower extremities
because of lack of blood supply.

Diabetic men were more than twice as likely to die of all causes compared with men without diabetes.
As blood glucose increased, the risk of dying climbed higher regardless of age, weight, blood
pressure, cholesterol and smoking status.

reduction in blood glucose by just 0.1 per

Researchers estimated that a
cent could reduce mortality rates by about five per cent in
western countries.

Importance of Tight Blood Sugar Control

An aggressive and intensive control of elevated levels of blood sugar in patients with diabetes is
absolutely essential. Studies
have shown that in intensively treated
patients, diabetic eye disease decreased by 76%, kidney disease
decreased by 54%, and nerve disease decreased by 60%.
Aggressive control with intensive therapy means achieving fasting glucose levels between 70-
120 mg/dl; glucose levels of less than 180 mg/dl after meals; and a near normal hemoglobin A1C
levels.

Not only will you feel better, stay healthy, and have more energy. You will also live longer.

Type II Diabetes - Curable?

Diabetes is a disease that has become prevalent only in the past 100
years. Before then, when everyone ate whole foods and sugar intake was
moderate, diabetes was hardly a problem. It's a simple of matter of supply
and demand. If the ingestion of grain products and refined sugars exceed the
demand, the body is put into high gear to rid itself of the excess sugar.
Diabetes is resulted when this process carries on for an extended period of
time and ultimately fails. No other disease state can be cured as
easily as NIIDM.

All you have to do is to reduce the supply of sugar to the body to a moderate
level without sacrificing energy production. The secret lies not in
avoiding carbohydrates as the most common source of sugar. The
key is knowing what kind of carbohydrate to eat and which kind to
avoid

Diabetes Protocol
Attention

Because of tremendous individual variation, the use of nutritionals

should therefore be personalized for your body. One person’s nutrient
can be another person’s toxin. If you have a specific health concern
and wish my personalized nutritional recommendation, write to me by
clicking here.

The major goal in treating diabetes mellitus is controlling elevated blood sugars (glucose) without
causing abnormally low levels of blood sugar. Type I diabetes mellitus is treated with insulin, exercise,
concurrent employment of
and a diabetic diet. Type II diabetes mellitus is treated with
nutritional supplements, a low glycemic index diet to control
blood sugar level, and exercise. If these measures fail to contain the elevated blood
sugars, oral medications and insulin need to be considered.

1. Key Nutritional Supplements

A VARIETY OF NUTRIENTS AND HERBS can help offset the toll diabetes takes on your body.
Supplements cannot, however, reverse the disease by themselves. Incorporating these minerals and
vitamins can help to normalize blood sugar. If you already have diabetes or suspect you might have it,
consult a health care practitioner before taking any
supplements.

A. Chromium:.
Chromium is an essential trace mineral nutrient. Like iron, zinc, selenium, copper, and several other
essential trace minerals, chromium plays a critical role in maintaining normal health and well-being.

Chromium helps insulin work efficiently. Many well controlled clinical studies through the years and
the majority show blood glucose improvements in the patients tested.
Important studies include one from the Human Nutrition Research Center of the United States
Department of Agriculture conducted in 1996. Researchers in the study randomized 180 adult-onset
diabetics into 3 groups of 60 each: one group received placebo twice per day, the second received 100
mcg twice daily of chromium as chromium picolinate and the third received 500 mcg of chromium as
chromium picolinate twice daily. Their blood work was examined at baseline, at 2 months and at 4
months. The patients were told to remain on their anti-diabetic medications and continue with their diets
and activity levels as before. The results were impressive: blood glucose, insulin levels, cholesterol and
Hemoglobin A1C all decreased, with the higher dose generally (but not always) more effective than the
200 mcg.

Dietary Intake of Chromium

Few foods are rich sources of chromium in the Western diet, the best being organic meats, mushrooms,
wheat germ, broccoli and processed meats. Data from U. S. Government sources show that the great
majority of Americans get less chromium in their daily diets than the amount recommended by nutrition
The RDA Committee recommends 50-200 mcg of
experts.
chromium/day; the vast majority of Americans get less than 50
mcg/day. It is estimated that as many as 80% of all Americans
are deficient in this mineral and may not know it.
Unfortunately, it is not possible to get enough chromium by food alone without excessive calories
and obesity. To obtain 200 mcg by food alone, one has to take in over 8,000 calories a day. A large
part of the problem has to do with processed food and the
increase consumption of sugar. The modern American consumes an average of 120
pounds of sugar per year from all sources. These ingested sugars (such as table sugar and products
made with it) bring insulin and chromium into the blood and cause chromium to be excreted in the urine
after it's through working with the insulin on the increase in blood sugar.

Inadequate chromium intake from processed food, increased chromium losses due to increased sugar
consumption, decreasing chromium tissue levels as we age are the main reasons why the majority of
Americans and diabetics are deficient in chromium. Studies show an improvement in blood sugar in
significant numbers of diabetics and pre-diabetics with modest chromium supplementation. It should,
however, take place alongside the two other proven ways of normalizing sugar: low-fat, high
complex-carbohydrate of low glycemic index type diets for weight loss/weight maintenance and
regular exercise.

Assessment of Chromium Status

Deciding whether or not someone is chromium deficient cannot be done easily. Routine blood tests
are generally not accurate. The
only generally accepted method for the
assessment of chromium status is to supplement an individual
who has abnormalities of either blood sugar, cholesterol,
triglycerides or all three with the trace element. If the laboratory
values improve, then chromium insufficiency is presumed.

Safety of Chromium

Chromium comes in various forms. The dietary form is called chromium tri-
valent. This is non-toxic and necessary for essential bodily functions. Chromium in its hexa-valent
form is used in industries and that is highly toxic.

It is extremely difficult to poison laboratory animals with oral dietary tri-valent forms of
chromium. For example, cats fed 1,000 mg of trivalent chromium per day showed no signs of toxicity.
The equivalent daily dose for a 150 lb person would be approximately 35,000 mg per day or 3.5 million
mcg per day. In terms of the number of 200 mcg tablets, this would be 175,000 tablets per day for a
human.

"Trivalent chromium has such a low order of toxicity that deleterious effects from excessive intake of this
form of chromium do not occur readily. Trivalent chromium becomes toxic only at extremely high
amounts - chromium then acts as a gastric irritant rather than as a toxic element interfering with
essential metabolism or biochemistry." Modern Nutrition In Health and Disease, Eighth Ed., 1994. Shils,
Olson and Shike, eds.

The safety issue had been questioned by a study published in December 1995, which attempted to link
chromosomal damage in the test tube to oral supplementation of chromium picolinate. Researchers in
this study added unnaturally high amounts of chromium picolinate to cultured Chinese hamster ovarian
cancer. Some of these cells showed chromosomal damage. This was not particularly surprising,
since this concentration applied was 3,000 times the blood level of people who are ingesting
It is interesting to note that another
chromium picolinate as supplements.
form of chromium, chromium polynicotinate, did not have this
toxic effect.
It is important to note that very few essential minerals tested in this way would be found to be without
toxicity. For example, merely doubling the blood concentration of the mineral calcium is fatal to humans.

A further study was conducted by Dr. Richard Anderson, the lead scientist for trace minerals at the U.S.
Department of Agriculture's Human Nutrition Research Center, Beltsville, Md., His research team fed
rats a stock diet . Added to the diet was 0, 5, 25, 50 or 100 micrograms (mcg) of chromium per gram of
feed for a period of six months. The supplements were added to the feed in the form of chromium
chloride or chromium picolinate. The highest supplemented level measured approximately 1500
mcg/day per kilogram of body weight. Translated to a human equivalent would mean that a 150 lb (70
kg) individual would have to consume 1.05 million micrograms, or more than 5,000 tablets containing
200 mcg of chromium each daily for six months to equal the rat intake. This study found no harmful
effects in animals supplemented with two widely used forms of dietary chromium: chromium
chloride and chromium picolinate.

Forms of Chromium

There are various forms of dietary chromium. These vary in bioavailability (absorption and retention)
and biological activity (ability to potentate and harmonize insulin). Inorganic chromium such as
chromium chloride is unfortunately poorly absorbed (0.5-2%) and has little effect on insulin because it
must first be converted into a biologically active form, which the body has a limited ability to do.

The two most popular forms of organic chromium are niacin-bound chromium (also called chromium
polynicotinate) and chromium picolinate. Although picolinate and polynicotinate sound alike, there
are significant differences between the two compounds.

Chromium Polynicotinate is actually a family of niacin-bound chromium compounds. Niacin-bound

chromium strongly potentiates insulin - chromium's most vital function - while chromium picolinate is less
effective comparatively speaking.

Niacin-bound chromium such as chromium

polynciotinate is also more
bioavailable than chromium picolinate. An Animal study at the University of
California found that chromium polynicotinate is better absorbed and retained up to 311% better than
Such high bioavailability
chromium picolinate and 672% better than chromium chloride.
means that chromium polynicotinate can deliver more of the
benefits that chromium has to offer.
B. VITAMIN C:
As a strong antioxidant, this vitamin enhances capillary strength, which improves blood flow. Dietary
sources including leafy greens, broccoli, peppers, oranges, and grapefruit are the primary source of
dietary vitamin C, followed by commercial supplements.

Vitamin C administration has beneficial effects on sugar and fat metabolism in NIIDM. In a randomized
double-blind cross-over study, in which 56 diabetic patients participated, it has been established that a
supplementation of high doses of ascorbic
acid (2 grams a day) markedly
improves the blood sugar regulation in patients with NIDDM. It was
recorded that the vitamin C supplementation in the NIDDM group resulted in a statistically significant
decrease of the fasting blood sugar of 10.1 to 9.1 mmol/liter. In this group the vitamin C supplement also
succeeded in lowering the level of LDL cholesterol and of triglycerides in the blood. The greater the
amount of vitamin C taken, the greater reduction in LDL cholesterol and plasma free radicals.
The plasma free radicals are also lower compared to the placebo group. This was reported in the
Journal of the American College of Nutrition (Aug. 1995).

Vitamin C also reduces the potential of complications arising from persistent

high sugar environment in the body. Specifically, vitamin C prevents
accumulation of sorbitol (a sugar equivalent) in cells and protect against most
complications resulting from oxidation. A
large population based
study found that patients with high blood levels
of Vitamin C had a lower HbA1C.
Furthermore, patients with diabetes have low levels of Vitamin C in their cells, which can result in
impaired wound healing. High dose supplements have been shown to prevent sorbitol accumulation and
glycosilation of proteins, both of which are important factors in the development of diabetic
complications such as cataracts. 1 to 2 gram daily of Vitamin C is recommended for diabetic patients.

C. VITAMIN E:
Vitamin E reduces oxidative stress, thus improving membrane physical characteristics and related
activities in glucose transport.

This antioxidant promotes healing of diabetes-related lesions, whose cause is undetermined.

Researchers have extensively investigated the possible effects of vitamin E supplementation on the
cardiac autonomic nervous system in patients with type 2 diabetes and cardiac autonomic neuropathy. It
was reported in the American Journal of Clinical Nutrition that daily vitamin E supplementation (600 mg)
for 4 months improved the ratio of cardiac sympathetic to parasympathetic tone in patients with NIIDM.
In short, Vitamin E (800
This effect might be mediated by a decline in oxidative stress.
to 1200 I.U.) improves insulin action and prevents a host of
long-term complications of diabetes including neuropathy.
In another study, 21 NIIDM patients with microangiopathic complications were divided into 2 groups, in
which 11 patients took 900 mg of vitamin E daily and the other group of 10 diabetic patients took a
placebo daily for 6 months. The vitamin E was provided in tablets containing 100 mg of dl-alpha-
tocopheryl acetate. The mean age of these subjects was 58 years. This study showed that these
diabetic patients had impaired erythrocyte osmotic fragility, and that pharmacological doses of vitamin E
increased the resistance of erythrocytes to osmotic hemolysis in patients with microangiopathy.

Vitamin E also appears to play a significant role in the prevention of diabetes. Studies
have
shown that a low vitamin-E concentration was associated with a
3.9 times greater risk of developing diabetes.

Questions? Ask me.

D. Digestive enzymes:
Largely because of our modern diets, which are deficient in enzymes, most of us deplete our body's
natural enzyme level as we age. Tests have shown that a 70-year-old person has only about half
the enzyme level of a 20-year-old. A newborn baby has 100 times the enzymes levels of an elderly
person! As we become enzyme-deficient, we age faster. Lack of enzymes also puts stress on vital
organs like the pancreas, liver and spleen, causing a metabolic deficit.

Unfortunately, cooking any food at temperatures above above 116 degrees Fahrenheit kills all enzymes.
All canned or bottled foods contain no enzymes because they are cooked before being processed.
Raw vegetables and fruits can be an excellent natural source of enzymes if they are allowed to ripen.
Unfortunately, they contain no enzymes when they are picked "green" (often the case in supermarkets
because they have to be transported over long distances). Enzymes can only develop when they ripen
on the plant. Irradiating food, or treating it with preservatives can also kill enzymes.

Enzymes in raw food can actually digest as much as 75 percent of the food itself without the help of
enzymes secreted by your body. Without sufficient enzyme levels, the foods you eat can't be completely
broken down and absorbed. Diabetics
have a greatly weakened state of
their pancreas and digestive tract. Two common deficiencies in
the diabetic are lipase and amylase.
 Lipase. The lipase level in the pancreatic juice of many diabetics was found to be decreased.
Most people associate diabetes with sugar intolerance, but fat intolerance is the major enzyme
culprit. The inability to digest fat interferes with insulin metabolism and the transport of glucose
into the cell by insulin. Lipase breaks down neutral fats (triglycerides) into glycerol (an alcohol)
and fatty acids (see quick definition). Lipase deficiency is therefore associated with
diabetes and glucosuria (sugar in the urine without symptoms of diabetes).

 Amylase. Researchers have shown that over 80% of the diabetics examined had a deficiency
of amylase in their intestinal secretions. Amylase supplementation has been associated
with increased utilization of sugar and lowered blood sugar levels in diabetics.

E. Magnesium:
Magnesium is involved in many areas of glucose metabolism. Its deficiency is common
among diabetics. Supplementation of magnesium may prevent some of the complications of
diabetes, such as retinopathy and heart disease. The RDA for magnesium is 350 mg day for adult
males and 300 mg for adult females. The diabetic may need 700 mg. The average diet
contains about 200 mg a day, so the majority of adults are deficient. Magnesium occurs abundantly in
whole foods such as seeds, nuts, whole grains, and green leafy vegetable, but food processing takes
out a large portion. In addition to magnesium at least 50 mg of vitamin B6 should be taken, as the
level of intracellular vitamin B6 appears to be linked to the magnesium content of the cell. Without
adequate B6, magnesium's entrance into the cell is impaired.

2. Auxiliary Supporting nutrients

A. ALPHA-LIPOIC ACID: Lipoic Acid is an antioxidant that is especially effective for the treatment of
diabetic poly neuropathy- the nerve degeneration that often accompanies diabetes - which causes pain,
tingling, and numbness in the hands and feet. Red and organ meats are the richest dietary sources, but
it is also found in carrots, yams, beets, and spinach. Take 300-500 mg a day.

B. BITTER MELON: A member of the squash family, this plant normalizes glucose levels and is used as
the sole remedy for diabetes in some parts of China and India. Clinical trials have shown good results
with NIIDM who were given 2 ounces of the juices. Drink 2 ounces of the juice daily for the first week,
and then increase the dose to 8 ounces.

C. BLUEBERRY: Incorporating this fruit into your diet on a regular basis helps protect your arteries and
nerves from damage due to diabetes. Eat at least 1/2 cup of fresh berries every day, or take 25 mg
capsules two times a day.

D. Bilberry (European Blueberry): This is a plant from Europe. Bilberry leaf tea has a long history of
folk use in the treatment of diabetes. This use is supported by research which has shown that an oral
intake reduces blood sugar levels in normal and diabetic animals. Bilberry flavonoids (anthocyanosides)
have been shown to increase intracellular vitamin C levels, decrease the leakiness and breakage of
small vessels commonly associated with vascular damage from diabetes, has an affinity for blood
vessels of the eye and retina, and improves circulation t the retina. This affinity is consistent with several
clinical trials showing positive results with diabetic retinopathy. The dose widely used in Europe is
standardized to contain 25% anthocyanidine. Take 50 mg to 100 mg three times a day.

E. VITAMIN A: This antioxidant helps convert beta-carotene efficiently, which reduces the risk of
blindness in diabetics. Foods rich in vitamin A include green leafy vegetables, sweet potatoes, fish,
watermelon, and cantaloupe. Take 2,500 I.U. daily.

F. ZINC: Diabetics typically excrete excessive amounts of zinc in the urine and therefore require
supplementation. Taken daily, this mineral helps control blood-sugar levels. Take 30 mg a day.

G. GINKGO BILOBA: Gingko has been shown to improve cerebral and peripheral vascular blood flow.
This is important for diabetics who commonly suffer from peripheral vascular insufficiency. Dosage is
standardized to contain 24% gingko flavoglyosides. Take 40 to 80 mg three times a day.

H. GYMNEA SYLVESTRE: This Ayurvedic medicine has been used in India for centuries to improve
blood-sugar levels. It works to regenerate the insulin-producing beta cells in the pancreas. Gymnea
extract has shown positive clinical results in reduce blood sugar in both Type I and II diabetics. It is
interesting to note that no blood-sugar-lowering effect is seen in healthy volunteers. Take 200 mg 1 -2
times a day.

I. Vitamin B12: Vitamin B12 supplementation has been used successfully to treat diabetic neuropathy.
Vitamin B12 deficiency is characterized by numbness of the feet, pins-and-needles sensation, or a
burning feeling - common symptoms of diabetic neuropathy. Oral supplementation with 500 to 2,000
mcg per day is usually sufficient.

J. Vanadium: The amount of vanadium we get in our diet appears to be 50-60 mcg. In the therapeutic
use in diabetes management, dosage required is often 1000-fold greater. Unfortunately, vanadium
compounds have not been extensively tested in clinical trails. The use of vanadium for treatment of
diabetes should best be taken under the supervision of a knowledgeable physician.

K. FISH OILS: These oils help improve insulin efficiency by enhancing blood flow to arteries and
reducing the clumping of red blood cells. Coldwater fish, such as salmon, are a good source, or you can
take 500 mg capsules twice a day, or simply eat 8-12 ounces of fish per week.

Attention

Because of tremendous individual variation, the use of nutritionals

should therefore be personalized for your body. One person’s nutrient
can be another person’s toxin. If you have a specific health concern
and wish my personalized nutritional recommendation, write to me by
clicking here.

3. Diabetic Low Glycemic Index Diet:

Dietary control of diabetes comes down to 2 simple principles:

a. Eat less (fewer calories) to maintain ideal body weight.

b. Eat low glycemic index foods that do not turn into sugar
quickly
The Glycemic Index (GI)
The glycemic index represents the magnitude of the increase in blood glucose that occurs after
ingestion of the food. This index measures how much your blood sugar increases in the two or
three hours after eating.

When you make use of the glycemic index to prepare healthy meals, it helps to keep your blood sugar
levels under control. GI tends to be lower for foods that are present in relatively large particles,
minimally processed, and are ingested along with fat and protein.

Below are the general guidelines to what is considered high or low Glycemic Index (GI) foods.

High GI Foods

The following foods are considered unacceptable:

· Foods containing sugar, honey, molasses, & corn syrup.

· Breads - all white breads, all white flour products, corn breads
· Grains - rice, rice products, millet, corn, corn products
· Cereals - all cereals except those on the Low GI List below
· Pasta - thick, large pasta shapes
· Fruits - bananas, watermelon, pineapple, raisins
· Vegetables - potatoes, corn, carrots, beets, turnips, parsnips
· Snacks - potato chips, corn chips, popcorn, rice cakes, pretzels
· Alcohol - beer, liqueurs, all liquor except red wine

Low GI Foods

Look at what you can have:

· Breads - whole rye, pumpernickel, whole wheat pita

· Grains - barley, bulgur, kasha
· Cereals - Special K, All Bran, Fiber One, regular oatmeal
· Pasta - whole-wheat pasta, bean threads
· All meats
· All dairy products (no sugars)
· Whole Fruits - all except the High GI fruits above
· Green leafy Vegetables - all except the High GI vegetables listed above
· Snacks - nuts, olives, cheese, pita chips, fried pork rinds
· Alcohol - red wine
· Misc. - olives, eggs, peanut butter (no sugar)

Anti-Aging Food Pyramid for Diabetes

This Diet consists of 50-55% complex carbohydrates of low
glycemic type (whole fruits, above ground vegetables, whole
grains), 20-25% protein (preferably from plant sources), 25-30%
fat. The normal 5% sweets, candies and dessert should be
avoided.

There are three major layers to the Anti-Aging Food Pyramid. They are
divided into daily, 2-3 times a week, and weekly layers. Imagine a pyramid
with three layers, each layer getting much narrower as it gets closer to the tip.

The daily broad base layers of the pyramid starts with 10 glasses of pure
filtered water a day and complex carbohydrates supplying up to 55% of the
calories These carbohydrates are those of low glycemic index type - barley,
cereal, legumes, and above ground vegetables. A limited amount of nuts,
which is a fatty food, is also included in this first base layer. Three servings of
vegetables should be eaten daily. High glycemic index complex carbohydrates
such as wheat, rice, and corn should be restricted. Moderate amounts are
acceptable if they are mixed with fat and protein.

Eggs also form part of the base layers. It is a good protein source. One egg
per day is acceptable (including those used in cooking and baking). Organic
eggs are the best.

Olive oil and fats from fish; nuts are part of this daily layer. 25-30% of the
calories in your comes from fats. The fats in the diet should come mainly from
olive oil, which is high in monounsaturated fats and also a good source of
antioxidant. Some come from the fish, poultry and meat consumed.

The second layer is a much smaller layer containing protein food from fish
and poultry. You should eat from this group 2-3 times a week. Fish should be
those that live in deep and cold water, such as salmon and tuna. Poultry
should preferably come from free-range chickens.

The third layer, which is very small, contains foods that one should eat 1 time
a week. These include sweets, red meat (lean). If blood sugar is severely
impaired, sweets should be avoided altogether.

Diet Tips for Diabetes Mellitus

a. Reduce overall fat, especially trans- fat commonly found in fried food so the
overall calories is immediately reduced, as a result, weight loss is inevitable. Use oils or foods that are
high in Omega-3 fatty acid, such as olive oil, rapeseeds oil, flaxseed and flaxseed oil, for they lower
insulin requirements.
b. Eliminate refined carbohydrates and sugar from your diet, as they
increase the blood sugar immediately. Substitute complex carbohydrates that have lots of fiber. Beware
that sweet snacking is a frequent behavior at times of stress. Fruit should be the major source of
sweetness in your diet, as they are low in calories, high in fibers, and many other minerals and vitamins
which are essential for keeping the body healthy.

c. Watch the glycemic Index (a rating system to measure food's effects on blood sugar
levels) of the carbohydrates that you consume. The higher the glycemic index, the more pronounced the
food will have on your blood sugar, and scientific studies have shown that leads to excessive food intake
in obese subjects.

d. Celery, Bitter Melon, Onion, Garlic, Globe Artichoke,

Jerusalem artichoke, Asparagus and Spinach are vegetables
that alleviate Diabetes Mellitus.
f. Refrain from excessive protein in your diet. Try meat substitutes or non-
animal protein foods such as legumes tofu. Eat more fish, chicken and very little red meats (12-16 oz.
per month). Legumes are excellent insulin regulators.

g. Split your menu into 6 small meals per day, rather than the traditional 3
square meals. This way, you will maintain a balance in your blood sugar and the level of nutrients in
your body throughout the day.

4 . Exercise
While most
No diabetes program is complete without a well-balanced exercise program.
people think of exercise as a way to reduce body weight
(especially since 80% of diabetes are obese), exercise does
much more, including reducing insulin resistance and
impotence. Numerous studies have confirmed that exercise can cause a reduction in insulin
resistance and thus diabetes. For example, a study was conducted on 5,159 men aged 40 to 59 years
with no history of coronary heart disease, type 2 diabetes or stroke. During an average follow-up period
of 16.8 years, there were 616 cases of major coronary heart disease cases and 196 incident cases of
type 2 diabetes. Risk decreased progressively for type 2 diabetes, according to the Archives of Internal
Medicine 2000 (160:2108-2116).

A well-balanced exercise must include three components:

a. Flexibility training
b. Cardiovascular training.
c. Strength training.
Ideally, about 2000 calories should be burned per week. Working
out with 30 minutes of aerobics exercise at moderate intensity 5
times a week plus 15-20 minutes of strength training 3 times a
week will accomplish this goal.

5. Prescription Medications
If the above protocol fails, drugs and insulin have to be used. Oral Medications commonly prescribed fall
into one of 4 categories:
 A. Medications that Increase the Insulin Output by the Pancreas, such as
chlorpropamide and tolbutaminde, glyburide, glipizide, and glimepiride.

B. Medications that decrease the amount of glucose coming from the liver such as
metformin (Glucophage). Metformin does not alter concentrations of insulin in the blood
and, therefore, rarely causes low blood glucose levels.

C. Medications that increase the sensitivity of cells to insulin, such as Troglitazone (Rezulin) which
was taken off the market in March 2000 due to liver toxicity, or rosiglitazone (Avandia) whose long-term
safety profile is not known.

D. Medications that Decrease the Absorption of Carbohydrates from the Intestine such as Precose.
Precose has significant gastrointestinal side effects. Abdominal pain, diarrhea, and gas are common and
are seen in up to 75% of patients.

Summary:
Type 1 Diabetes Mellitus is a disease that requires insulin to
sustain life.

Type 2 Diabetes Mellitus (NIIDM) is a disease that is largely

curable.
Treatment of NIIDM from a drug-free perspective includes a
protocol consisting of 3 steps taken concurrently:

1. Diet of low glycemic index food to reduce sugar imbalance.

2. Exercise to maintain ideal body weight and reduce insulin

resistance.

3. Nutritional Supplements, including: Chromium Polynicotinate

400- 1200 mcg a day, Vitamin C 1- 2 grams a day, Vitamin E 800-
1200 I.U. a day, and magnesium 200-300 mg two to three times a
day.

Auxiliary supplements include alpha lipoic acid 300-500 mg a day, bitter melon 2
ounces a day, blueberry 25 mg two times a day, vitamin B12 500- 2000mcg a day, and gingko
biloba 40 to 80 mg three times a day.

If the above fails to control blood sugar, prescription medications should be considered. Conversely,
those who are already on medications may be weaned off slowly under the supervision of a physician
and following the above protocol.

Message from Dr. Lam

I hope you have enjoyed reading this article. If you have areas you
 don’t understand, comments (good or bad), or if you have a specific
health concern, feel free to write to me by clicking here.

About The Author

Michael Lam, M.D., M.P.H., A.B.A.A.M. is a specialist in Preventive and Anti-Aging Medicine.
He is currently the Director of Medical Education at the Academy of Anti-Aging Research,
U.S.A. He received his Bachelor of Science degree from Oregon State University, and his
Doctor of Medicine degree from Loma Linda University School of Medicine, California. He
also holds a Masters of Public Health degree and is Board Certification in Anti-aging
Medicine by the American Board of Anti-Aging Medicine. Dr. Lam pioneered the formulation of
the three clinical phases of aging as well as the concept of diagnosis and treatment of sub-
clinical age related degenerative diseases to deter the aging process. Dr. Lam has been
published extensively in this field. He is the author of The Five Proven Secrets to Longevity
(available on-line). He also serves as editor of the Journal of Anti-Aging Research.

For More Information

For the latest anti-aging related health issues, visit Dr. Lam at www.LamMD.com. Feel free to
email Dr. Lam at dr@LamMD.com if you have any questions.

Reprint Information

This article may, in its unabridged, unaltered form and in its entirety only, be reprinted and
republished without permission provided that it is for personal and non commercial education
use only and further provided that credit be given to the author, with copyright notice and
www.LamMD.com clearly displayed as source. Written permission from Dr. Lam is
required for all other use.

©2002 Michael Lam, M.D. All Rights Reserved.

References:
Modern Nutrition In Health and Disease, Eighth Ed., 1994. Shils, Olson and Shike, eds

Abraham AS, et al.: The effects of chromium supplementation on serum glucose and lipids in patients with and without non-
insulin dependent diabetes. Metabolism 41:768-771, 1992.

Allen, FM: Blueberry Leaf Extract: Physiologic and Clinical Properties in Relation to Carbohydrate Metabolism. JAMA
89:1577-81, 1927.

Anderson R, et al.: Beneficial effects of chromium for people with Type II Diabetes. Diabetes. 45(Suppl. 2):124A.
Anderson R: Chromium metabolism and its role in disease prevention in man. Clin Physiol Biochem. 4(1):31-41, 1986.

Anderson RA, et al.: Supplemental chromium effects on glucose, insulin, glucagon, and urinary chromium losses in subjects
consuming low-chromium diets. Am J of Clin Nutr. 54:909-916, 1991.

Anderson, R. A., et al. Chromium supplementation of human subjects: Effects on glucose, insulin, and lipid variables.
Metabolism. 32:894-899, 1983.

Anderson, RA, et al. Elevated intake of supplemental chromium improves glucose and insulin variables in individuals with
type 2 diabetes. Diabetes (1997) 46:1786-1791.

Araki, A, et al.: Plasma homocysteine concentrations in Japanese patients with non-insulin-dependent diabetes mellitus:
Effect of parenteral methylcobalamin treatment. Atherosclerosis. 103:149-157, 1993.
Baskaran, K, et al.: Antidiabetic effects of a leaf extract from Gymnema Sylvestre in non-insulin-dependent diabetes mellitus
patients. J of Ethnopharmacology. 30:295-305, 1990.

Basualdo, CG, et al. Vitamin A (retinol) status of first nation adults with non-insulin-dependent diabetes mellitus. J Am Coll
Nutr. 16(1):39-45, 1997.

Bever, B and Zahnd, G: Plants with Oral Hypoglycemic Action. Quart J Crude Drug Res 17:139-96, 1979.

Bilberry - the vision herb. Mediherb Professional Review. Number 59. August 1997.

Chromium supplements judged safe. Food Chemical News. November 17, 1997, pp 9.

Cohen, N, et al.: Oral vanadyl sulfate improves hepatic and peripheral insulin sensitivity in patients with non-insulin-
dependent diabetes mellitus. J of Clin Investigations. 95(6):2501-2509, 1995.

Davies S, et al.: Age-related decreases in chromium levels in 51,665 hair, sweat, and serum samples from 40,872 patients -
implications for the prevention of cardiovascular disease and type II diabetes mellitus. Metabolism. 46(5):469-473, 1997.

Eibi, NL, et al.: Hypomagnesemia in type II diabetes: Effect of a 3-month replacement therapy. Diabetes Care. 18:188, 1995.

Estrada, EH, et al.: Stimulation of glucose uptake by the natural coenzyme a-lipoic acid/thioctic acid. Diabetes. 45:1798-
1804, 1996.

Evans GW: The effect of chromium picolinate on insulin controlled parameters in humans. Int J Biosocial Med Research.
11:163-180, 1989.

Friday KE, et al.: The effect of omega-3 fatty acid supplementation on glucose homeostasis and plasma lipoproteins in type II
diabetic subjects. Am J of Clin Nutr. 45:871, 1987.

Gaby AR, et al.: Nutritional Therapy in Medical Practice: Reference Manual and Study Guide. Wright/Gaby Seminars, Kent,
Washington. Pages 54-64, 1996.

George Washington University, Department of Pharmacology, Washington, D.C., Chromium Toxicity Study, 1995
Glauber H, et al.: Adverse effect of omega-3 fatty acids in non-insulin dependent diabetes mellitus. Ann Intern Med. 108:663-
668, 1988.

Henricksson, J, et al.: Influence of exercise on insulin sensitivity. J Cardio Risk 2(4):303-309, 1995.

Jacobs, S, et al.:Enhancement of glucose disposal in patients with type 2 diabetes by alpha-lipoic acid. Drug Res. 45:872-
874, 1995 .

Kaats, G. R., et al.: Effects of chronium picolinate supplementation on body composition: A randomized double masked,
placebo controlled study. Curr Ther Res. 57:747-756, 1996.

Krone CA , Ely JT: Vitamin C and glycohemoglobin revisited. Clin Chem, 47(1): 148 2001

Lee NA, et al.: Beneficial effect of chromium supplementation on serum triglyceride levels in NIDDM. Diabetes Care.
17:1449-1452, 1994.

Manzella D, Barbieri M, Ragno E, Paolisso G: Chronic administration of pharmacologic doses of vitamin E improves the
cardiac autonomic nervous system in patients with type 2 diabetes Am J Clin Nutr 73: 1052-1057. 2001

Mertz W, et al.: Present knowledge of the role of chromium. Federation Proceedings. 33:2275-2280, 1974.

Miller, JC, et al.: Replacing starch with sucrose in a high glycaemic index breakfast cereal lowers glycaemic and insulin
responses. Eur J Clin Nutr 48(10):749-752, 1994.

Murray, M and Pizzorno, J: Encyclopedia of Natural Medicine. Rocklin, CA: Prima Publishing, 1998.

Nadler, JL, et al.: Magnesium deficiency produces insulin resistance and increased thromboxane synthesis. Hypertension
21(6 Pt 2):1024-1029, 1993.

Okabayashi, Y, et al.: Effect of Gymnema sylvestre, R.Br. on glucose homeostasis in rats. Diabetes Res Clin Pract. 9(2):143-
148, 1990.

Paolisso G, et al.: Metabolic benefits deriving from chronic vitamin C supplementation in aged non-insulin dependent
diabetics. J Am Coll Nutr Aug 14:4 387-92, 1995.

Paolisso, G, et al.: Improved insulin response and action by chronic magnesium administration in aged NIDDM subjects.
Diabetes Care. 12:265-269, 1989.

Schroeder HA: Serum cholesterol and glucose levels in rats fed refined and less refined sugars and chromium. J Nutr.
97:237--242, 1969.

Sparkman DR: Chromium picolinate safety. All Natural Muscle Development. 35(6):40, 1998.

Tutuncu NB, Bayraktar M, Pehlivanoglu B: The effect of vitamin E supplementation on erythrocyte osmotic fragility in diabetic
patients. Clin Hemorheol Microcirc 20(3):201-7, 1999.

U. S. Dept. of Agriculture, Human Nutrition Research Center, Chromium Study, 1996

United States Department of Agriculture. Agricultural Research Service Quarterly Report of Selected Research Projects. Jul-
Sept, 1997.

Wagh, SS, et al.: Mode of action of lipoic acid in diabetes. J of Bioscience. 11:59-74, 1987.

Welihinda, J, et al.: The insulin-releasing activity of the tropical plant Momardica charantia. Acta Biologica Medica Germania.
41:1229-1440, 1982.

Welihinda, J, et al.: Effect of Momardica charantia on the glucose tolerance in maturity onset diabetes. J of
Ethnopharmacology 17:277-282, 1986.

Ziegler, D, et al.: Effects of treatment with the antioxidant alpha-lipoic acid on cardiac autonomic neuropathy in NIDDM
patients. A 4-month randomized controlled multicenter trial (DEKAN Study). Diabetes Care. 20(3):369-373, 1997.

http://www.drlam.com/A3R_brief_in_doc_format/Diabetes.cfm
Diabetes Mellitus

What is diabetes mellitus?

Diabetes is a disease in which the body doesn't produce or properly use insulin. Insulin is a hormone
produced in the pancreas, an organ near the stomach. Insulin is needed to turn sugar and other food
into energy. When you have diabetes, your body either doesn’t make enough insulin or can’t use its own
insulin as well as it should, or both. This causes sugars to build up too high in your blood.

Diabetes mellitus is defined as a fasting blood glucose of 126 milligrams per deciliter (mg/dL) or more.
“Pre-diabetes” is a condition in which blood glucose levels are higher than normal but not yet diabetic.
People with pre-diabetes are at increased risk for developing type 2 diabetes, heart disease and stroke,
and have one of these conditions:

 impaired fasting glucose (100 to 125 mg/dL)

 impaired glucose tolerance (fasting glucose less than 126 mg/dL and a glucose level
between 140 and 199 mg/dL two hours after taking an oral glucose tolerance test)

What are type 1 and type 2 diabetes?

Type 2 diabetes is the most common form. It appears most often in middle-aged adults; however,
adolescents and young adults are developing type 2 diabetes at an alarming rate. It develops when the
body doesn’t make enough insulin and doesn’t efficiently use the insulin it makes (insulin resistance).

Type 1 diabetes usually occurs in children and young adults. In type 1, the pancreas makes little or no
insulin. Without daily injections of insulin, people with type 1 diabetes won’t survive.

Both forms of diabetes may be inherited in genes. A family history of diabetes can significantly increase
the risk of developing diabetes. Untreated diabetes can lead to many serious medical problems. These
include blindness, kidney disease, nerve disease, limb amputations and cardiovascular disease (CVD).

How are insulin resistance, diabetes and CVD related?

Diabetes is treatable, but even when glucose levels are under control, it greatly increases the risk of
heart disease and stroke. In fact, most people with diabetes die of some form of heart or blood vessel
disease.

Pre-diabetes and subsequent type 2 diabetes usually result from insulin resistance. When insulin
resistance or diabetes occur with other CVD risk factors (such as obesity, high blood pressure, abnormal
cholesterol and high triglycerides), the risk of heart disease and stroke rises even more.

Insulin resistance is associated with atherosclerosis (fatty buildups in arteries) and blood vessel
disease, even before diabetes is diagnosed. That’s why it’s important to prevent and control insulin
resistance and diabetes. Obesity and physical inactivity are important risk factors for insulin resistance,
diabetes and cardiovascular disease.

How is diabetes treated?

When diabetes is detected, a doctor may prescribe changes in eating habits, weight control and
exercise programs, and even drugs to keep it in check. It's critical for people with diabetes to have
regular checkups. Work closely with your healthcare provider to manage diabetes and control any other
risk factors. For example, blood pressure for people with diabetes and high blood pressure should be
lower than 130/80 mm Hg.

AHA Recommendation
Diabetes is a major risk factor for stroke and coronary heart disease, which includes heart attack.
People with diabetes may avoid or delay heart and blood vessel disease by controlling the other risk
factors. It's especially important to control weight and blood cholesterol with a low-saturated-fat, low-
cholesterol diet and regular aerobic physical activity. It's also important to lower high blood pressure and
not to smoke.

For information on hyperglycemia and hypoglycemia, please see the related entry in this encyclopedia.

Related AHA publications:

 Heart and Stroke Facts

 Know the Facts, Get the Stats
 Diabetes, Heart Disease and Stroke (also in Spanish)
 An Eating Plan for Healthy Americans
 Managing your Weight (also in Spanish)
 Easy Food Tips for Heart-Healthy Eating (also in Spanish)
 Reading Food Labels: A Handbook for People With Diabetes, order from American Diabetes
Association (1-800-232-3472)
 "How Can I Manage My Weight?" in Answers By Heart kit (also in Spanish kit)

Related AHA Scientific Statements:

Diabetes Mellitus

http://www.americanheart.org/presenter.jhtml?identifier=4546
diabetes mellitus

On this page:

diabetes mellitus
Medical Encyclopedia

Diabetes Information
Helpful information about Diabetes including treatment options.
www.healthology.com

Home > Library > Health > Medical Encyclopedia

Diabetes Mellitus

Definition

Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or when 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. The
treatment includes changes in diet, oral medications, and in some cases, daily injections of insulin.

Description

Diabetes mellitus is a chronic disease that causes serious health complications including renal (kidney)
failure, heart disease, stroke, and blindness. Approximately 14 million Americans (about 5% of the
population) have diabetes. Unfortunately, as many as one-half are unaware that they have it.

Background

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 bonds to a receptor site on the outside of 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 will also 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.
Types of diabetes mellitus

Type I 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 I diabetes. This form is
also called insulin-dependent diabetes because people who develop this type need to have daily
injections of insulin.

Brittle diabetics are a subgroup of Type I where patients have frequent and rapid swings of blood sugar
levels between hyperglycemia (a condition where there is too much glucose or sugar in the blood) and
hypoglycemia (a condition where there is abnormally low levels of glucose or sugar in the blood). These
patients may require several injections of different types of insulin during the day to keep the blood
sugar level within a fairly normal range.

The more common form of diabetes, Type II, 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 the diabetics in the United
States are Type II diabetics. 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 are also more likely to
develop Type II diabetes than those who remain in their original countries.

Type II is considered a milder form of diabetes because of its slow onset (sometimes developing over
the course of several years) and because it can usually be controlled with diet and oral medication. The
consequences of uncontrolled and untreated Type II diabetes, however, are the just as serious as those
for Type I. This form is also called noninsulin-dependent diabetes, a term that is somewhat misleading.
Many people with Type II 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. The condition is usually treated by diet, however, insulin
injections may be required. These women who have diabetes during pregnancy are at higher risk for
developing Type II diabetes within 5–10 years.

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

Causes and symptoms

Causes

The causes of diabetes mellitus are unclear, however, 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 I diabetes, the immune system, the body's
defense system against infection, is believed to be triggered by a virus or another microorganism to
destroy the cells in the pancreas that produce insulin. In Type II diabetes, age, obesity, and family
history of diabetes play a roll.

In Type II 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 II diabetes can begin so
gradually that a person may not know that they have 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 II 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 II diabetes mellitus include people who:
  are obese (more than 20% above their ideal body weight)
 have a relative with diabetes mellitus
 belong to a high-risk ethnic population (African-American, Native American,
Hispanic, or Native Hawaiian)
 have been diagnosed with gestational diabetes or have delivered a baby
weighing more than 9 lbs (4 kg)
 have high blood pressure (140/90 mmHg or above)
 have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL
and/or a triglyceride level greater than or equal to 250 mg/dL
 have had impaired glucose tolerance or impaired fasting glucose on previous
testing

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 glucocorticorids), and the anti-inflammation drug
indomethacin. Several drugs that are used to treat mood disorders (such as anxiety and depression)
can also 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.

Symptoms

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 I 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 II 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.

Diagnosis

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

Urine tests

Clinistix and Diastix are paper strips or dipsticks that change color when dipped in urine. The test strip is
compared to a chart which 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 in Type I diabetics, 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.

Blood 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 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.

Treatment

There is currently no cure for diabetes; the condition, however, can be managed so that patients can live
a relatively normal life. Treatment of diabetes focuses on two goals: keeping blood glucose within
normal range and preventing the development of long-term complications. Careful monitoring of diet,
exercise, and blood glucose levels are as important as the use of insulin or oral medications in
preventing complications of diabetes.

Dietary changes

Diet and moderate exercise are the first treatments implemented in diabetes. For many Type II
diabetics, 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 their 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 are usually 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 American Dietetic
Association 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.

For many Type II diabetics, weight loss is an important factor in controlling their condition. The food
exchange system, along with a plan of moderate exercise, can help them lose excess weight and
improve their overall health.
Oral medications

Oral medications are available to lower blood glucose in Type II diabetics. The drugs first prescribed for
Type II 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, glimeperide, and glipizide. The way that 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 troglitizone. The choice of the right
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
also has stomach ulcers. While these medications are an important aspect of treatment for Type II
diabetes, they are not a substitute for a well planned diet and moderate exercise. Oral medications are
not effective for Type I diabetes, in which the patient produces little or no insulin.

Insulin

Patients with Type I 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 II 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.

Purified human insulin is most commonly used, however, insulin from beef and pork sources are also
available. Insulin may be given as an injection of a single dose of one type of insulin once a day.
Different types of insulin can be mixed and given in one dose or split into two or more doses during a
day. Patients who require multiple injections over the course of a day may be able to use an insulin
pump that administers small doses of insulin on demand. The small battery-operated pump is worn
outside the body and is connected to a needle that is inserted into the abdomen. Pumps can be
programmed to inject small doses of insulin at various times during the day, or the patient may be able
to adjust the insulin doses to coincide with meals and exercise.

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.

Surgery

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.

Alternative treatment

Since diabetes can be life-threatening if not properly managed, patients should not attempt to treat this
condition without medicial 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 cetain points. A qualified practitioner should be
consulted. Herbal remedies may also 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:
  fenugreek (Trigonella foenum-graecum) has been shown in some studies to
reduce blood insulin and glucose levels while also lowering cholesterol
 bilberry (Vaccinium myrtillus) may lower blood glucose levels, as well as
helping to maintain healthy blood vessels
 garlic (Allium sativum) may lower blood sugar and cholesterol levels
 onions (Allium cepa) may help lower blood glucose levels by freeing insulin to
metabolize it
 cayenne pepper (Capsicum frutescens) can help relieve pain in the peripheral
nerves (a type of diabetic neuropathy)
 ginkgo (Gingko biloba) may maintain blood flow to the retina, helping to
prevent diabetic retinopathy

Any therapy that lowers stress levels can also 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.

Prognosis

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 are also more common in diabetics.

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.

Prevention

Research continues on ways to prevent diabetes and to detect those at risk for developing diabetes.
While the onset of Type I diabetes is unpredictable, the risk of developing Type II 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 II diabetes and preventing further complications of the
disease.

Resources

BOOKS

"Diabetes Mellitus." In Professional Guide to Diseases. 5th ed. Springhouse, PA: Springhouse
Corporation, 1995.

Foster, Daniel W. "Diabetes Mellitus." In Harrison's Principles of Internal Medicine, ed. Anthony S. Fauci,
et al. New York: McGraw-Hill, 1997.

Garber, Alan J. "Diabetes Mellitus." In Internal Medicine,ed. Jay H. Stein, et al. St. Louis: Mosby, 1998.
Karam, John H. "Diabetes Mellitus & Hypoglycemia." In Current Medical Diagnosis and Treatment,
1998. 37th ed. Ed. Stephen McPhee, et al. Stamford: Appleton & Lange, 1997.

Sherwin, Robert S. "Diabetes Mellitus." In Cecil Textbook of Medicine, ed. J. Claude Bennett and Fred
Plum. Philadelphia: W. B. Saunders Co., 1996.

Smit, Charles Kent, John P. Sheehan, and Margaret M. Ulchaker. "Diabetes Mellitus." In Family
Medicine, Principles and Practice. 5th ed. Ed. Robert B. Taylor. New York: Springer-Verlag, 1998.

PERIODICALS

"Trends in the Prevalence and Incidence of Self-Reported Diabetes Mellitus-United States, 1980-1994."
Morbidity & Mortality Weekly Report 46 (1997): 1014-1018.

"Updated Guidelines for the Diagnosis of Diabetes in the US." Drugs & Therapy Perspectives 10 (1997):
12-13.

ORGANIZATIONS

American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 342-2383.
<http://www.diabetes.org>.

American Dietetic Association. 216 W. Jackson Blvd., Chicago, IL 60606-6995. (312) 899-0040.
<http://www.eatright.org>.

Juvenile Diabetes Foundation. 120 Wall St., 19th Floor, New York, NY 10005. (800) 533-2873.
<http://www.jdf.org>.

National Diabetes Information Clearinghouse. 1 Information Way, Bethesda, MD 20892-3560. (800)

860-8747. <http://www.niddk.nih.gov/health/diabetes/ndic.htm>.

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Building 31, Room 9A04, 31
Center Drive, MSC 2560, Bethesda, MD 208792-2560. (301) 496-3583. <http://www.niddk.nih.gov>.

OTHER

Centers for Disease Control. <http://www.cdc.gov/nccdphp/ddt/ddthome.htm>.

"Insulin-Dependent Diabetes." National Institute of Diabetes and Digestive and Kidney Diseases.
National Institutes of Health, NIH Publication No. 94-2098.

"Noninsulin-Dependent Diabetes." National Institute of Diabetes and Digestive and Kidney Diseases.
National Institutes of Health, NIH Publication No. 92-241.

[Article by: Altha Roberts Edgren]

Dictionary

Home > Library > Words > Dictionary

diabetes mel·li·tus (mə-lī'təs, mĕl'ĭ-)
n.
 1. A severe, chronic form of diabetes caused by insufficient production of insulin
and resulting in abnormal metabolism of carbohydrates, fats, and proteins. The
disease, which typically appears in childhood or adolescence, is characterized
by increased sugar levels in the blood and urine, excessive thirst, frequent
urination, acidosis, and wasting. Also called insulin-dependent diabetes, type
1 diabetes.
2. A mild form of diabetes that typically appears first in adulthood and is
exacerbated by obesity and an inactive lifestyle. This disease often has no
symptoms, is usually diagnosed by tests that indicate glucose intolerance, and
is treated with changes in diet and an exercise regimen. Also called non-
insulin-dependent diabetes, type 2 diabetes.

[New Latin diabētēs mellītus : Latin diabētēs, diabetes + Latin mellītus, honey-sweet.]

http://www.answers.com/topic/diabetes-mellitus?cat=health

Medical Diagnosis

Home > Library > Health > Medical Reference

Diabetes Mellitus

What is diabetes mellitus?

Diabetes mellitus is a group of metabolic diseases characterized by high bloodsugar (glucose) levels,
which result from defects in insulin secretion, or action, or both. Diabetes mellitus, commonly referred to
as diabetes, means "sweet urine." 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 bythe 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 mellitus, the absence or insufficient production of insulin causes
hyperglycemia. Diabetes mellitus is a chronic medical condition, meaning it can last a lifetime.

What is the impact of diabetes?

Over time, diabetes mellitus can lead to blindness, kidney failure, and nerve damage. Diabetes mellitus
is also an important factor in accelerating thehardening and narrowing of the arteries (atherosclerosis),
leading to strokes, coronary heart diseases, and other blood vessel diseases. Diabetes mellitus affects
15 million people (about 8% of the population) in the United States. In addition, an estimated 12 million
people in the United States have diabetes and don't even know it. From an economic perspective, the
total annual economic cost of diabetes in 1997 was estimated to be 98 billion dollars in the United
States. The per capita cost resulting from diabetes in 1997 amounted to $10,071, while to health care
costs for people without diabetes incurred a per capita cost of $2,699. During this same year, 13.9
million days of hospital stay were attributed to diabetes, while 30.3 million physician office visits were
diabetesrelated. Remember, these numbers reflect only the population in the UnitedStates. Globally, the
statistics are staggering.

Related Links on MedicineNet.com

 Page 2 of this Article

 Related Medical Procedures and Tests
 The Doctor's Response

Disclaimer: Information on this web site is provided for informational purposes only
and is not a substitute for professional medical advice. You should not use the
information on this web site for diagnosing or treating a medical or health condition.
You should carefully read all product packaging. If you have or suspect you have a
medical problem, promptly contact your professional healthcare provider.
Statements and information regarding dietary supplements have not been evaluated
or approved by the Food and Drug Administration. Please consult your healthcare
provider before beginning any course of supplementation or treatment.

Alternative Medicine Encyclopedia

Home > Library > Health > Alternative Medicine Encyclopedia

Diabetes Mellitus

Definition

Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or when 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, tiredness, excessive thirst, and hunger.

Description

Diabetes mellitus is a chronic disease that causes serious health complications including renal (kidney)
failure, heart disease, stroke, and blindness. Approximately 14 million Americans (about 5% of the
population) have diabetes. Unfortunately, as many as one-half of them are unaware that they have it.

Background

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 cells.
Insulin is a hormone or chemical produced by cells in the pancreas, an organ
located behind the stomach. Insulin binds to receptor sites on the outside of
cells and acts like a key to open a door-way

SYMPTOMS OF DIABETES MELLITUS

Excessive thirst
Increased appetite
Increased urination
Weight loss
Fatigue
Nausea
Blurred vision
Frequent vaginal infections in women
Impotence in men
Frequent yeast infections

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 instead
of 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. The excess sugar is excreted in the urine. It
is not unusual for people with undiagnosed diabetes to be constantly thirsty, to drink large quantities of
water, and to 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. If left untreated, ketoacidosis can lead to coma and death.

Types of Diabetes Mellitus

Type I 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 3 people in 1,000 develop Type I diabetes. This form also is
called insulin-dependent diabetes because people who develop this type need to have injections of
insulin 1–2 times per day.

Brittle diabetics are a subgroup of Type I where patients have frequent and rapid swings of blood sugar
levels between hyperglycemia (a condition where there is too much glucose or sugar in the blood) and
hypoglycemia (a condition where there are abnormally low levels of glucose or sugar in the blood).
These patients may require several injections of different types of insulin or an insulin pump during the
day to keep their blood sugar within a fairly normal range.

The more common form of diabetes, Type II, 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 the diabetics in the United
States are Type II diabetics. In 2003, a report noted that nearly one-third of the U.S. population over age
20 has this form of diabetes but remains undiagnosed. Sometimes called age-onset or adult-onset
diabetes, this form of diabetes occurs most often in people who are overweight and do not exercise. It
also is 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 are
also more likely to develop Type II diabetes than those who remain in their original countries.

Type II is considered a milder form of diabetes because of its slow onset (sometimes developing over
the course of several years) and because it can usually be controlled with diet and oral medication. The
consequences of uncontrolled and untreated Type II diabetes, however, are just as serious as those for
Type I. This form also is called noninsulin-dependent diabetes, a term that is somewhat misleading.
Many people with Type II diabetes can control the condition with diet and oral medications, however,
insulin injections sometimes are necessary.

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. The condition usually is treated by diet, however, insulin
injections may be required. Women who have diabetes during pregnancy are at higher risk for
developing Type II 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.

Causes & Symptoms

The causes of diabetes mellitus are unclear, however, 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 I diabetes, an autoimmune response is
believed to be triggered by a virus or another microorganism that destroys the cells that produce insulin.
In Type II diabetes, age, obesity, and family history of diabetes play a role.

In Type II 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 II diabetes can begin so
gradually that a person may not know that he or she has it. Early signs are tiredness, 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 II diabetes to be detected while a
patient is seeing a doctor about a health concern that was caused by the yet undiagnosed diabetes.

Individuals who are at high risk of developing Type II diabetes mellitus include people who:

 are obese (more than 20% above their ideal body weight)
 have a relative with diabetes mellitus
 belong to a high-risk ethnic population (African-American, Native American,
Hispanic, or Native Hawaiian)
 have been diagnosed with gestational diabetes or have delivered a baby
weighing more than 9 lb (4 kg)
 have high blood pressure (140/90 mmHg or above)
 have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL
and/or a triglyceride level greater than or equal to 250 mg/dL
 have had impaired glucose tolerance or impaired fasting glucose on previous
testing

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 glucocorticorids), 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.

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 un-controlled diabetes, is common in Type I 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 tiredness, and drowsiness.
Patients with ketoacidosis will also have a sweet breath odor. Left untreated, this condition can lead to
coma and death.

With Type II 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.

Diagnosis

Diabetes is suspected based on symptoms. Urine tests and blood tests can be used to confirm a
diagnosis of diabetes based on the amount of glucose in the urine and blood. Urine tests also can
detect ketones and protein in the urine which 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 under
treatment.

Urine Tests

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 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 in Type I diabetics, 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, which may not show up on dipstick tests.

Blood Tests

Fasting glucose test. Blood is drawn from a vein in the patient's arm after the patient has not eaten for at
least eight hours, 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
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 a plasma glucose level of at least 11.1 mmol/L, a fasting plasma
glucose level of at least 7 mmol/L; or a two-hour plasma glucose level of at least 11.1 mmol/L during an
oral glucose tolerance test.

In 2002, scientists announced that a new simple blood test to screen for diabetes had been developed.
Prior to that time, community-wide screening procedures had not proven cost-effective. The new
screening test proved cost-effective if conducted in physician offices on patients with three known risk
factors of obesity, self-reported high blood pressure, and family history of diabetes.

Home blood glucose monitoring kits are available so diabetics 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 diet or doses of insulin.

Treatment

There is currently no cure for diabetes. Diet, exercise, and careful monitoring of blood glucose levels are
the keys to manage diabetes so that patients can live a relatively normal life. Diabetes can be life-
threatening if not properly managed, so patients should not attempt to treat this condition without
medical supervision. Treatment of diabetes focuses on two goals: keeping blood glucose within normal
range and preventing the development of long-term complications. Alternative treatments cannot
replace the need for insulin but they may enhance insulin's effectiveness and may lower blood glucose
levels. In addition, alternative medicines may help to treat complications of the disease and improve
quality of life.

Diet

Diet and moderate exercise are the first treatments implemented in diabetes. For many Type II
diabetics, weight loss may be an important goal to help 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 depends
on the patient's 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. In 2002,
a Korean study demonstrated that eating a combination of whole grains and legume powder was
beneficial in lowering blood glucose levels in men with diabetes.
Keeping track of the number of calories provided by different foods can be complicated, so patients are
usually 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 American Dietetic Association
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 the
foods they eat as long as they don't exceed the number of exchanges prescribed. The food exchange
system, along with a plan of moderate exercise, can help diabetics lose excess weight and improve their
overall health. Certain foods will be emphasized over others to promote a healthy heart as well.

Supplements

CHROMIUM PICOLINATE. Several studies have had conflicting results on the effectiveness of
chromium picolinate supplementation for control of blood glucose levels. In one study, approximately
70% of the diabetics receiving 200 micrograms of chromium picolinate daily reduced their need for
insulin and medications. While some studies have shown that supplementation caused significant
weight loss, and decreases in blood glucose and serum triglycerides, others have shown no benefit.
Chromium supplementation may cause hypoglycemia and other side effects.

MAGNESIUM. Magnesium deficiency may interfere with insulin secretion and uptake and worsen the
patient's control of blood sugar. Also, magnesium deficiency puts diabetics at risk for certain
complications, especially retinopathy and cardiovascular disease.

VANADIUM. Vanadium has been shown to bring blood glucose to normal levels in diabetic animals.
Also, people who took vanadium were able to decrease their need for insulin.

Chinese Medicine

Non-insulin dependent diabetics who practiced daily qigong for one year had decreases in fasting blood
glucose and blood insulin levels. Acupuncture may relieve pain in patients with diabetic neuropathy.
Acupuncture also may help to bring blood glucose to normal levels in diabetics who do not require
insulin.

Best when used in consultation with a Chinese medicine physician, some Chinese patent medicines that
alleviate symptoms of or complications from diabetes include:

 Xiao Ke Wan (Emaciation and Thirst Pill) for diabetics with increased levels of
sugar in blood and urine.
 Yu Quan Wan (Jade Spring Pill) for diabetics with a deficiency of Yin.
 Liu Wei Di Huang Wan (Six Ingredient Pill with Rehmannia) for stabilized
diabetics with a deficiency of Kidney Yin.
 Jin Gui Shen Wan (Kidney Qi Pill) for stabilized diabetics with a deficiency of
Kidney Yang.

Herbals

Herbal medicine can have a positive effect on blood glucose and quality of life in diabetics. The results
of clinical study of various herbals are:

 Wormwood (Artemisia herba-alba) decreased blood glucose.

 Gurmar (Gymnema sylvestre) decreased blood glucose levels and the need for
insulin.
 Coccinia indica improved glucose tolerance.
 Fenugreek seed powder (Trigonella foenum graecum) decreased blood glucose
and improved glucose tolerance.
 Bitter melon (Momordica charantia) decreased blood glucose and improved
glucose tolerance.
  Cayenne pepper (Capsicum frutescens) can help relieve pain in the peripheral
nerves (a type of diabetic neuropathy).

Other herbals that may treat or prevent diabetes and its complications include:

 Bilberry (Vaccinium myrtillus) may lower blood glucose levels and maintain
healthy blood vessels.
 Garlic (Allium sativum) may lower blood sugar and cholesterol levels.
 Onions (Allium cepa) may help lower blood glucose levels.
 Ginkgo (Ginkgo biloba) improves blood circulation.

Yoga

Studies of diabetics have shown that practicing yoga leads to decreases in blood glucose, increased
glucose tolerance, decreased need for diabetes medications, and improved insulin processes. Yoga
also enhances the sense of well-being.

Biofeedback

Many studies have been performed to test the benefit of adding biofeedback to the diabetic's treatment
plan. Relaxation techniques, such as visualization, usually were included. Biofeedback can have
significant effects on diabetes including improved glucose tolerance and decreased blood glucose
levels. In addition, biofeedback can be used to treat diabetic complications and improve quality of life.

Allopathic Treatment

Traditional treatment of diabetes begins with a well balanced diet and moderate exercise. Medications
are prescribed only if the patient's blood glucose cannot be controlled by these methods.

Oral Medications

Oral medications are available to lower blood glucose in Type II diabetics. Drugs first prescribed for
Type II diabetes are in a class of compounds called sulfonylureas and include tolbutamide, tolazamide,
acetohexamide, chlorpropamide, glyburide, glimeperide, and glipizide. The way that 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 troglitizone.
These medications are not a substitute for a well planned diet and moderate exercise. Oral medications
are not effective for Type I diabetes, in which the patient produces little or no insulin.

Insulin

Patients with Type I diabetes need daily injections of insulin to help their bodies use glucose. Some
patients with Type II diabetes may need to use insulin injections if their diabetes cannot be controlled.
Injections are given subcutaneously—just under the skin, using a small needle and syringe. Purified
human insulin is most commonly used, however, insulin from beef and pork sources also is available.
Insulin may be given as an injection of a single dose of one type of insulin once a day. Different types of
insulin can be mixed and given in one dose or split into two or more doses during a day. Patients who
require multiple injections over the course of a day may be able to use an insulin pump that administers
small doses of insulin on demand. In 2002, reports announced that early research shows a synthetic
insulin called insulin glargine might show promise for patients at risk for hypoglycemia from insulin
therapy. Clinical trials showed that when used in combination with certain other short-acting insulins, it
safely regulated blood glucose for longer durations and was well tolerated by patients.

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, sweaty, shaky, cranky, confused, and tired. 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 candy, sugar
cubes, or juice.
Surgery

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

Expected Results

Uncontrolled diabetes is a leading cause of blindness, end-stage renal disease, and limb amputations. It
also doubles the risk of heart disease and increases the risk of stroke. Eye problems including
cataracts, glaucoma, and retinopathy also are more common in diabetics. Kidney disease is a common
complication of diabetes and may require kidney dialysis or a kidney transplant. Babies born to diabetic
mothers have an increased risk of birth defects and distress at birth.

Diabetic peripheral neuropathy is a condition where nerve endings, particularly in the legs and feet,
become less sensitive. Diabetic foot ulcers are a 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 contributes 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. Severely infected
tissue breaks down and rots, often necessitating amputation of toes, feet, or legs.

Prevention

Research continues on ways to prevent diabetes and to detect those at risk for developing diabetes.
While the onset of Type I diabetes is unpredictable, the risk of developing Type II diabetes can be
reduced by maintaining ideal weight and exercising regularly. The physical and emotional stress of
surgery, illness, and alcoholism can increase the risks of diabetes, so maintaining a healthy lifestyle is
critical to preventing the onset of Type II diabetes and preventing further complications of the disease.

In early 2002, researchers announced that patients at high risk for developing diabetes who took an
ACE inhibitor called ramipril reduced their risk of developing diabetes substantially. Another report at
Duke University showed that sustained intensive exercise could forestall development of diabetes or
cardiovascular disease in high-risk patients. The benefits of long-term exercise even continue one
month after exercising stops. In 2003, advances in genetics found a key gene that may explain why
some people are more susceptible to the disease than others.

Resources

Books

Foster, Daniel W. "Diabetes Mellitus." In Harrison's Principles of Internal Medicine. 14th ed. Edited by
Anthony S. Fauci, et al. New York: McGraw-Hill, 1998.

Garber, Alan J. "Diabetes Mellitus." In Internal Medicine. Edited by Jay H. Stein, et al. St. Louis: Mosby,
1998.

Karam, John H. "Diabetes Mellitus & Hypoglycemia." In Current Medical Diagnosis & Treatment 1998.
37th ed. Edited by L.M. Tierney, Jr., S.J. McPhee, and M.A. Papadakis. Stamford, CT: Appleton &
Lange, 1998.

McGrady, Angele and James Horner. "Complementary/Alternative Therapies in General Medicine:

Diabetes Mellitus." In Complementary/Alternative Medicine: An Evidence Based Approach. Edited by
John W. Spencer and Joseph J. Jacobs. St. Louis: Mosby, 1999.

Sherwin, Robert S. "Diabetes Mellitus." In Cecil Textbook of Medicine. 20th ed. Edited by J. Claude
Bennett and Fred Plum. Philadelphia, PA: W.B. Saunders Company, 1996.

Smit, Charles Kent, John P. Sheehan, and Margaret M. Ulchaker. "Diabetes Mellitus." In Family
Medicine, Principles and Practice. 5th ed. Edited by Robert B. Taylor. New York: Springer-Verlag, 1998.
Ying, Zhou Zhong and Jin Hui De. "Endocrinology." In Clinical Manual of Chinese Herbal Medicine and
Acupuncture. New York: Churchill Livingston, 1997.

Periodicals

"Exercise Can Forestall Diabetes in At-Risk Patients." Diabetes Week (March 25, 2002):2.

Fox, Gary N., and Zijad Sabovic. "Chromium Picolinate Supplementation for Diabetes Mellitus." The
Journal of Family Practice 46 (1998): 83-86.

Hartnett, Terry."Early Results Show Promise for Synthetic Insulin." Diabetes Week (March 18, 2002):4.

Jenkins, David JA, et al."Type 2 Diabetes and the Vegetarian Diet." American Journal of Clinical
Nutrition (September 2003):610S.

"Mouse, Stripped of a Key Gene, Resists Diabetes." Biotech Week (September 24, 2003):557.

"Nearly One-third of Diabetes Undiganosed, According to New Government Data." Medical Letter on the
CDC & FDA (September 28, 2003):13.

"Ramipril Cuts Diabetes Risk." Family Practice News 32, no. 3 (February 1, 2002):10.

"Simple Blood Test Could Detect New Cases of Diabetes." Diabetes Week (January 21, 2002):4.

"Whole Grain and Legume Powder Diet Benefits Diabetics and the Healthy." Diabetes Week (January 7,
2002):8.

"Trends in the Prevalence and Incidence of Self-Reported Diabetes Mellitus-United States, 1980-1994."
Morbidity & Mortality Weekly Report 46 (1997): 1014-1018.

"Updated Guidelines for the Diagnosis of Diabetes in the US." Drugs & Therapy Perspectives 10 (1997):
12-13.

Organizations

American Diabetes Association. 1660 Duke Street, Alexandria, VA 22314. (703) 549-1500. Diabetes
Information and Action Line: (800) DIABETES. http://www.diabetes.org.

American Dietetic Association. 430 North Michigan Avenue, Chicago, IL 60611. (312) 822-0330.
http://www.eatright.org.

Juvenile Diabetes Foundation International. 120 Wall Street, New York, NY 10005-4001. (212) 785-
9595. (800) JDF-CURE.

National Diabetes Information Clearinghouse. 1 Information Way, Bethesda, MD 20892-3560. (301)

654-3327.

National Institutes of Health. National Institute of Diabetes, Digestive and Kidney Diseases. 9000
Rockville Pike, Bethesda, MD 20892. (301) 496-3583. http://www.niddk.nih.gov.

Other

Centers for Disease Control and Prevention Diabetes. http://www.cdc.gov/nccdphp/ddt/ddthome.htm.

"Insulin-Dependent Diabetes." National Institute of Diabetes and Digestive and Kidney Diseases.
National Institutes of Health, NIH Publication No. 94-2098.

"Noninsulin-Dependent Diabetes." National Institute of Diabetes and Digestive and Kidney Diseases.
National Institutes of Health, NIH Publication No. 92-241.
[Article by: Belinda Rowland; Teresa G. Odle]

Children's Health Encyclopedia

Home > Library > Health > Children's Health Encyclopedia

Diabetes Mellitus

Definition

Diabetes mellitus is a chronic disease in which the body is not able to correctly process glucose for cell
energy due to either an insufficient amount of the hormone insulin or a physical resistance to the insulin
the body does produce. Without proper treatment through medication and/or lifestyle changes, the high
blood glucose (or blood sugar) levels caused by diabetes can cause long-term damage to organ
systems throughout the body.

Description

There are three types of diabetes mellitus: type 1 (also called juvenile diabetes or insulin-dependent
diabetes), type 2 (also called adult-onset diabetes), and gestational diabetes. While type 2 is the most
prevalent, consisting of 90 to 95 percent of diabetes patients in the United States, type 1 diabetes is
more common in children. Gestational diabetes occurs in pregnancy and resolves at birth.

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 (primarily sugars
and starches). Glucose from the digested food circulates in the blood as a ready energy source for any
cells that need it. However, glucose requires insulin in order to be processed for cellular energy.

Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the
stomach. Insulin bonds to a receptor site on the outside of a cell. It acts like a key to open a doorway
into the cell through which glucose can enter. When there is not enough insulin produced (as is the case
with type 1 diabetes) or when the doorway no longer recognizes the insulin key (which happens in type
2 and gestational diabetes), glucose stays in the bloodstream rather entering the cells. The high blood
glucose, or blood sugar, levels that result are known as hyperglycemia.

Type 1 Diabetes

Type 1 diabetes occurs when the beta cells of the pancreas are damaged and stop producing the
hormone insulin. While the exact cause of this cell damage is not completely understood, it is thought to
be a combination of environmental and autoimmune factors. Despite the name juvenile diabetes, type 1
diabetes can be diagnosed at any stage of life, although diagnosis in childhood through young
adulthood is most common.

Children who develop type 1 diabetes must eventually take regular insulin injections to keep blood
glucose levels under control and do the job of the pancreas. Regular home testing of blood sugar levels
is also important to make sure that the treatment is working effectively and to avoid a diabetic
emergency such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Type 2 Diabetes

The hallmark characteristic of type 2 diabetes is insulin resistance. The pancreas typically produces
enough insulin (often too much insulin); however, cells are resistant to the insulin and it may not work as
effectively. Type 2 is the most common form of diabetes, and most individuals with the disease are
adults. However, children and adolescents can develop type 2 diabetes too, particularly if they are
overweight and have a history of type 2 diabetes in their family.

Type 2 diabetes is treated with diet, exercise, and in some cases, oral medication and/or insulin. Self-
monitoring of blood glucose levels is also important to assess how well treatment is working.
Demographics

An estimated 18.2 million Americans live with diabetes, and over 5 million of those remain undiagnosed.
Up to 95 percent of diabetes patients in the United States have type 2 diabetes; the vast majority of
Americans with diabetes are over 20 years of age. Those under 20 represent only 206,000 of the total
cases of diabetes in the United States.

While type 2 diabetes is a growing problem among American youth due to climbing obesity rates and
more sedentary lifestyles, type 1 diabetes is more prevalent in children and adolescents. An estimated
one in 400 to 500 children have type 1 diabetes.

The American Diabetes Association reports that in 2002, diabetes cost Americans an estimated $132
billion in direct medical costs and indirect expenses such as lost productivity and disability payments.

Causes and Symptoms

The causes of diabetes are not completely understood; however, there seem to be both genetic and
environmental factors involved in the development of both type 1 and type 2 diabetes, meaning that a
person may have a genetic predisposition to developing diabetes, but it takes an environmental factor
such as a viral infection or excessive weight gain to actually make the disease surface.

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 causes an autoimmune reaction that eventually destroys the
insulin-producing cells (i.e., beta cells) in the pancreas. Up to 90 percent of cases of type 1 diabetes are
the autoimmune subtype, sometimes called type 1A or immune-mediated diabetes.

The other subtype of type 1 diabetes is called idiopathic, or type 1B diabetes. People who have
idiopathic type 1 diabetes also experience beta cell destruction, but it is due to a chromosomal
abnormality or an unknown cause rather than any autoimmune process. Only tests for islet cell
antibodies and other autoimmune markers can differentiate between the two subtypes, and because
testing can be costly and treatment for both is the same (i.e., insulin), a physician may not necessarily
order tests for autoimmunity.

Finally, damage caused by diseases of the pancreas (such as pancreatitis), endocrine disorders (e.g.,
endocrine tumors), and drugs or toxins can also destroy beta cell function.

In type 2 diabetes, family history, age, weight, activity level, and ethnic background can all play a role in
the genesis of the disease. Individuals who are at high risk of developing type 2 diabetes mellitus
include the following groups:

 people who are overweight or obese (more than 20 percent above their ideal
body weight)
 people who have a parent or sibling with type 2 diabetes
 those who belong to a high-risk ethnic population (African-American, Native
American, Asian-American, Hispanic, or Pacific Islander)
 people who live a sedentary lifestyle (i.e., exercise less than three times a
week)
 women who have been diagnosed with gestational diabetes or have delivered a
baby weighing more than 9 lbs (4 kg)
 people with high blood pressure (140/90 mmHg or above)
 people with high density lipoprotein cholesterol (HDL, or "good" cholesterol)
level less than or equal to 35 mg/dl and/or a triglyceride level greater than or
equal to 250 mg/dl

Several common medications can cause chronic high blood sugar levels and/or promote insulin
resistance. These include atypical antipsychotics, beta blockers, corticosteroids, diuretics, estrogens,
lithium, protease inhibitors, niacin, and some thyroid preparations.
Both type 1 and type 2 diabetes share similar symptoms caused by chronically high blood glucose
levels.

Symptoms of both type 1 and type 2 diabetes include:

 excessive thirst
 frequent urination
 weight loss
 increased appetite
 unexplained fatigue
 slow healing cuts, bruises, and wounds
 frequent or lingering infections (e.g., urinary tract infection)
 mood swings and irritability
 blurred vision
 headache
 high blood pressure
 dry and itchy skin
 tingling, numbness, or burning in hands or feet

Symptoms of diabetes can develop suddenly (over days or weeks) in previously healthy children or
adolescents, or can develop gradually, particularly in the case of type 2 diabetes.

Children and adolescents sometimes develop a condition known as diabetic ketoacidosis (DKA) at the
time of their diagnosis. Ketones are acid compounds that form in the blood when the body breaks down
fats and proteins for energy. When blood sugars are high (i.e., over 249 mg/dl, or 13.8 mmol/L) for
prolonged periods of time, ketones build up in the bloodstream to dangerous levels. Symptoms of DKA
include abdominal pain, excessive thirst, nausea and vomiting, rapid breathing, extreme lethargy, and
drowsiness. Patients with ketoacidosis will also have a fruity or sweet breath odor. Left untreated, this
condition can lead to coma and has the potential to be fatal. DKA is more common in people with type 1
diabetes, although it can occur in type 2 diabetes as well.

Symptoms of type 2 diabetes can begin so gradually that a person may not know that he or she has it. 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, such as heart disease, chronic
infections (e.g., urinary tract infections, yeast infections), blurred vision, numbness in the feet and legs,
or slow-healing wounds.

When to Call the Doctor

If left untreated, diabetes is a life-threatening condition. Any child displaying symptoms of diabetes
should be taken to a doctor or emergency care facility for evaluation immediately.

Diagnosis

Diagnosis of diabetes is suspected based on symptoms and confirmed by blood tests that measure the
level of glucose in blood plasma. Dipstick or reagent test strips that measure glucose in the urine can
only detect glucose levels above 180 mg/dl and are non-specific, so they are not useful in the diagnosis
of diabetes. However, they are a non-invasive way to obtain a fast and simple reading that a physician
might use as a basis for ordering further diagnostic blood tests for diabetes, particularly in children.

Blood tests are the gold standard for the diagnosis of both type 1 and type 2 diabetes in children and
adults. The American Diabetes Association recommends that a random plasma glucose, fasting plasma
glucose, or oral glucose tolerance test (OGTT) be used for diagnosis of diabetes. The OGTT is
commonly used as a screening measure for gestational diabetes. Fasting plasma glucose is the test of
choice unless a child is exhibiting classic symptoms of diabetes, in which case a random (or casual)
plasma glucose test is acceptable.
Unless hyperglycemia is obvious (e.g., blood glucose levels are extremely high or the child experiences
DKA), the fasting or random plasma glucose test should be confirmed on a subsequent day with a
repeat test.

Fasting Plasma Glucose Test

Blood is drawn from a vein in the child's arm following an eight-hour fast (i.e., no food or drink), 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 fasting plasma glucose level of 126 mg/dl (7.0 mmol/l)
or higher indicates diabetes (with a confirming retest on a subsequent day).

Random Plasma Glucose Test

Blood is drawn at any time of day, regardless of whether the patient has eaten. A random plasma
glucose concentration of 200 mg/dl (11.1 mmol/l) or higher in the presence of symptoms indicates
diabetes.

Oral Glucose Tolerance Test

Blood samples are taken both before and several times after a patient drinks 75 grams of a glucose-
based beverage. If plasma glucose levels taken two hours after the glucose drink is consumed are 200
mg/dl (11.1 mmol/L) or higher, the test is diagnostic of diabetes (and should be confirmed on a
subsequent day if possible).

Although the same diagnostic blood tests are used for both types of diabetes, whether a child is
diagnosed as type 1 or type 2 can typically be determined based on her personal and medical history.
The majority of children diagnosed in childhood are type 1, but if blood test results indicate prediabetes
and a child is significantly overweight and has a history of type 2 diabetes in her family, type 2 is a
possibility.

Further blood tests can help to differentiate between type 1 and type 2 when the diagnosis is unclear.
One of these is an assessment of c-peptide levels, a protein released along with insulin that can help a
physician determine whether or not a patient is producing sufficient amounts of insulin. The other is a
GAD (Glutamic Acid Decarboxylase) autoantibody test. The presence of GAD autoantibodies may
indicate the beginning of the autoimmune process that destroys pancreatic beta cells.

Treatment

Children with type 1 diabetes must take insulin injections or infusions. Their dosage needs may change
over time. Sometimes children will experience a decreased need for insulin once blood sugars are
brought under control following diagnosis. Their insulin needs may go down, and in some cases, they
can stop taking injections for a time. This phenomenon, known as the honeymoon period, can last
anywhere from a few days to months.

Children with diabetes and their parents should learn to operate a home blood glucose monitor. Home
testing can prevent dangerous highs and lows and help parents and children understand how food and
exercise impact blood sugar levels. Blood glucose levels taken before meals are also used to calculate
dose size of insulin. A small needle or lancet is used to prick the finger or alternate site and a drop of
blood is collected on a test strip that is inserted into a monitor. The monitor then calculates and displays
the blood glucose reading on a screen. Although individual blood glucose targets should be determined
by a medical professional in light of a child's medical history, the general goal is to keep them as close
to normal (i.e., 90 to 130 mg/dl or 5 to 7.2 mmol/L before meals) as possible.

Insulin

Children 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 also 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, an insulin pen
injector, an insulin infusion pump, or a jet injector device. Injection sites can be anywhere on the body
where there is a layer of fat available, including the upper arm, abdomen, or upper thigh.
Insulin may be given as an injection of a single dose of one type of insulin once a day, or different types
of insulin can be mixed and given in one dose or split into two or more doses during a day. Patients who
require multiple injections over the course of a day may be able to use an insulin pump that administers
small doses of insulin on demand. The small battery-operated pump is worn outside the body and is
connected to a cannula (a thin, flexible plastic tube) that is inserted into the abdomen called an insertion
set. Pumps are programmed to infuse a small, steady infusion of insulin (called a basal dose)
throughout the day, and larger doses (called boluses) before meals. Because of the basal infusion,
pumps can offer many children much tighter control over their blood glucose levels and more flexibility
with their diet than insulin shots afford them.

Regular insulin is fast-acting and starts to work within 15 to 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 to 26 hours. Ultra-lente is a long-acting form of insulin that starts to work
within four to eight hours and lasts 28 to 36 hours. Peakless, or basal-action insulin (insulin glargine, or
Lantus) starts working in 15 minutes and has a duration of between 18 and 26 hours.

Nutritional Concerns

Because dietary carbohydrates are the primary source of glucose for the body (the other source being
the liver), it is very important that children with diabetes learn to read labels and be aware of the amount
of carbohydrates in the foods they eat. Children and their parents are usually advised to consult a
registered dietitian (RD) to create an individualized, easy to manage food plan that fits their family's
health and lifestyle needs. A well-balanced, nutritious diet provides approximately 50 to 60 percent of
calories from carbohydrates, approximately 10 to 20 percent of calories from protein, and less than 30
percent of calories from fat. The number of calories required depends on age, weight, and activity level.
An RD can also teach the family how to use either the dietary exchange lists or carbohydrate counting
system to monitor food intake.

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 by their RD based on their caloric requirements.

Carbohydrate counting involves totaling the grams of carbohydrates in the foods your child eats to
ensure the child does not exceed her goal for the day. In the simple-carb counting method, one
carbohydrate choice or unit equals 15 grams of carbohydrates (which is equivalent to one starch or fruit
exchange in the exchange method). The number of carb choices allowed daily is based on caloric
requirements.

Children with type 1 diabetes who use fast-acting insulin before meals may find that carb counting gives
them tighter control of their blood glucose levels, since they can compute the number of insulin units
based on both their carbohydrate intake (called the carbohydrate to insulin ratio) and before-meal blood
glucose readings.

Dietary changes and moderate exercise are usually the first treatments implemented in type 2 diabetes.
Weight loss may be an important goal in helping overweight children and adolescents control their blood
sugar levels. Exercise helps keep blood glucose levels down and has other health benefits, as well.

Oral Medications

Children with type 2 diabetes may be prescribed oral medications if they are unable to keep their blood
glucose levels under control with dietary and exercise measures. As of 2004, metformin was the only
oral medication approved by the U.S. FDA for use in children over age ten. Metformin (trade name
Glucophage) is in the biguanide class of drugs and works by reducing the amount of glucose the liver
produces and the amount of circulating insulin in the body. Other adult type 2 diabetes medications,
such as sulfonylureas and meglitinide drugs, which work by increasing insulin production, may be
prescribed off-label for pediatric use.

Transplants
Transplantation of a healthy pancreas into a patient with type 1 diabetes can eliminate the need for
insulin injections; however, this transplant is typically 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 life-long drug therapy needed to prevent organ rejection, particularly in the
case of children.

A second type of transplant procedure, as of 2004 in experimental clinical trials and not available to
children, is an islet cell transplant. In this type of treatment, insulin-producing islet cells are harvested
from a donor pancreas and injected into the liver of a recipient, where they attach to new blood vessels
and (ideally) begin producing insulin. A lifetime regimen of immunosuppressive drugs is required to
prevent rejection of the transplanted cells.

Prognosis

As of 2004 diabetes is a chronic and incurable disease. While stem cell research holds great promise
for future therapies and potential cures, as of the early 2000s the best hope for keeping children well
with diabetes and avoiding long-term complications is maintaining good blood glucose control. The
landmark Diabetes Control and Complications Trial (DCCT) found that patients with type 1 diabetes who
kept their blood sugar levels as close to normal as possible reduced their risk for developing diabetic
eye disease by 76 percent, for diabetic kidney disease by 50 percent, and for diabetic neuropathy by 60
percent.

Diabetes and its related complications was the sixth leading cause of death in 2000. According to the
National Institutes of Health, cardiovascular, or heart and blood vessel disease, is the leading cause of
diabetes-related death. Uncontrolled diabetes is a leading cause of blindness, end-stage renal disease,
and limb amputations. Eye problems including cataracts, glaucoma, and diabetic retinopathy also are
more common in people with diabetes.

Diabetic neuropathy is the result of nerve damage caused by uncontrolled diabetes. Autonomic
neuropathy affects the autonomic nervous system and can cause gastroparesis (nerve damage of the
stomach), neurogenic bladder (nerve damage of the urinary bladder), and a host of other problems with
involuntary functions of the nervous system.

In peripheral neuropathy (PN), nerve damage in the extremities (e.g., the legs and feet) causes
numbness, pain, and burning. Diabetic foot ulcers are a particular problem since frequently 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 calluses becoming infected and difficult to
treat. The most serious consequence of this condition is the potential for amputation of toes, feet, or legs
due to severe infection.

Diabetic kidney disease is another common complications of diabetes. Long-term complications may
include the need for kidney dialysis or a kidney transplant due to kidney failure. Diabetes is the number
one cause of chronic kidney failure in America.

Children and adults with the autoimmune form of type 1 diabetes are also at greater risk for other
autoimmune disorders, including thyroid disease, celiac sprue (sometimes called gluten intolerance),
autoimmune hepatitis, myasthenia gravis, and pernicious anemia.

Prevention

As of 2004 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 may be reduced by maintaining ideal weight and exercising regularly. Both physical and
emotional stress can cause increases in blood glucose levels, so getting regular immunizations and
well-child check-ups, practicing good sleep and hygiene habits, encouraging emotional and social
growth, and maintaining a stress-controlled lifestyle is important for children with type 1 or type 2
diabetes.

Parental Concerns
Parents of children with diabetes must work with their child's teachers and school administrators to
ensure that their child is able to test her blood sugars regularly, take insulin as needed, and have access
to food or drink to treat a low. Someone at school should also be trained in how to administer a
glucagon injection, an emergency treatment for a hypoglycemic episode when a child loses
consciousness.

Section 504 of the Rehabilitation Act of 1973 enables parents to develop both a Section 504 plan (which
describes a child's medical needs) and an individualized education plan (IEP) (which describes what
special accommodations a child requires to address those needs). An IEP should cover such issues as
blood glucose monitoring, dietary plans, and treating highs and lows. If school staff has little to no
experience with diabetes, bringing in a certified diabetes educator (CDE) to offer basic training may be
useful.

Children with diabetes can lead an active life and enjoy most of the activities and foods their peers do,
with a few precautions to avoid blood sugar highs or lows. A certified diabetes educator that has
experience working with children can help them understand the importance of regular testing as well as
methods for minimizing discomfort. Diabetes summer camps, where children can learn about diabetes
care in the company of peers and counselors who also live with the disease, may be useful from both a
health and a social standpoint. In addition, peer support groups can sometimes help children come to
terms with their diabetes.

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 child with
symptoms of hypoglycemia may be hungry, cranky, confused, and tired. The patient may become
sweaty and shaky. Left untreated, a child 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 candy, juice, glucose gel, or another high sugar snack. A child who loses consciousness due
to a low should never be given food or drink due to the risk of choking. In these cases, a glucagon
injection should be administered and the child should be taken to the nearest emergency care facility.

While exercise can lower blood glucose levels, children with diabetes can and do excel in sports. Proper
hydration, frequent testing, and a before-game or practice snack can prevent hypoglycemia. Coaches or
another onsite adult should be aware of a child's medical condition and be prepared to treat a
hypoglycemic attack if necessary.

The other potential danger to a child with diabetes—diabetic ketoacidosis—is uncommon and most
likely to occur prior to a diagnosis. It may also happen if insulin is discontinued or if the body is under
stress due to illness or injury. Ketones in the urine can be detected using dipstick tests (e.g., Ketostix),
or detected using a home ketone blood monitor. Early detection facilitates early treatment and can
prevent full-blown DKA.

Because the symptoms of DKA can mimic the flu, and the flu can increase blood sugar levels, a child
who comes down with a flu-like illness should be monitored closely and tested regularly. An increase in
insulin may also be necessary; parents of children with diabetes should talk with their pediatrician about
a sick day plan for their child before they need it.

See also Hypoglycemia.

Resources

Books

The American Diabetes Association Complete Guide to Diabetes, 3rd ed. Alexandria, VA: American
Diabetes Association, 2002.

Brackenridge, Betty, and Richard Rubin. Sweet Kids: How to Balance Diabetes Control and Good
Nutrition with Family Peace, 2nd ed. Alexandria, VA: American Diabetes Association, 2002.

Ford-Martin, Paula, with Ian Blumer. The Everything Diabetes Book. Avon, MA: Adams Media, 2004.

Organizations
American Diabetes Association. 1701 North Beauregard St., Alexandria, VA 22311. Web site:
www.diabetes.org.

American Dietetic Association. 216 W. Jackson Blvd., Chicago, IL 60606–6995. Web site:
www.eatright.org.

Children with Diabetes. 5689 Chancery Place, Hamilton, OH 45011. Web site:
www.childrenwithdiabetes.org.

Juvenile Diabetes Research Foundation. 120 Wall St., 19th Floor, New York, NY 10005. Web site:
www.jdrf.org.

National Diabetes Information Clearinghouse. 1 Information Way, Bethesda, MD 20892–3560. Web site:
www.niddk.nih.gov/health/diabetes/ndic.htm.

Web Sites

"2004 Clinical Practice Recommendations." Diabetes Care, January, 2004. Available online at
(accessed December 26, 2004).

Ford-Martin, Paula. "About Diabetes" Available online at (accessed December 26, 2004).

Mendosa, David. David Mendosa's Diabetes Directory. Available online at

www.mendosa.com/diabetes.htm (accessed December 26, 2004).

[Article by: Paula Ford-Martin Altha Roberts Edgren Teresa G. Odle]

Encyclopedia of Public Health

Home > Library > Health > Public Health Encyclopedia

Diabetes Mellitus

The term "diabetes mellitus" represents a group of conditions characterized by abnormally high blood
glucose levels (hyperglycemia). In 1997, nearly 16 million people in the United States had diabetes;
approximately 10.3 million were diagnosed with the conditions, while an estimated 5.4 million were
undiagnosed. Diabetes may be complicated by uncontrolled hyperglycemia, and treated diabetes may
be complicated by abnormally low blood glucose levels (hypoglycemia). Maternal diabetes is associated
with an increased incidence of major birth defects. Over time, diabetes may cause complications
involving the eyes (retinopathy), kidneys (nephropathy), and nerves (neuropathy). Diabetes is also
associated with an increased incidence of cardiovascular disease, including stroke, heart attack, and
peripheral vascular disease. In the United States today, diabetes is a leading cause of birth defects,
blindness, kidney failure, and nontraumatic leg amputations. It is also a major contributor to
cardiovascular disease. Diabetes is the seventh leading cause of death in the United States, and
medical care for people with diabetes is estimated to cost over $100 billion per year.

When diabetes is associated with marked hyperglycemia, it produces characteristic symptoms and
signs; particularly increased thirst (polydipsia), increased urination (polyuria), and unexplained weight
loss. At other times, hyperglycemia sufficient to cause changes in the eyes, kidneys, and nerves, and to
increase the risk of cardiovascular disease, may be present without clinical symptoms. During this
asymptomatic period, an abnormality in glucose metabolism may be demonstrated by measuring fasting
venous glucose or venous glucose after an oral glucose challenge.

Diagnosis

When a patient is symptomatic and the plasma glucose is unequivocally elevated, a diagnosis of
diabetes presents no difficulty. When a patient is without clinical symptoms, a diagnosis of diabetes is
more difficult. According to a 1997 American Diabetes Association (ADA) report, there are three ways to
diagnose diabetes (see Table 1). All require measurement of venous plasma glucose, and each must be
confirmed on a subsequent day by any one of the three methods. In general, the oral glucose tolerance
test is not recommended for routine clinical use and is performed only in patients with elevated but
nondiagnostic fasting plasma-glucose levels with a high index of suspicion for diabetes.

Classification

Once a diagnosis of diabetes mellitus is established, it is necessary to differentiate the various forms of
the syndrome. Prior to 1979, diabetes was

Table 1

Criteria for the Three Methods Diagnosis of Diabetes Mellitus in Nonpregnant

Adults
* In the absence of unequivocal hyperglycemia with acute metabolic decompensation,
these criteria should be confirmed by repeat testing on a different day. The third
measure (OGTT) is not recommended for routine clinical use.
SOURCE: Expert Committee on the Diagnosis and Classification of Diabetes Mellitus:
Report of the Expert Committee on the Diagnosis and Classification of Diabetes
Mellitus (1997). Diabetes Care 20:1183-1197.
1. Symptoms of diabetes plus casual plasma glucose concentration ≥200 mg/dL
(11.1 mmol/L).* Casual is defined as any time of day without regard to time
Criteria for the Three Methods Diagnosis of Diabetes Mellitus in Nonpregnant
Adults
since last meal. The classic symptoms of diabetes include polyuria, polydipsia,
and unexplained weight loss.
2. Fasting Plasma Glucose ≥ 126 mg/dL (7.0 mmol/L).* Fasting is defined as no
caloric intake for at least 8 hours.

3. 2-hour Plasma Glucose ≥ 200 mg/dL (11.1 mmol/L) during an Oral Glucose
Tolerance Test (OGTT).* The test should be performed using a glucose load
containing the equivalent of 75 g. anhydrous glucose dissolved in water.

classified on the basis of age at diagnosis as either juvenile-onset diabetes mellitus (JODM) or adult-
onset diabetes mellitus (AODM). In the late 1970s and early 1980s, a new classification system
recognized two major forms of diabetes: insulin-dependent diabetes mellitus (IDDM or type I diabetes)
and non-insulin-dependent diabetes mellitus (NIDDM or type II diabetes). In 1997, the American
Diabetes Association recommended modifications to this classification system that eliminated the terms
"insulin-dependent diabetes mellitus" and "non-insulin-dependent diabetes mellitus" and their acronyms.
The terms "type 1" and "type 2" were retained, with Arabic numerals replacing the Roman numerals.
Other specific types of diabetes were also recognized.

Type 1 diabetes is caused by pancreatic beta cell (B-cell) destruction. Immune-mediated type 1 diabetes
results from cell-mediated autoimmune destruction of the B-cells of the pancreatic islets. This type of
diabetes also has strong genetic or human leukocyte antigen (HLA) associations that can be either
predisposing or protective. Another form of type 1 diabetes, termed "idiopathic" type 1 diabetes, is
strongly inherited but lacks immunologic evidence for B-cell autoimmunity and is not HLA-associated.
Most patients with

Table 2

Incidence of Diagnosed Diabetes per 1,000 Population by Age, United

States, 1994.
Age Group
0–4 45–64 65+ Total
SOURCE: Centers for Disease Control and Prevention (1997). Diabetes Surveillance,
1997. Atlanta, GA: CDC.
1.59 7.20 8.84 3.61

idiopathic type 1 diabetes are of African or Asian descent.

Type 1 diabetes accounts for approximately 5 percent of diagnosed diabetes in the United States—
approximately 500,000 Americans have type 1 diabetes. Type 1 diabetes commonly occurs in childhood
and adolescence, but it can occur at any age. Patients with type 1 diabetes are prone to ketoacidosis
(decompensated diabetes with hyperglycemia and presence of abnormal acids [ketones] in the blood).
Many affected patients have no family history of diabetes. Although most patients with type 1 diabetes
are lean when they are diagnosed, the presence of obesity is not incompatible with the diagnosis.

Type 2 diabetes is characterized by both impairment of insulin secretion and defects in insulin action. It
is often unclear which abnormality is the primary cause of hyperglycemia. Although patients with this
type of diabetes may have insulin levels that appear normal or elevated, insulin levels are always low
relative to the elevated plasma glucose levels. Thus, insulin secretion is defective in these patients and
insufficient to compensate for the degree of insulin resistance. Although the specific origin of type 2
diabetes is not known, autoimmune destruction of B-cells does not occur. Although type 2 diabetes is
associated with a strong genetic predisposition, the genetics of this form of diabetes are complex and
not clearly defined.

Type 2 diabetes accounts for approximately 95 percent of diagnosed diabetes in the United States (9.8
million cases), and for the vast majority of the cases of undiagnosed diabetes. The risk of type 2
diabetes increases with age, obesity, and physical inactivity. As such, it is often regarded as a disease
associated with a modern Western lifestyle. Type 2 diabetes occurs more frequently in women with prior
gestational diabetes and in individuals with hypertension and dyslipidemia. Affected patients often have
a family history of diabetes. Type 2 diabetes is more common in African Americans, Hispanic Americans,
and Native Americans than in non-Hispanic white Americans. Ketoacidosis seldom occurs
spontaneously in type 2 diabetes, but it may arise in association with the stress of another illness.
Approximately 70 percent of patients with type 2 diabetes are obese.

Treatment

Large, prospective, randomized, controlled clinical trials in both type 1 and type 2 diabetes have
demonstrated that normal or near-normal blood glucose control can delay or prevent the development of
major birth defects and the development and progression of complications affecting the eyes, kidneys,
and nerves. Accordingly, the goals for management for both type 1 and type 2 diabetes are to achieve
glucose levels as close to the nondiabetic range as possible while minimizing the side-effects of
treatment (hypoglycemia and weight gain).

In nondiabetic subjects, blood glucose levels are between 70 and 90 mg/dl (milligrams per deciliter) in
the fasting state and rise to 120 to 140 mg/dl one to two hours after meals. These values reflect normal
glucose tolerance. Average glucose levels may be assessed by measurement of glycosylated
hemoglobin (hemoglobin A1c), is a measure of the average blood glucose level over the previous two to
four months. In nondiabetic subjects, hemoglobin A1c is generally less than 6.1 percent, and in poorly
controlled diabetic subjects, it may rise to 12 percent or higher.

In general, the goals of treatment are to achieve blood glucose and hemoglobin A1c levels as close to
the nondiabetic range as possible with diet, physical activity, and medications.

Diet. In type 1 diabetes, diet is designed to provide adequate nutrients for growth and development and
for the maintenance of ideal body weight. The recommended diet includes approximately 20 percent of
daily calories from protein, 30 percent from fat, and 50 percent from complex carbohydrates. Simple
sugars are limited to prevent excessive glucose excursions, and carbohydrate content is distributed into
regular meals and

Table 3

Prevalence of diagnosed diabetes per 1,000 population by age, sex, and race,
United States, 1994
Age Group
Population 0–44 45–64 65–74 75+ Total
From Centers for Disease Control and Prevention. Diabetes Surveillance, 1997.
Atlanta, GA. U.S. Department of Health and Human Services, 1997.
white males 7.8 57.7 96.0 106.8 28.4
black males 10.6 120.8 171.8 120.6 35.9
white females 7.9 51.9 97.2 89.2 30.5
black females 12.1 134.5 171.8 173.5 47.9
Total 8.3 62.2 101.5 103.3 30.8

snacks so that a similar quantity of carbohydrate is consumed at approximately the same time each day.

In type 2 diabetes, caloric content is adjusted to achieve and maintain an ideal body weight or, in those
who are obese, to produce gradual weight loss or at least weight maintenance. Dietary composition may
also be adjusted in light of intercurrent conditions. For example, sodium may be restricted for patients
with hypertension, and both total fat and saturated fat may be restricted for those with high cholesterol.

Exercise. Exercise lowers blood glucose and improves glucose tolerance in diabetics. Other benefits of
exercise are reductions in LDL cholesterol and triglycerides levels, and improvements in HDL
cholesterol, improvements in blood pressure, improved cardiovascular fitness, and an increased sense
of well-being and quality of life. Because exercise may potentiate the hypoglycemic effect of injected
insulin and may, paradoxically, result in elevated blood glucose levels and the rapid development of
ketosis in type 1 diabetic patients in poor metabolic control, the goal of management in type 1 diabetes
is to permit people to enjoy and participate safely in physical and sport activities. In type 2 diabetes,
exercise is frequently prescribed as an adjunct to reduced-calorie diets for weight reduction and to
improve insulin resistance.

Medications. Because patients with type 1 diabetes are absolutely insulin deficient, treatment requires
insulin injections. Although one or two injections per day are often adequate to prevent symptoms of
hyperglycemia, intensive therapy employing three or four insulin injections per day, or continuous
subcutaneous insulin infusion, may be necessary to achieve near-normal glucose control.

Both oral medications and injected insulin are used for the treatment of type 2 diabetes. Four groups of
oral agents are currently available: insulin secretagogues, which enhance nutrient-stimulated insulin
secretion; the biguanides, which suppress abnormal glucose production by the liver; the
thiazolidinediones, which reduce insulin resistance at the level of muscle and fat; and the alpha-
glucosidase inhibitors, which slow the breakdown and absorption of carbohydrates and reduce
postprandial glucose excursions. To the extent that these four groups of oral medications have different
mechanisms of action, they can be used clinically in combination. When oral agents are ineffective in
controlling hyperglycemia or achieving glycemic goals, insulin is added or substituted.

Monitoring

Self-monitoring of blood glucose is integral to modern diabetes therapy. A lancet is used to obtain a
small drop of blood, which is placed on a reagent strip and inserted in a small battery-powered meter.
The meter reports the blood glucose level in less than a minute. Results of self-monitoring of blood
glucose are used to guide adjustments in diet, exercise, and medications, for the monitoring and
treatment of hypoglycemia, and in the home management of intercurrent illness.

Incidence and Prevalence

The number of people developing diabetes and the number of people with diabetes are increasing
worldwide. In 2000, it was estimated that 154 million persons, or 4.2 percent of the world's population,
twenty years of age and older had diabetes. By the year 2025, it is estimated that nearly 300 million
persons, or 5.4 percent of the world's population, twenty years of age and older will have diabetes. The
major part of this increase will occur in developing countries due to the aging of the population and
increasing urbanization (associated with increased body weight and decreased physical activity).

In 1994, there were 939,000 Americans newly diagnosed with diabetes, with a disproportionate number
among the elderly and minority populations. The incidence of diagnosed diabetes was3.61 cases per
1,000 persons per year in 1994 (see Table 2).

In 1994, about 8 million persons in the United States (3.1 percent of the population) reported that they
had diabetes. The prevalence of diagnosed diabetes increases with age (see Table 3).

Mortality

Diabetes is the seventh leading cause of deaths in the United States. The highest death rates due to
diabetes are observed in older Americans and in minority populations. Death certificates underestimate
diabetes mortality because of underreporting of diabetes. Only about 10 percent of people with diabetes
who die have diabetes listed as the underlying cause of death on their death certificates, and only about
40 percent have it listed anywhere on their death certificates. Diabetes was the underlying cause of
death for approximately 57,000 Americans in 1994, and diabetes was recorded on the death certificate
of approximately 182,000 Americans. In 1994, black women had the highest death rates due to
diabetes, followed by white women and men. That same year, 44 percent of all diabetes-related deaths
(80,000 deaths) had cardiovascular disease listed as the underlying cause. Of these deaths,
approximately 60 percent were caused by ischemic heart disease and 15 percent by stroke.

Complications and Comorbidities Associated With Diabetes

Diabetic Ketoacidosis (DKA). Ketoacidosis is an acute metabolic complication of diabetes associated

with hyperglycemia, nausea, vomiting, abdominal pain, dehydration, ketonemia, and acidosis. In 1994,
DKA was the primary diagnosis for 89,000 hospital discharges and a listed diagnosis for 113,000
hospital discharges. Clinical trials have demonstrated that improved education in self-management and
improved access to care can prevent up to 70 percent of DKA hospitalizations.

Adverse Outcomes of Pregnancy. Each year in the United States, type 1 diabetes complicates
approximately 7,000 pregnancies and type 2 diabetes complicates approximately 12,000 pregnancies.
Up to 1,700 infants (9%) of mothers with pregnancies complicated by diabetes (in the U.S.) are born
with birth defects affecting the brain, spinal cord, heart, kidneys, and skeleton. Clinical trials have
demonstrated that with intensive glycemic control before conception and during the first trimester, the
incidence of major birth defects may be reduced to 2 percent, the rate that occurs in infants of
nondiabetic mothers.

Diabetic Eye Disease. Diabetes is the leading cause of new cases of legal blindness in Americans
between twenty and seventy-four years of age. As many as 40,000 Americans become blind each year
as a result of diabetes. In type 1 diabetes, most legal blindness is due at least in part to diabetic
retinopathy. Timely diagnosis and appropriate laser treatment can prevent up to 90 percent of blindness
due to diabetic retinopathy. In type 2 diabetes, cataract, glaucoma, and senile macular degeneration are
more frequent causes of blindness.

Diabetic Kidney Disease. Diabetic nephropathy is characterized by hypertension, proteinuria, and

progressive renal insufficiency. Diabetes is now the leading cause of end-stage renal disease (kidney
failure requiring dialysis or kidney transplant for survival). In 1997, over 33,000 Americans developed
end-stage renal disease due to diabetes. Early detection, aggressive blood pressure control, and
treatment with angiotensin-converting enzyme inhibitors can reduce the progression of diabetic
nephropathy by about 60 percent.

Amputations. Diabetic neuropathy, peripheral vascular disease, and infection predispose people with
diabetes to gangrene and amputations. More than half of all nontraumatic lower extremity amputations
(LEAs) occur in people with diabetes. In 1994, there were approximately 67,000 diabetes-related
hospital discharges with LEA reported as a procedure in the United States. Clinical trials have
demonstrated that early detection of insensitive and deformed feet and multidisciplinary foot-care
programs can reduce the rate of amputation by more than 50 percent.

Cardiovascular Disease Cardiovascular disease (CVD) is the leading cause of morbidity and

Table 4

Incidence of hospital discharge for cardiovascular disease per 1,000 diabetic

population by age and sex, United States, 1994
Age Group
Population 0–44 45–64 65–74 75+ Total
From Centers for Disease Control and Prevention. Diabetes Surveillance, 1997.
Atlanta, GA. U.S. Department of Health and Human Services, 1997.
males 34.3 110.6 228.3 264.9 146.3
females 18.3 101.8 191.3 245.8 139.6
Total 26.1 105.8 207.4 253.0 142.7

mortality in people with diabetes. Stroke, heart attack, and peripheral vascular disease are two to four
times more common in people with diabetes than in people without diabetes. In 1994, there were
1,144,000 diabetes-related hospital discharges that had CVD listed as the primary discharge diagnosis
(see Table 4). Part of the increased incidence of cardiovascular disease in people with diabetes is due to
the greater prevalence of cardiovascular risk factors, including hypertension, dyslipidemia, and cigarette
smoking. Clinical trials have demonstrated that pharmacologic treatments for hypertension and
dyslipidemia are as effective, if not more effective, in people with diabetes compared to people without
diabetes.

Costs of Diabetes
Health care costs incurred by people with diabetes include non-diabetes-related and diabetes-related
costs. In the United States, in 1992, the direct cost of non-diabetes-related and diabetes-related medical
care incurred by people with diabetes was estimated to be $105.2 billion. The direct cost of medical care
attributable to diabetes was estimated to be $45.2 billion and the indirect cost of diabetes was estimated
to be $46.6 million (see Table 5).

In 1992, per capita health care expenditures for people with diabetes averaged $9,493, compared to
$2,604 for people without diabetes. When adjusted for age, per capita health care expenditures for
people with diabetes were approximately

Table 5

Costs of diabetes mellitus in the United States, 1992 ($ billion)

Attributable to Among People with
Type of Cost Setting
diabetes* diabetes**
*From Fox-Ray N, Wills S, Thamer M: Direct and Indirect Costs of Diabetes in the
United States in 1992. Alexandria, VA: American Diabetes Association, pp. 1-27,
1993.
**From Rubin RJ, Altman WM, Mendelson DN: Health care expenditures for people
with diabetes mellitus, 1992. J Clin Endocrinol Metab 78:809A-809F, 1994.
Direct Hospital 37.2 65.2
Nursing home 1.8 —
Office 1.1 11.0
Outpatient 2.9 12.5
Emergency room 0.2 1.3
Drugs 1.7 9.9
Home health 0.0 4.0
Dental — 1.4
Total 45.2 105.2
Indirect Illness 8.5 —
Disability 11.2 —
Death 27.0 —
Total 46.6

$3,800 higher for people with diabetes than for people without diabetes ($6,425 versus $2,604).

The fact that 62 percent of direct health care costs among people with diabetes and 82 percent of costs
directly attributable to diabetes are incurred in the hospital setting suggests that the majority of costs are
associated with the treatment of the late, chronic complications of diabetes.

Screening for Type 2 Diabetes

One-third of diabetes in the United States is undiagnosed, and one-third to one-half of all diabetes
worldwide is undiagnosed. This finding, combined with the fact that glycemic management can prevent
or delay the development of complications, and the fact that diabetic patients may already have
complications at clinical diagnosis, have lead some to call for public health screening for type 2
diabetes. In general, screening is appropriate in asymptomatic populations when six specific conditions
are met (see Table 6).

Table 6

Characteristics of Diseases that Warrant Diabetes Screening

SOURCE: Engelgau, M. M.; Venkat Narayan, K. M.; and Herman, W. H. (2000).
Characteristics of Diseases that Warrant Diabetes Screening
"Screening for Type 2 Diabetes." Diabetes Care 23:1563–1580.
 The disease represents an important health problem
 The natural history of the disease is understood
 The disease has a recognizable preclinical stage during which it may be
diagnosed
 Early treatment confers greater benefit than later treatment
 Reliable and acceptable tests exist which can detect the preclinical disease

 The costs of case-finding and treatment are reasonable

Diabetes imposes substantial morbidity and mortality on the population. The natural history of type 2
diabetes is well understood, and with systematic testing, diabetes can be diagnosed in asymptomatic,
preclinical, subjects. Unfortunately, although it is clear that intensified management can improve
outcomes, no studies have demonstrated the effectiveness or safety of early treatment. Likewise, there
is no consensus as to the optimal approach to screening for type 2 diabetes. Ideally, a screening test
should be both sensitive and specific. Generally, however, trade-offs must be made between sensitivity
and specificity (increasing sensitivity reduces specificity, and increasing specificity reduces sensitivity).
In some health systems, the costs of screening and treatment are reasonable, but in others they are
simply unaffordable. Finally, although it is recognized that screening must be an ongoing process, no
empirical data exist to indicate the optimal screening frequency.

Questionnaires that use self-reported demographic, behavioral, and past medical history to assign a
person to a higher or lower risk group; fasting, random, and postprandial urine glucose tests; fasting,
random, and postprandial capillary whole blood and capillary plasma glucose tests; fasting, random, and
postprandial venous whole blood and plasma glucose tests; and hemoglobin A1c have all been
evaluated as screening tests for diabetes. In general, questionnaires perform rather poorly as screening
tests for diabetes. Measurement of glycosuria using a cut-off point greater than or equal to a trace value
generally has a low sensitivity and a high specificity. Capillary or venous whole blood or plasma glucose
determinations have generally performed better than urine glucose testing. With both urine and blood
testing, random, postprandial, and glucose-loaded tests perform better than fasting tests. There is little
consensus, however, as to optimal cut-points for defining positive tests. Screening with hemoglobin A1c
has suffered from lack of standardization of the assay. Even as this problem has been addressed, the
test has generally been found to be specific but less sensitive than glucose measurements.

Accordingly, the American Diabetes Association has recommended that clinicians should be vigilant and
recognize clinical histories and signs suggestive of diabetes that warrant testing. Generally, screening of
high-risk individuals for type 2 diabetes should be performed only as part of ongoing medical care,
understanding that the evidence is incomplete and questions remain as to the benefits and risks of early
treatment, the optimal screening methods and cut-points, and screening frequency. Community-based
screening for diabetes is generally associated with a low yield and poor follow-up, and it probably does
not represent a good use of resources.

(SEE ALSO: Cardiovascular Diseases; Glycosylated Hemoglobin; Noncommunicable Disease Control;

Nutrition; Screening)

Bibliography

Centers for Disease Control and Prevention (1997). Diabetes Surveillance, 1997. Atlanta, GA: CDC.

DCCT Research Group (1993). "The Effect of Intensive Treatment of Diabetes on the Development and
Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus." New England Journal
of Medicine 329: 977–986.

Engelgau, M. M.; Venkat Narayan, K. M.; and Herman, W. H. (2000). "Screening for Type 2 Diabetes."
Diabetes Care 23:1563–1580.

Fox-Ray, N.; Mills, S.; and Thamer, M. (1993). Direct and Indirect Costs of Diabetes in the United States
in 1992. Alexandria, VA: American Diabetes Association.
King, H.; Aubert, R. E.; and Herman, W. H. (1998). "Global Burden of Diabetes, 1995–2025: Prevalence,
Numerical Estimates, and Projections." Diabetes Care 21:1414–1431.

Lebovitz, H. E., ed. (1998) Therapy for Diabetes Mellitus and Related Disorders, 3rd edition. Alexandria,
VA: American Diabetes Association.

National Diabetes Data Group (1995). Diabetes in America, 2nd edition. Bethesda, MD: National
Institute of Health.

Rubin, R. J.; Altman, W. M.; and Mendelson, D. N. (1994). "Health Care Expenditures for People with
Diabetes Mellitus, 1992." Journal of Clinical Endocrinolical Metabolism 78:809a–809f.

UK Prospective Diabetes Study (UKPDS) Group (1998). "Intensive Blood-Glucose Control with
Sulphonylureas or Insulin Compared with Conventional Treatment and Risk of Complications in Patients
with Type 2 Diabetes." Lancet 352:857–853. (Published erratum appears in Lancet 354:602.

— WILLIAM H. HERMAN; LIZA L. ILAG

Britannica Concise Encyclopedia

Home > Library > Reference > Britannica Concise Encyclopedia

diabetes mellitus

Disorder of insufficient production of or reduced sensitivity to insulin. Insulin, synthesized in the islets of
Langerhans (see Langerhans, islets of), is necessary to metabolize glucose. In diabetes, blood sugar
levels increase (hyperglycemia). Excess sugar is excreted in the urine (glycosuria). Symptoms include
increased urine output, thirst, weight loss, and weakness. Type 1, or insulin-dependent diabetes mellitus
(IDDM), an autoimmune disease in which no insulin is produced, must be treated by insulin injections.
Type 2, or non-insulin-dependent diabetes mellitus (NIDDM), in which tissues do not respond to insulin,
is linked to heredity and obesity and may be controlled by diet; it accounts for 90% of all cases, many of
which go undiagnosed for years. Untreated diabetes leads to accumulation of ketones in the blood,
followed by acidosis (high blood acid content) with nausea and vomiting and then coma. Careful
attention to content and timing of meals, with periodic checking of blood sugar, may manage diabetes. If
not, injected or oral insulin is necessary. Complications, including heart disease, diabetic retinopathy (a
leading cause of blindness), kidney disease, and nerve disorders, especially in the legs and feet,
account for most deaths. Degree of blood-sugar control does not always correlate with progression of
complications. Gestational diabetes may occur as a complication of pregnancy.

For more information on diabetes mellitus, visit Britannica.com.

Sports Science and Medicine

Home > Library > Health > Sports Science and Medicine
diabetes mellitus

A disorder of carbohydrate metabolism characterized by an increased blood glucose level

(hyperglycaemia) and the presence of glucose in the urine (glycosuria). There are two main types of
diabetes mellitus: Type I diabetes (also known as juvenile-onset diabetes and insulin-dependent
diabetes) generally has a sudden onset in young people who develop almost total insulin deficiency that
usually requires daily insulin injections; Type II diabetes (also known as adult-onset diabetes and non-
insulin-dependent diabetes) usually develops gradually in adulthood and is caused by delayed or
impaired insulin secretion, impaired insulin action (see insulin resistance), or excessive glucose output
by the liver. Exercise is often an important part of the management of diabetes. It can be effective in
modifying the course of the disease, helping to reduce the risk of vascular complications (e.g. coronary
artery disease). Regular aerobic exercise might also reduce the risk of developing Type II diabetes and
it improves the control of food glucose levels in those who already have the disease. However, it is
important that the diabetic, coach, and friends are well acquainted with potential problems during
exercise, such as hypoglycaemia. A glucose drink or some other simple and quick source of glucose
should be available if needed to prevent insulin shock. Physical activity reduces the concentration of
insulin in the blood, and acute bouts of exercise increases the sensitivity of target cells to insulin,
reducing the dosages required by a diabetic. Diabetics often suffer complications such as peripheral
neuropathy which can reduce sensation in the feet and peripheral vascular disease, which may impair
blood circulation in the feet. They therefore need to pay particular attention to their feet, taking care to
select proper footwear, especially if they perform weight-bearing exercises (e.g. road running). The
American Academy of Pediatrics, Committee on Sports Medicine states that diabetics can participate in
all sports with proper attention to blood glucose concentration, hydration, and insulin therapy. The
Committee advises that blood glucose concentration should be monitored every 30 min during
continuous exercise and 15 min after completion of exercise.

Columbia Encyclopedia

Home > Library > Reference > Columbia Encyclopedia

diabetes or diabetes mellitus (məlī'təs) , chronic disorder of glucose (sugar)
metabolism caused by inadequate production or use of insulin, a hormone produced in
specialized cells (beta cells in the islets of Langerhans) in the pancreas that allows the
body to use and store glucose. It is a leading cause of death in the United States and is
especially prevalent among African Americans. The treatment of diabetes was
revolutionized when F. G. Banting and C. H. Best isolated insulin in 1921.

The Disorder

The lack of insulin results in an inability to metabolize glucose, and the capacity to store glycogen (a
form of glucose) in the liver and the active transport of glucose across cell membranes are impaired.
The symptoms are elevated sugar levels in the urine and blood, increased urination, thirst, hunger,
weakness, weight loss, and itching. Prolonged hyperglycemia (excess blood glucose) leads to increased
protein and fat catabolism, a condition that can cause premature vascular degeneration and
atherosclerosis (see arteriosclerosis). Uncontrolled diabetes leads to diabetic acidosis, in which ketones
build up in the blood. Patients have sweet-smelling breath, and may suffer confusion, unconsciousness,
and death. There are two distinct types of diabetes mellitus: insulin-dependent and noninsulin-
dependent.

Insulin-dependent Diabetes

Insulin-dependent diabetes (Type I), also called juvenile-onset diabetes, is the more serious form of the
disease; about 10% of diabetics have this form. It is caused by destruction of pancreatic cells that make
insulin and usually develops before age 30. Type I diabetics have a genetic predisposition to the
disease. There is some evidence that it is triggered by a virus that changes the pancreatic cells in a way
that prompts the immune system to attack them. The symptoms are the same as in the non-insulin-
dependent variant, but they develop more rapidly and with more severity. Treatment includes a diet
limited in carbohydrates and saturated fat, exercise to burn glucose, and regular insulin injections,
sometimes administered via a portable insulin pump. Transplantation of islet cells has also proved
somewhat successful since 1999, after new transplant procedures were developed, but the number of
pancreases available for extraction of the islet cells is far smaller than the number of Type I diabetics.
Patients receiving a transplant must take immunosuppressive drugs to prevent rejection of the cells, and
many ultimately need to resume insulin injections, but despite that transplants provide real benefits for
some whose diabetes has become difficult to control.

Noninsulin-dependent diabetes

Noninsulin-dependent diabetes (Type 2), also called adult-onset diabetes, results from the inability of
the cells in the body to respond to insulin. About 90% of diabetics have this form, which is more
prevalent in minorities and usually occurs after age 40. Although the cause is not completely
understood, there is a genetic factor and 90% of those affected are obese. As in Type I diabetes,
treatment includes exercise and weight loss and a diet low in total carbohydrates and saturated fat.
Some individuals require insulin injections; many rely on oral drugs, such as sulphonylureas, metformin,
acarbose, or a dipeptidyl peptidase–IV (DPP-IV) inhibitor.

Complications

Diabetes affects the way the body handles fats, leading to fat accumulation in the arteries and potential
damage to the kidneys, eyes, heart, and brain, and statins (cholesterol-lowering drugs) may be
prescribed to prevent heart disease. It is the leading cause of kidney disease. Many patients require
dialysis or kidney transplants (see transplantation, medical). Most cases of acquired blindness in the
United States are caused by diabetes. Diabetes can also affect the nerves, causing numbness or pain in
the face and extremities. A complication of insulin therapy is insulin shock, a hypoglycemic condition that
results from an oversupply of insulin in relation to the glucose level in the blood (see hyperinsulinism).

Bibliography

See A. Bloom, Diabetes Explained (1973); Portland Area Diabetes Program, Diabetes and Insulin
(1988); M. Davidson, Diabetes Mellitus: Diagnosis and Treatment (1991).

Health Dictionary

Home > Library > Health > Health Dictionary

diabetes mellitus (deye-uh-BEE-teez, deye-uh-BEE-tuhs MEL-uh-tuhs)

A chronic disease in which carbohydrates cannot be metabolized properly (see metabolism) because
the pancreas fails to secrete an adequate amount of insulin. Without enough insulin, carbohydrate
metabolism is upset, and levels of sugar in the blood rise.

Wikipedia

Home > Library > Reference > Wikipedia

diabetes mellitus

Diabetes mellitus
Classification & external resources
ICD-10 E10.–E14.
ICD-9 250
MedlinePlus 001214
eMedicine med/546 emerg/134
MeSH C18.452.394.750
For the disease characterized by excretion of large amounts of very dilute urine, see
diabetes insipidus. For diabetes mellitus in pets, see diabetes in cats and dogs.

Diabetes mellitus (IPA pronunciation: [ˌdaɪəˈbitəs]) is a metabolic disorder characterized by

hyperglycemia (high blood sugar) and other signs, as distinct from a single illness or condition. The
World Health Organization recognizes three main forms of diabetes: type 1, type 2, and gestational
diabetes (occurring during pregnancy),[1] which have similar signs, symptoms, and consequences, but
different causes and population distributions. Ultimately, all forms are due to the beta cells of the
pancreas being unable to produce sufficient insulin to prevent hyperglycemia.[2] Type 1 is usually due to
autoimmune destruction of the pancreatic beta cells which produce insulin. Type 2 is characterized by
tissue-wide insulin resistance and varies widely; it sometimes progresses to loss of beta cell function.
Gestational diabetes is similar to type 2 diabetes, in that it involves insulin resistance; the hormones of
pregnancy cause insulin resistance in those women genetically predisposed to developing this
condition.
 Diabetes mellitus

Types 1 and 2 are incurable chronic conditions, but have been Types of Diabetes
treatable since insulin became medically available in 1921, and Diabetes mellitus type 1
today are usually managed with a combination of dietary Diabetes mellitus type 2
treatment, tablets (in type 2) and, frequently, insulin
supplementation. Gestational diabetes typically resolves with Gestational diabetes
delivery.
Pre-diabetes:
Diabetes can cause many complications. Acute complications Impaired fasting glycaemia
(hypoglycemia, ketoacidosis or nonketotic hyperosmolar coma) Impaired glucose tolerance
may occur if the disease is not adequately controlled. Serious Disease Management
long-term complications include cardiovascular disease (doubled Diabetes management:
risk), chronic renal failure (diabetic nephropathy is the main cause
of dialysis in developed world adults), retinal damage (which can •Diabetic diet
lead to blindness and is the most significant cause of adult •Anti-diabetic drugs
blindness in the non-elderly in the developed world), nerve •Conventional insulinotherapy
damage (of several kinds), and microvascular damage, which may
cause erectile dysfunction (impotence) and poor healing. Poor •Intensive insulinotherapy
healing of wounds, particularly of the feet, can lead to gangrene Other Concerns
which can require amputation — the leading cause of non- Cardiovascular disease
traumatic amputation in adults in the developed world. Adequate
treatment of diabetes, as well as increased emphasis on blood
pressure control and lifestyle factors (such as not smoking and Diabetic comas:
keeping a healthy body weight), may improve the risk profile of •Diabetic hypoglycemia
most aforementioned complications. •Diabetic ketoacidosis
•Nonketotic hyperosmolar

Terminology Diabetic myonecrosis

Diabetic nephropathy
The term diabetes (Greek: διαβήτης) was coined by Aretaeus of Diabetic neuropathy
Cappadocia. It is derived from the Greek word διαβαίνειν, Diabetic retinopathy
diabaínein that literally means "passing through," or "siphon", a
reference to one of diabetes' major symptoms—excessive urine Diabetes and pregnancy
production. In 1675 Thomas Willis added the word mellitus to the
disease, a word from Latin meaning "honey", a reference to the
Blood tests
sweet taste of the urine. This sweet taste had been noticed in Fructosamine
urine by the ancient Greeks, Chinese, Egyptians, and Indians. In Glucose tolerance test
1776 Matthew Dobson confirmed that the sweet taste was
because of an excess of a kind of sugar in the urine and blood of
Glycosylated hemoglobin
people with diabetes.[3]

The ancient Indians tested for diabetes by observing whether ants were attracted to a person's urine,
and called the ailment "sweet urine disease" (Madhumeha). The Korean, Chinese, and Japanese words
for diabetes are based on the same ideographs (糖尿病) which mean "sugar urine disease".

Diabetes, without qualification, usually refers to diabetes mellitus, but there are several rarer conditions
also named diabetes. The most common of these is diabetes insipidus (insipidus meaning "without
taste" in Latin) in which the urine is not sweet; it can be caused by either kidney (nephrogenic DI) or
pituitary gland (central DI) damage.

The term "type 1 diabetes" has universally replaced several former terms, including childhood-onset
diabetes, juvenile diabetes, and insulin-dependent diabetes. "Type 2 diabetes" has also replaced
several older terms, including adult-onset diabetes, obesity-related diabetes, and non-insulin-dependent
diabetes. Beyond these numbers, there is no agreed standard. Various sources have defined "type 3
diabetes" as, among others:

 Gestational diabetes[4]
 Insulin-resistant type 1 diabetes (or "double diabetes")
 Type 2 diabetes which has progressed to require injected insulin.
 Latent autoimmune diabetes of adults (or LADA or "type 1.5" diabetes)
History
Although diabetes has been recognized since antiquity, and treatments of various efficacy have been
known in various regions since the Middle Ages, and in legend for much longer, pathogenesis of
diabetes has only been understood experimentally since about 1900.[5] The discovery of a role for the
pancreas in diabetes is generally ascribed to Joseph von Mering and Oskar Minkowski, who in 1889
found that dogs whose pancreas was removed developed all the signs and symptoms of diabetes and
died shortly afterwards.[6] In 1910, Sir Edward Albert Sharpey-Schafer suggested that people with
diabetes were deficient in a single chemical that was normally produced by the pancreas—he proposed
calling this substance insulin, from the Latin insula, meaning island, in reference to the insulin-producing
islets of Langerhans in the pancreas.[5]

The endocrine role of the pancreas in metabolism, and indeed the existence of insulin, was not further
clarified until 1921, when Sir Frederick Grant Banting and Charles Herbert Best repeated the work of
Von Mering and Minkowski, and went further to demonstrate they could reverse induced diabetes in
dogs by giving them an extract from the pancreatic islets of Langerhans of healthy dogs.[7] Banting, Best,
and colleagues (especially the chemist Collip) went on to purify the hormone insulin from bovine
pancreases at the University of Toronto. This led to the availability of an effective treatment—insulin
injections—and the first patient was treated in 1922. For this, Banting and laboratory director MacLeod
received the Nobel Prize in Physiology or Medicine in 1923; both shared their Prize money with others
in the team who were not recognized, in particular Best and Collip. Banting and Best made the patent
available without charge and did not attempt to control commercial production. Insulin production and
therapy rapidly spread around the world, largely as a result of this decision.

The distinction between what is now known as type 1 diabetes and type 2 diabetes was first clearly
made by Sir Harold Percival (Harry) Himsworth, and published in January 1936.[8]

Despite the availability of treatment, diabetes has remained a major cause of death. For instance,
statistics reveal that the cause-specific mortality rate during 1927 amounted to about 47.7 per 100,000
population in Malta.[9]

Other landmark discoveries include:[5]

 identification of the first of the sulfonylureas in 1942

 the determination of the amino acid order of insulin (by Sir Frederick Sanger,
for which he received a Nobel Prize)
 the radioimmunoassay for insulin, as discovered by Rosalyn Yalow and
Solomon Berson (gaining Yalow the 1977 Nobel Prize in Physiology or
Medicine)[10]
 the three-dimensional structure of insulin
 Dr Gerald Reaven's identification of the constellation of symptoms now called
metabolic syndrome in 1988
 Demonstration that intensive glycemic control in type 1 diabetes reduces
chronic side effects more as glucose levels approach 'normal' in a large
longitudinal study,[11] and also in type 2 diabetics in other large studies
 identification of the first thiazolidinedione as an effective insulin sensitizer
during the 1990s

Causes and types

Glucose metabolism
Mechanism of insulin release in normal pancreatic beta cells. Insulin production is
more or less constant within the beta cells, irrespective of blood glucose levels. It is
stored within vacuoles pending release, via exocytosis, which is triggered by
increased blood glucose levels.

Because insulin is the principal hormone that regulates uptake of glucose into most cells from the blood
(primarily muscle and fat cells, but not central nervous system cells), deficiency of insulin or the
insensitivity of its receptors plays a central role in all forms of diabetes mellitus.

Much of the carbohydrate in food is converted within a few hours to the monosaccharide glucose, the
principal carbohydrate found in blood. Some carbohydrates are not converted. Notable examples
include fruit sugar (fructose) that is usable as cellular fuel, but it is not converted to glucose and does
not participate in the insulin / glucose metabolic regulatory mechanism; additionally, the carbohydrate
cellulose (though it is actually many glucose molecules in long chains) is not converted to glucose, as
humans and many animals have no digestive pathway capable of handling cellulose. Insulin is released
into the blood by beta cells (β-cells) in the pancreas in response to rising levels of blood glucose (e.g.,
after a meal). Insulin enables most body cells (about 2/3 is the usual estimate, including muscle cells
and adipose tissue) to absorb glucose from the blood for use as fuel, for conversion to other needed
molecules, or for storage. Insulin is also the principal control signal for conversion of glucose (the basic
sugar used for fuel) to glycogen for internal storage in liver and muscle cells. Reduced glucose levels
result both in the reduced release of insulin from the beta cells and in the reverse conversion of
glycogen to glucose when glucose levels fall, although only glucose thus recovered by the liver re-
enters the bloodstream as muscle cells lack the necessary export mechanism.

Higher insulin levels increase many anabolic ("building up") processes such as cell growth and
duplication, protein synthesis, and fat storage. Insulin is the principal signal in converting many of the
bidirectional processes of metabolism from a catabolic to an anabolic direction, and vice versa. In
particular, it is the trigger for entering or leaving ketosis (ie, the fat burning metabolic phase).

If the amount of insulin available is insufficient, if cells respond poorly to the effects of insulin (insulin
insensitivity or resistance), or if the insulin itself is defective, glucose will not be handled properly by
body cells (about ⅔ require it) or stored appropriately in the liver and muscles. The net effect is
persistent high levels of blood glucose, poor protein synthesis, and other metabolic derangements, such
as acidosis.

Type 1 diabetes mellitus

Main article: Diabetes mellitus type 1

Type 1 diabetes mellitus—formerly known as insulin-dependent diabetes (IDDM), childhood diabetes or
also known as juvenile diabetes, is characterized by loss of the insulin-producing beta cells of the islets
of Langerhans of the pancreas leading to a deficiency of insulin. It should be noted that there is no
known preventative measure that can be taken against type 1 diabetes. Most people affected by type 1
diabetes are otherwise healthy and of a healthy weight when onset occurs. Diet and exercise cannot
reverse or prevent type 1 diabetes. Sensitivity and responsiveness to insulin are usually normal,
especially in the early stages. This type comprises up to 10% of total cases in North America and
Europe, though this varies by geographical location. This type of diabetes can affect children or adults
but was traditionally termed "juvenile diabetes" because it represents a majority of cases of diabetes
affecting children.

The main cause of beta cell loss leading to type 1 diabetes is a T-cell mediated autoimmune attack.[2]
The principal treatment of type 1 diabetes, even from the earliest stages, is replacement of insulin.
Without insulin, ketosis and diabetic ketoacidosis can develop and coma or death will result.

Currently, type 1 diabetes can be treated only with insulin, with careful monitoring of blood glucose
levels using blood testing monitors. Emphasis is also placed on lifestyle adjustments (diet and exercise).
Apart from the common subcutaneous injections, it is also possible to deliver insulin by a pump, which
allows continuous infusion of insulin 24 hours a day at preset levels and the ability to program doses (a
bolus) of insulin as needed at meal times. An inhaled form of insulin, Exubera, was approved by the
FDA in January 2006.[12]

Type 1 treatment must be continued indefinitely. Treatment does not impair normal activities, if sufficient
awareness, appropriate care, and discipline in testing and medication is taken. The average glucose
level for the type 1 patient should be as close to normal (80–120 mg/dl, 4–6 mmol/l) as possible. Some
physicians suggest up to 140–150 mg/dl (7-7.5 mmol/l) for those having trouble with lower values, such
as frequent hypoglycemic events. Values above 200 mg/dl (10 mmol/l) are often accompanied by
discomfort and frequent urination leading to dehydration. Values above 300 mg/dl (15 mmol/l) usually
require immediate treatment and may lead to ketoacidosis. Low levels of blood glucose, called
hypoglycemia, may lead to seizures or episodes of unconsciousness.

Type 2 diabetes mellitus

Main article: Diabetes mellitus type 2

Type 2 diabetes mellitus—previously known as adult-onset diabetes, maturity-onset diabetes, or non-

insulin-dependent diabetes mellitus (NIDDM)—is due to a combination of defective insulin secretion and
insulin resistance or reduced insulin sensitivity (defective responsiveness of tissues to insulin), which
almost certainly involves the insulin receptor in cell membranes. In the early stage the predominant
abnormality is reduced insulin sensitivity, characterized by elevated levels of insulin in the blood. 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, but as the disease progresses the impairment of
insulin secretion worsens, and therapeutic replacement of insulin often becomes necessary. There are
numerous theories as to the exact cause and mechanism for this resistance, but central obesity (fat
concentrated around the waist in relation to abdominal organs, and not subcutaneous fat, it seems) is
known to predispose individuals for insulin resistance, possibly due to its secretion of adipokines (a
group of hormones) that impair glucose tolerance. Abdominal fat is especially active hormonally. Obesity
is found in approximately 55% of patients diagnosed with type 2 diabetes.[13] Other factors include aging
(about 20% of elderly patients are diabetic in North America) and family history (Type 2 is much more
common in those with close relatives who have had it), although in the last decade it has increasingly
begun to affect children and adolescents, likely in connection with the greatly increased childhood
obesity seen in recent decades in some places.

Type 2 diabetes may go unnoticed for years in a patient before diagnosis, as visible symptoms are
typically mild or non-existent, without ketoacidotic episodes, and can be sporadic as well. However,
severe long-term complications can result from unnoticed type 2 diabetes, including renal failure,
vascular disease (including coronary artery disease), vision damage, etc.

Type 2 diabetes is usually first treated by attempts to change physical activity (generally an increase is
desired), the diet (generally to decrease carbohydrate intake), and weight loss. These can restore
insulin sensitivity, even when the weight loss is modest, for example, around 5 kg (10 to 15 lb), most
especially when it is in abdominal fat deposits. Some Type 2 diabetics can achieve satisfactory glucose
control, sometimes for years, as a result. However, the underlying tendency to insulin resistance is not
lost, and so attention to diet, exercise, and weight loss must continue. The usual next step, if necessary,
is treatment with oral antidiabetic drugs. As insulin production is initially unimpaired in Type 2s, oral
medication (often used in various combinations) can still be used to improve insulin production (e.g.,
sulfonylureas), to regulate inappropriate release of glucose by the liver (and attenuate insulin resistance
to some extent (e.g., metformin), and to substantially attenuate insulin resistance (e.g.,
thiazolidinediones). According to one study, overweight patients treated with metformin compared with
diet alone, had relative risk reductions of 32% for any diabetes endpoint, 42% for diabetes related death
and 36% for all cause mortality and stroke.[14] When oral medications fail (cessation of beta cell insulin
secretion is not uncommon amongst Type 2s), insulin therapy will be necessary to maintain normal or
near normal glucose levels. A disciplined regimen of blood glucose checks is recommended in most
cases, most particularly and necessarily when taking medications.

Gestational diabetes
Main article: Gestational diabetes

Gestational diabetes also involves a combination of inadequate insulin secretion and responsiveness,
resembling type 2 diabetes in several respects. It develops during pregnancy and may improve or
disappear after delivery. Even though it may be transient, gestational diabetes may damage the health
of the fetus or mother, and about 20%–50% of women with gestational diabetes develop type 2 diabetes
later in life.

Gestational diabetes mellitus (GDM) occurs in about 2%–5% of all pregnancies. It is temporary and fully
treatable but, if untreated, may cause problems with the pregnancy, including macrosomia (high birth
weight), fetal malformation and congenital heart disease. It requires careful medical supervision during
the pregnancy.

Fetal/neonatal risks associated with GDM include congenital anomalies such as cardiac, central
nervous system, 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
profusion due to vascular impairment. Induction may be indicated with decreased placental function.
Cesarean section may be performed if there is marked fetal distress or an increased risk of injury
associated with macrosomia, such as shoulder dystocia.

Other types
There are several rare causes of diabetes mellitus that do not fit into type 1, type 2, or gestational
diabetes:

 Genetic defects in beta cells (autosomal or mitochondrial)

 Genetically-related insulin resistance, with or without lipodystrophy
(abnormal body fat deposition)
 Diseases of the pancreas (e.g. chronic pancreatitis, cystic fibrosis)
 Hormonal defects
 Chemicals or drugs

The tenth version of the International Statistical Classification of Diseases (ICD-10) contained a
diagnostic entity named "malnutrition-related diabetes mellitus" (MRDM or MMDM, ICD-10 code E12). A
subsequent WHO 1999 working group recommended that MRDM be deprecated, and proposed a new
taxonomy for alternative forms of diabetes.[1] Classifications of non-type 1, non-type 2, non-gestational
diabetes remains controversial.[citation needed]

Genetics
Both type 1 and type 2 diabetes are at least partly inherited. Type 1 diabetes appears to be triggered by
some (mainly viral) infections, or in a less common group, by stress or environmental exposure (such as
exposure to certain chemicals or drugs). There is a genetic element in individual susceptibility to some
of these triggers which has been traced to particular HLA genotypes (i.e., the genetic "self" identifiers
relied upon by the immune system). However, even in those who have inherited the susceptibility, type 1
diabetes mellitus seems to require an environmental trigger. A small proportion of people with type 1
diabetes carry a mutated gene that causes maturity onset diabetes of the young (MODY).

Wolfram's syndrome - Wolfram's syndrome is an autosomal recessive neurodegenerative disorder first

evident in childhood. It consists of diabetes insipidus, diabetes mellitus, optic atrophy, and deafness,
hence the acronym DIDMOAD.[15]

There is a stronger inheritance pattern for type 2 diabetes. Those with first-degree relatives with type 2
have a much higher risk of developing type 2, increasing with the number of those relatives.
Concordance among monozygotic twins is close to 100%[citation needed], and about 25% of those with the
disease have a family history of diabetes. Candidate genes include KCNJ11 (potassium inwardly
rectifying channel, subfamily J, member 11), which encodes the islet ATP-sensitive potassium channel
Kir6.2, and TCF7L2 (transcription factor 7–like 2), which regulates proglucagon gene expression and
thus the production of glucagon-like peptide-1.[2]

Another risk factor is obesity, particularly central obesity (i.e., that in and around abdominal organs),
which is found in approximately 85% of North American patients diagnosed with this type, so some
experts believe that inheriting a tendency toward obesity also contributes.

Diagnosis

Signs and symptoms

The classical triad of diabetes symptoms is polyuria (frequent urination), polydipsia (increased thirst and
consequent increased fluid intake), polyphagia (increased appetite). Weight loss may occur. These
symptoms may develop quite fast in type 1, particularly in children (weeks or months) but may be subtle
or completely absent—as well as developing much more slowly—in type 2. In type 1 there may also be
weight loss (despite normal or increased eating) and irreducible fatigue. These symptoms may also
manifest in type 2 diabetes in patients whose diabetes is poorly controlled.

When the glucose concentration in the blood is high (ie, above the "renal threshold"), reabsorption of
glucose in the proximal renal tubuli is incomplete, and part of the glucose remains in the urine
(glycosuria). This increases the osmotic pressure of the urine and thus inhibits the resorption of water by
the kidney, resulting in an increased urine production (polyuria) and an increased fluid loss. Lost blood
volume will be replaced osmotically from water held in body cells, causing dehydration and increased
thirst.

Prolonged high blood glucose causes glucose absorption and so shape changes in the shape of the
lens in the eye, leading to vision changes. Blurred vision is a common complaint leading to a diabetes
diagnosis; Type 1 should always be suspected in cases of rapid vision change. Type 2 is generally more
gradual, but should still be suspected.

Patients (usually with type 1 diabetes) may also present with diabetic ketoacidosis (DKA), an extreme
state of metabolic dysregulation eventually characterized by the smell of acetone on the patient's breath,
Kussmaul breathing (a rapid, deep breathing), polyuria, nausea, vomiting and abdominal pain, and any
of many altered states of consciousness or arousal (e.g., hostility and mania or, equally, confusion and
lethargy). In severe DKA, coma (unconsciousness) may follow, progressing to death. In any form, DKA
is a medical emergency and requires expert attention.

A rarer, but equally severe, possibility is hyperosmolar nonketotic state, which is more common in type 2
diabetes, and is mainly the result of dehydration due to loss of body water. Often, the patient has been
drinking extreme amounts of sugar-containing drinks, leading to a vicious circle in regard to the water
loss.

Diagnostic approach
The diagnosis of type 1 diabetes, and many cases of type 2, is usually prompted by recent-onset
symptoms of excessive urination (polyuria) and excessive thirst (polydipsia), often accompanied by
weight loss. These symptoms typically worsen over days to weeks; about 25% of people with new type
1 diabetes have developed some degree of diabetic ketoacidosis by the time the diabetes is recognized.
The diagnosis of other types of diabetes is usually made in other ways. The most common are (1)
ordinary health screening, (2) detection of hyperglycemia when a doctor is investigating a complication
of longstanding, though unrecognized, diabetes, and (3) new signs and symptoms due to the diabetes,
such as vision changes or unexplainable fatigue.

1. Diabetes screening is recommended for many people at various stages of life,

and for those with any of several risk factors. The screening test varies
according to circumstances and local policy, and may be a random blood
glucose test, a fasting blood glucose test, a blood glucose test two hours after
75 g of glucose, or an even more formal glucose tolerance test. Many
healthcare providers recommend universal screening for adults at age 40 or 50,
and often periodically thereafter. Earlier screening is typically recommended
for those with risk factors such as obesity, family history of diabetes, high-risk
ethnicity (Mestizo, Native American, African American, Pacific Island, and
South Asian ancestry).
2. Many medical conditions are associated with diabetes and warrant screening.
A partial list includes: high blood pressure, elevated cholesterol levels,
coronary artery disease, past gestational diabetes, polycystic ovary syndrome,
chronic pancreatitis, fatty liver, hemochromatosis, cystic fibrosis, several
mitochondrial neuropathies and myopathies, myotonic dystrophy, Friedreich's
ataxia, some of the inherited forms of neonatal hyperinsulinism, etc. The risk
of diabetes is higher with chronic use of several medications, including high-
dose glucocorticoids, some chemotherapy agents (especially L-asparaginase),
as well as some of the antipsychotics and mood stabilizers (especially
phenothiazines and some atypical antipsychotics).
3. Diabetes is often detected when a person suffers a problem frequently caused
by diabetes, such as a heart attack, stroke, neuropathy, poor wound healing or
a foot ulcer, certain eye problems, certain fungal infections, or delivering a
baby with macrosomia or hypoglycemia.

Diagnostic criteria
Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by
demonstrating any one of the following:[1]

 fasting plasma glucose level at or above 126 mg/dL (7.0 mmol/l).

 plasma glucose at or above 200 mg/dL or 11.1 mmol/l two hours after a 75 g
oral glucose load as in a glucose tolerance test.
 random plasma glucose at or above 200 mg/dL or 11.1 mmol/l.

A positive result should be confirmed by another of the above-listed methods on a different day, unless
there is no doubt as to the presence of significantly-elevated glucose levels. Most physicians prefer
measuring a fasting glucose level because of the ease of measurement and the considerable time
commitment of formal glucose tolerance testing, which can take two hours to complete. By current
definition, two fasting glucose measurements above 126 mg/dL or 7.0 mmol/l is considered diagnostic
for diabetes mellitus.

Patients with fasting sugars between 6.1 and 7.0 mmol/l (ie, 110 and 125 mg/dL) are considered to have
"impaired fasting glycemia" and patients with plasma glucose at or above 140mg/dL or 7.8 mmol/l two
hours after a 75 g oral glucose load are considered to have "impaired glucose tolerance". "Prediabetes"
is either impaired fasting glucose or impaired glucose tolerance; the latter in particular is a major risk
factor for progression to full-blown diabetes mellitus as well as cardiovascular disease.

While not used for diagnosis, an elevated level of glucose irreversibly bound to hemoglobin (termed
glycosylated hemoglobin or HbA1c) of 6.0% or higher (the 2003 revised U.S. standard) is considered
abnormal by most labs; HbA1c is primarily used as a treatment-tracking test reflecting average blood
glucose levels over the preceding 90 days (approximately). However, some physicians may order this
test at the time of diagnosis to track changes over time. The current recommended goal for HbA1c in
patients with diabetes is <7.0%, which as defined as "good glycemic control", although some guidelines
are stricter (<6.5%). People with diabetes who have HbA1c levels within this range have a significantly
lower incidence of complications from diabetes, including retinopathy and diabetic nephropathy.[16]

Complications
The complications of diabetes are far less common and less severe in people who have well-controlled
blood sugar levels.[17][18] In fact, the better the control, the lower the risk of complications. Hence, patient
education, understanding, and participation is vital. Healthcare professionals treating diabetes also often
attempt to address health issues that may accelerate the deleterious effects of diabetes. These include
smoking (stopping), elevated cholesterol levels (control or reduction with diet, exercise or medication),
obesity (even modest weight loss can be beneficial), high blood pressure (exercise or medication if
needed), and lack of regular exercise.

Acute complications
Main articles: Diabetic ketoacidosis , Nonketotic hyperosmolar coma ,
Hypoglycemia , and Diabetic coma
Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is an acute, dangerous complication and is always a medical emergency.
Lack of insulin causes the liver to turn fat into ketone bodies, a fuel mainly for the brain. Large
concentration of ketone bodies in the blood decreases the blood's pH, leading to most of the symptoms
of DKA. On presentation at hospital, the patient in DKA is typically dehydrated and breathing both fast
and deeply. Abdominal pain is common and may be severe. The level of consciousness is typically
normal until late in the process, when lethargy (dulled or reduced level of alertness or consciousness)
may progress to coma. Ketoacidosis can become severe enough to cause hypotension, shock, and
death. Prompt proper treatment usually results in full recovery, though death can result from inadequate
treatment, delayed treatment or from a variety of complications. It is much more common in type 1
diabetes than type 2, but can still occur in patients with type 2 diabetes.

Nonketotic hyperosmolar coma

While not generally progressing to coma, this hyperosmolar nonketotic state (HNS) is another acute
problem associated with diabetes mellitus. It has many symptoms in common with DKA, but an entirely
different cause, and requires different treatment. In anyone with very high blood glucose levels (usually
considered to be above 300 mg/dl (16 mmol/l)), water will be osmotically drawn out of cells into the
blood. The kidneys will also be "dumping" glucose into the urine, resulting in concomitant loss of water,
and causing an increase in blood osmolality. If fluid is not replaced (by mouth or intravenously), the
osmotic effect of high glucose levels combined with the loss of water will eventually result in very high
serum osmolality (ie, dehydration). The body's cells will become progressively dehydrated as water is
taken from them and excreted. Electrolyte imbalances are also common, and dangerous. This
combination of changes, especially if prolonged, will result in symptoms of lethargy (dulled or reduced
level of alertness or consciousness) and may progress to coma. As with DKA urgent medical treatment
is necessary, especially volume replacement. This is the 'diabetic coma' which more commonly occurs
in type 2 diabetics.

Hypoglycemia

Hypoglycemia, or abnormally low blood glucose, is a complication of several diabetes treatments. It may
develop if the glucose intake does not cover the treatment. The patient may become agitated, sweaty,
and have many symptoms of sympathetic activation of the autonomic nervous system resulting in
feelings similar to dread and immobilized panic. Consciousness can be altered, or even lost, in extreme
cases, leading to coma and/or seizures, or even brain damage and death. In patients with diabetes, this
can be caused by several factors, such as too much or incorrectly timed insulin, too much exercise or
incorrectly timed exercise (exercise decreases insulin requirements) or not enough food (actually an
insufficient amount of glucose producing carbohydrates in food). In most cases, hypoglycemia is treated
with sugary drinks or food. In severe cases, an injection of glucagon (a hormone with the opposite
effects of insulin) or an intravenous infusion of glucose is used for treatment, but usually only if the
person is unconscious. In hospital, intravenous dextrose is often used.

Amputation

Persons with poorly controlled diabetes often heal slowly, even from small cuts, abrasions, blisters, or
separated callus (corns). The underlying cause of this healing problem is impaired cirulation, which in
diabetics is usually adequate to support normal tissue function but which may be inadequate for the
additional ciruclation required to support tissue healing. In such cases, the damage, if unnoticed, left
untreated, or failing to heal, can result in an infection. The resulting infection, in extreme cases, can lead
to amputation.

Chronic complications
Vascular disease

Chronic elevation of blood glucose level leads to damage of blood vessels. In diabetes, the resulting
problems are grouped under "microvascular disease" (due to damage to small blood vessels) and
"macrovascular disease" (due to damage to the arteries).

The damage to small blood vessels leads to a microangiopathy, which can cause one or more of the
following:

 Diabetic retinopathy, growth of friable and poor-quality new blood vessels in

the retina as well as macular edema (swelling of the macula), which can lead
to severe vision loss or blindness. Retinal damage (from microangiopathy)
makes it the most common cause of blindness among non-elderly adults in the
US.
 Diabetic neuropathy, abnormal and decreased sensation, usually in a 'glove
and stocking' distribution starting with the feet but potentially in other nerves,
later often fingers and hands. When combined with damaged blood vessels
this can lead to diabetic foot (see below). Other forms of diabetic neuropathy
may present as mononeuritis or autonomic neuropathy.
 Diabetic nephropathy, damage to the kidney which can lead to chronic renal
failure, eventually requiring dialysis. Diabetes mellitus is the most common
cause of adult kidney failure worldwide in the developed world.

Macrovascular disease

Macrovascular disease leads to cardiovascular disease, to which accelerated atherosclerosis is a

contributor:

 Coronary artery disease, leading to angina or myocardial infarction ("heart

attack")
 Stroke (mainly the ischemic type)
 Peripheral vascular disease, which contributes to intermittent claudication
(exertion-related foot pain) as well as diabetic foot.
 Diabetic myonecrosis ('muscle wasting')

Diabetic foot, often due to a combination of neuropathy and arterial disease, may cause skin ulcer and
infection and, in serious cases, necrosis and gangrene. It is the most common cause of adult
amputation, usually of toes and or feet, in the developed world.
Carotid artery stenosis does not occur more often in diabetes, and there appears to be a lower
prevalence of abdominal aortic aneurysm. However, diabetes does cause higher morbidity, mortality and
operative risks with these conditions.[19]

Treatment and management

Main article: Diabetes management

Diabetes mellitus is currently a chronic disease, without a cure, and medical emphasis must necessarily
be on managing/avoiding possible short-term as well as long-term diabetes-related problems. There is
an exceptionally important role for patient education, dietetic support, sensible exercise, self glucose
monitoring, with the goal of keeping both short-term blood glucose levels, and long term levels as well,
within acceptable bounds. Careful control is needed to reduce the risk of long term complications. This
can be achieved with combinations of diet, exercise and weight loss (type 2), various oral diabetic drugs
(type 2 only), and insulin use (type 1 and increasingly for type 2 not responding to oral medication). In
addition, given the associated higher risks of cardiovascular disease, lifestyle modifications should be
undertaken to control blood pressure[20] and cholesterol by exercising more, smoking cessation,
consuming an appropriate diet, wearing diabetic socks, and if necessary, taking any of several drugs to
reduce pressure.

In countries using a general practitioner system, such as the United Kingdom, care may take place
mainly outside hospitals, with hospital-based specialist care used only in case of complications, difficult
blood sugar control, or research projects. In other circumstances, general practitioners and specialists
share care of a patient in a team approach. Optometrists, podiatrists/chiropodists, dietitians,
physiotherapists, clinical nurse specialists (eg, Certified Diabetes Educators), or nurse practitioners may
jointly provide multidisciplinary expertise. In countries where patients must provide their own health
care, the impact of out-of-pocket costs of diabetic care can be high. In addition to the medications and
supplies needed, patients are often advised to receive regular consultation from a physician (eg, at least
every three months).

Curing diabetes
The fact that type 1 diabetes is due to the failure of one of the cell types of a single organ with a
relatively simple function (i.e. the failure of the islets of Langerhans) has led to the study of several
possible schemes to cure this form diabetes mostly by replacing the pancreas or just the beta cells.[21] In
contrast, type 2 diabetes is more complex, with fewer prospects of a curative measure, but further
understanding of the underlying mechanism of insulin resistance may make a cure possible in the
future. Correcting insulin resistance would provide a cure for type 2 diabetes in many cases.[22]

Only those type 1 diabetics who have received a kidney-pancreas transplant (when they have
developed diabetic nephropathy) and become insulin-independent may now be considered "cured" from
their diabetes. Still, they generally remain on long-term immunosuppressive drug and there is a
possibility the autoimmune phenomenon will develop in the transplanted organ.[21]

Transplants of exogenous beta cells have been performed experimentally in both mice and humans, but
this measure is not yet practical in regular clinical practice. Thus far, like any such transplant, it has
provoked an immune reaction and long-term immunosuppressive drugs will be needed to protect the
transplanted tissue.[23] An alternative technique has been proposed to place transplanted beta cells in a
semi-permeable container, isolating and protecting them from the immune system. Stem cell research
has also been suggested as a potential avenue for a cure since it may permit regrowth of Islet cells
which are genetically part of the treated individual, thus perhaps eliminating the need for immuno-
suppressants. However, it has also been hypothesised that the same mechanism which led to islet
destruction originally may simply destroy even stem-cell regenerated islets.[21] A 2007 trial of 15 newly
diagnosed patients with type 1 diabetes treated with stem cells raised from their own bone marrow after
immune suppression showed that the majority did not require any insulin treatment for prolonged
periods of time.[24]

Microscopic or nanotechnological approaches are under investigation as well, in one proposed case
with implanted stores of insulin metered out by a rapid response valve sensitive to blood glucose levels.
At least two approaches have been demonstrated in vitro. These are, in some sense, closed-loop insulin
pumps.[citation needed]
A new discovery might have important implications for treatment of diabetes. Researchers at the Toronto
Hospital for Sick Children injected capsaicin into NOD mice (Non-obese diabetic mice, a strain that is
genetically predisposed to develop the equivalent of type 1 diabetes) to kill the pancreatic sensory
nerves. This treatment reduced the development of diabetes in these mice by 80%, suggesting a link
between neuropeptides and the development of diabetes. When the researchers injected the pancreas
of the diabetic mice with sensory neuropeptide (sP), they were 'cured' of the diabetes for as long as 4
months. Also, insulin resistance (characteristic of type 2 diabetes) was reduced. These research results
are in the process of being reproduced, and their applicability in humans will have to be established in
future. Any treatment that might result from this research is probably years away. [25]

Prevention
Type 1 diabetes risk is known to depend upon a genetic predisposition based on HLA types (particularly
types DR3 and DR4), an unknown environmental trigger, and an uncontrolled autoimmune response
which attacks the insulin producing beta cells.[26] Research from the 1980s suggested that breastfeeding
decreased the risk,[27]; various other nutritional risk factors are being studied, but few have a strong link
with the development of type 1 diabetes.[28]

Type 2 diabetes risk can be reduced in many cases by making changes in diet and increasing physical
activity.[29][30] A review article by the American Diabetes Association[31] recommends maintaining a healthy
weight, getting at least 2½ hours of exercise per week (marathon intensity or duration is not needed; a
brisk sustained walk appears sufficient at present), have a modest fat intake, and eating a good amount
of fiber and whole grains. Although they do not recommend alcohol consumption as a preventative, they
note that moderate alcohol intake (at or below one ounce of alcohol per day depending on body mass)
may reduce the risk. They state that there is not enough consistent evidence that eating foods of low
glycemic index is helpful, but nutritious, low glycemic-index (low carbohydrate) foods are encouraged. (It
should be noted that many low-GI foods are not recommended, for various reasons.)

Some studies have shown delayed progression to diabetes in predisposed patients through the use of
metformin,[30] rosiglitazone,[32] or valsartan.[33] Breastfeeding might also be correlated with the prevention
of type 2 of the disease in mothers.[34]

As of late 2006, although there are many claims of nutritional cures, there is no credible demonstration
for any. In addition, despite claims by some that vaccinations (eg, as for childhood diseases) may cause
diabetes, there are no studies proving any such connection.

Aging
According to the American Diabetes Association, approximately 18.3% (8.6 million) of Americans age 60
and older have diabetes. [35] Diabetes mellitus prevalence increases with age, and the numbers of older
persons with diabetes are expected to grow as the elderly population increases in number. The National
Health and Nutrition Examination Survey (NHANES III) demonstrated that, in the population over 65
years old, almost 18% to 20% have diabetes. [36]

Regarding another study more than 40% of Americans 65 yr and older meet diagnostic criteria for type 2
diabetes or IGT impaired glucose tolerance.[37] Older Americans are also more likely to have
complicating conditions such as retinopathy, hypertension, and kidney problems.

The way diabetes is managed changes with age. Insulin production decreases because of the age-
related impairment of pancreatic beta cells. Insulin resistance increases due to the loss of lean tissue
and the accumulation of fat, particularly intra-abdominal fat, and the decreased tissue sensitivity to
insulin. Glucose tolerance progressively declines with age, and there is a high prevalence of type 2
diabetes and postchallenge hyperglycemia in the older population.[37] Age-related glucose intolerance in
humans is often accompanied by insulin resistance, but circulating insulin levels are similar to those of
younger people. [38]

Researchers and clinicians agree that treatment goals for older patient with diabetes need to be
individualized and take into account health status, as well as life expectancy, level of dependence, and
willingness to adhere to a treatment regimen. [39] Following evaluation, one of two levels of care can be
recommended: symptom-preventing care or aggressive care. The decision is made jointly by the patient
and the primary caregiver. [40]
Public health and policy
The 1989 Declaration of St Vincent was the result of international efforts to improve the care accorded
to those with diabetes. Doing so is important both in terms of quality of life and life expectancy but also
economically - expenses to diabetes have been shown to be a major drain on health- and productivity-
related resources for healthcare systems and governments.

Several countries established more and less successful national diabetes programmes to improve
treatment of the disease.[41]

Epidemiology and statistics

In 2006, according to the World Health Organization, at least 171 million people worldwide suffer from
diabetes. Its incidence is increasing rapidly, and it is estimated that by the year 2030, this number will
double. Diabetes mellitus occurs throughout the world, but is more common (especially type 2) in the
more developed countries. The greatest increase in prevalence is, however, expected to occur in Asia
and Africa, where most patients will likely be found by 2030. The increase in incidence of diabetes in
developing countries follows the trend of urbanization and lifestyle changes, perhaps most importantly a
"Western-style" diet. This has suggested an environmental (i.e., dietary) effect, but there is little
understanding of the mechanism(s) at present, though there is much speculation, some of it most
compellingly presented.

Diabetes is in the top 10, and perhaps the top 5, of the most significant diseases in the developed world,
and is gaining in significance there and elsewhere (see big killers).

For at least 20 years, diabetes rates in North America have been increasing substantially. In 2005 there
are about 20.8 million people with diabetes in the United States alone. According to the American
Diabetes Association, there are about 6.2 million people undiagnosed and about 41 million people that
would be considered prediabetic.[42] However, the criteria for diagnosing diabetes in the USA means that
it is more readily diagnosed than in some other countries.[citation needed]The Centers for Disease Control has
termed the change an epidemic. The National Diabetes Information Clearinghouse estimates that
diabetes costs $132 billion in the United States alone every year. About 5%–10% of diabetes cases in
North America are type 1, with the rest being type 2. The fraction of type 1 in other parts of the world
differs; this is likely due to both differences in the rate of type 1 and differences in the rate of other types,
most prominently type 2. Most of this difference is not currently understood. The American Diabetes
Association point out the 2003 assessment of the National Center for Chronic Disease Prevention and
Health Promotion (Centers for Disease Control and Prevention) that 1 in 3 Americans born after 2000
will develop diabetes in their lifetime.[43][42]

See also
 List of terms associated with diabetes

References
1. ^ a b c World Health Organisation Department of Noncommunicable Disease
Surveillance (1999). Definition, Diagnosis and Classification of Diabetes
Mellitus and its Complications (PDF).
2. ^ a b c Rother, KI (2007). "Diabetes Treatment — Bridging the Divide". N Engl
J Med 356 (15): 1499-1501.
3. ^ Dobson M. Nature of the urine in diabetes. Med Obs Inqu 1776;5:298–310.
4. ^ Other "Types" of Diabetes. American Diabetes Association (August 25,
2005).
5. ^ a b c Patlak M (2002). "New weapons to combat an ancient disease: treating
diabetes". FASEB J 16 (14): 1853. PMID 12468446.
6. ^ Von Mehring J, Minkowski O. (1890). "Diabetes mellitus nach
pankreasexstirpation.". Arch Exp Pathol Pharmakol 26: 371-387.
7. ^ Banting FG, Best CH, Collip JB, Campbell WR, Fletcher AA (1922).
"Pancreatic extracts in the treatment of diabetes mellitus". Canad Med Assoc J
12: 141–146.
8. ^ Himsworth (1936). "Diabetes mellitus: its differentiation into insulin-
sensitive and insulin-insensitive types". Lancet i: 127–130.
9. ^ Department of Health (Malta), 1897–1972:Annual Reports.
10. ^ Yalow RS, Berson SA. Immunoassay of endogenous plasma insulin in man.
J Clin Invest 1960;39:1157-75. PMID 13846364.
11. ^ (1993) "The effect of intensive treatment of diabetes on the development
and progression of long-term complications in insulin-dependent diabetes
mellitus. The Diabetes Control and Complications Trial Research Group.". N
Engl J Med 329 (14): 977-86. PMID 8366922.
12. ^ Inhaled Insulin. Retrieved 11 April 2007.
13. ^ Eberhart, MS; Ogden C, Engelgau M, Cadwell B, Hedley AA, Saydah SH
(November 19, 2004). "Prevalence of Overweight and Obesity Among Adults
with Diagnosed Diabetes --- United States, 1988--1994 and 1999--2002".
Morbidity and Mortality Weekly Report 53 (45): 1066-1068. Retrieved on
2007-03-11.
14. ^ (1998) "Effect of intensive blood-glucose control with metformin on
complications in overweight patients with type 2 diabetes (UKPDS 34). UK
Prospective Diabetes Study (UKPDS) Group". Lancet 352 (9131): 854-65.
PMID 9742977.
15. ^ Diabetes Mellitus Classification & Pathogenesis. Diabetes Mellitus &
Hypoglycemia. Armenian Medical Network (2006). Retrieved on 2007-05-10.
16. ^ Genuth S (Jan-Feb 2006). "Insights from the diabetes control and
complications trial/epidemiology of diabetes interventions and complications
study on the use of intensive glycemic treatment to reduce the risk of
complications of type 1 diabetes.". Endocr Pract 12 Suppl 1: 34-41. PMID
16627378.
17. ^ Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ,
Raskin P, Zinman B; Diabetes Control and Complications Trial/Epidemiology
of Diabetes Interventions and Complications (DCCT/EDIC) Study Research
Group. Intensive diabetes treatment and cardiovascular disease in patients with
type 1 diabetes. N Engl J Med 2005;353:2643-53. PMID 16371630.
18. ^ The Diabetes Control and Complications Trial Research Group. The effect
of intensive diabetes therapy on the development and progression of
neuropathy. Ann Intern Med 1995;122:561-8. PMID 7887548.
19. ^ Weiss J, Sumpio B (2006). "Review of prevalence and outcome of vascular
disease in patients with diabetes mellitus.". Eur J Vasc Endovasc Surg 31 (2):
143-50. PMID 16203161.
20. ^ Adler AI, Stratton IM, Neil HA, Yudkin JS, Matthews DR, Cull CA, Wright
AD, Turner RC, Holman RR. Association of systolic blood pressure with
macrovascular and microvascular complications of type 2 diabetes (UKPDS
36): prospective observational study. BMJ 2000;321:412-9. PMID 10938049.
21. ^ a b c Vinik AI, Fishwick DT, Pittenger G. Advances in diabetes for the
millennium: toward a cure for diabetes. MedGenMed 2004;6:12. PMID
15647717.
22. ^ Rubino F, Gagner M. Potential of surgery for curing type 2 diabetes
mellitus. Ann Surg 2002;236:554-9. PMID 12409659.
23. ^ Shapiro, et al. International Trial of the Edmonton Protocol for Islet
Transplantation NEJM 2006 355: 1318-1330
24. ^ Voltarelli, JC; Couri CE, Stracieri AB, Oliveira MC, Moraes DA, Pieroni F,
Coutinho M, Malmegrim KC, Foss-Freitas MC, Simoes BP, Foss MC, Squiers
E, Burt RK. (2007). "Autologous nonmyeloablative hematopoietic stem cell
transplantation in newly diagnosed type 1 diabetes mellitus.". JAMA 297 (14):
1568-76. PMID 17426276.
25. ^ Razavi, Rozita; Yin Chan, F. Nikoo Afifiyan, Xue Jun Liu, Xiang Wan,
Jason Yantha, Hubert Tsui, Lan Tang, Sue Tsai, Pere Santamaria, John P.
Driver, David Serreze, Michael W. Salter, H.-Michael Dosch (2006). "RPV1+
Sensory Neurons Control β Cell Stress and Islet Inflammation in Autoimmune
Diabetes". Cell 127: 1123–1135.
26. ^ Daneman D (2006). "Type 1 diabetes". Lancet 367 (9513): 847-58. PMID
16530579.
27. ^ Borch-Johnsen K, Joner G, Mandrup-Poulsen T, Christy M, Zachau-
Christiansen B, Kastrup K, Nerup J (1984). "Relation between breast-feeding
and incidence rates of insulin-dependent diabetes mellitus. A hypothesis".
Lancet 2 (8411): 1083-6. PMID 6150150.
28. ^ Virtanen S, Knip M (2003). "Nutritional risk predictors of beta cell
autoimmunity and type 1 diabetes at a young age". Am J Clin Nutr 78 (6):
1053-67. PMID 14668264.
29. ^ Lindström J, Ilanne-Parikka P, Peltonen M, Aunola S, Eriksson J, Hemiö K,
Hämäläinen H, Härkönen P, Keinänen-Kiukaanniemi S, Laakso M,
Louheranta A, Mannelin M, Paturi M, Sundvall J, Valle T, Uusitupa M,
Tuomilehto J (2006). "Sustained reduction in the incidence of type 2 diabetes
by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study.".
Lancet 368 (9548): 1673-9. PMID 17098085.
30. ^ a b Knowler W, Barrett-Connor E, Fowler S, Hamman R, Lachin J, Walker E,
Nathan D (2002). "Reduction in the incidence of type 2 diabetes with lifestyle
intervention or metformin.". N Engl J Med 346 (6): 393-403. PMID
11832527.
31. ^ American Diabetes Association (2006). "Nutrition Recommendations and
Interventions for Diabetes–2006". Diabetes Care 29: 2140-57.
32. ^ Gerstein H, Yusuf S, Bosch J, Pogue J, Sheridan P, Dinccag N, Hanefeld M,
Hoogwerf B, Laakso M, Mohan V, Shaw J, Zinman B, Holman R (2006).
"Effect of rosiglitazone on the frequency of diabetes in patients with impaired
glucose tolerance or impaired fasting glucose: a randomised controlled trial".
Lancet 368 (9541): 1096-105. PMID 16997664.
33. ^ Kjeldsen SE, Julius S, Mancia G, McInnes GT, Hua T, Weber MA, Coca A,
Ekman S, Girerd X, Jamerson K, Larochelle P, Macdonald TM, Schmieder
RE, Schork MA, Stolt P, Viskoper R, Widimsky J, Zanchetti A; for the
VALUE Trial Investigators (2006). "Effects of valsartan compared to
amlodipine on preventing type 2 diabetes in high-risk hypertensive patients:
the VALUE trial.". J Hypertens 24 (7): 1405-1412. PMID 16794491.
34. ^ Stuebe AM, Rich-Edwards JW, Willett WC, Manson JE, Michels KB
(2005). "Duration of lactation and incidence of type 2 diabetes". JAMA 294
(20): 2601–10. PMID 16304074.
35. ^ Seniors and Diabetes. Elderly And Diabetes - Diabetes and Seniors.
LifeMed Media (2006). Retrieved on 2007-05-14.
 36. ^ Treatment of Diabetes - Geriatric Medicine. Diabetes Mellitus &
Hypoglycemia. Armenian Health Network, Health.am (2006). Retrieved on
2007-05-14.
37. ^ a b Harris, MI, Flegal KM, Cowie CC, Eberhardt MS, Goldstein DE, Little
RR, Wiedmeyer HS, and Byrd-Holt DD. (1998). Prevalence of diabetes,
impaired fasting glucose, and impaired glucose tolerance in U. S. adults: The
third National Health and Nutrition Examination Survey, 1988-1994. Diabetes
Care 21: 518-524.
38. ^ Annette M. Chang and Jeffrey B. Halter (2003). Aging and insulin secretion.
AJP - Endocrinology and Metabolism. Retrieved on 2007-05-14.
39. ^ Diabetes and Aging. Diabetes Dateline. National Institute of Diabetes and
Digestive and Kidney Diseases (2002). Retrieved on 2007-05-14.
40. ^ Kenneth L. Minaker (2006). Treatment and Management of Diabetes
Mellitus. Treatment of Diabetes - Geriatric Medicine. Armenian Health
Network, Health.am. Retrieved on 2007-05-14.
41. ^ Dubois, HFW and Bankauskaite, V (2005). "Type 2 diabetes programmes in
Europe" (PDF). Euro Observer 7 (2): 5–6.
42. ^ a b American Diabetes Association (2005). Total Prevalence of Diabetes &
Pre-diabetes. Retrieved on 2006-03-17.
43. ^ Narayan K, Boyle J, Thompson T, Sorensen S, Williamson D (2003).
"Lifetime risk for diabetes mellitus in the United States". JAMA 290 (14):
1884-90. PMID 14532317.

http://www.answers.com/topic/diabetes-mellitus?cat=health
Diabetes Mellitus, Type 1
Last Updated: June 27, 2006

Synonyms and related keywords: diabetes mellitus type 1, insulin-dependent diabetes, IDM, insulin-dependent dia
childhood diabetes, childhood diabetes mellitus, childhood-onset diabetes, childhood-onset diabetes mellitus, diabet
ketosis-prone diabetes, autoimmune diabetes mellitus, brittle diabetes mellitus, diabetic ketoacidosis, DKA, maturity-
AUTHOR INFORMATION
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Author: William H Lamb, MD, FRCP, FRCPCH, Clinical Lecturer, Department of Child Health, Th
William H Lamb, MD, FRCP, FRCPCH, is a member of the following medical societies: British Me
Editor(s): Arlan L Rosenbloom, MD, Adjunct Distinguished Service Professor Emeritus, Departm
Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharm
Pediatrics, Section of Pediatric Endocrinology, University of Arkansas and Arkansas Children's H
Uniformed Services University of the Health Sciences; and George P Chrousos, MD, FAAP, MA
School

Disclosure

INTRODUCTION
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Background: Diabetes mellitus (DM) is a chronic metabolic disorder caused by an absolute or relative deficiency of insulin, an an
absence, destruction, or other loss of these cells results in type 1 diabetes (insulin-dependent diabetes mellitus [IDDM]). Most chi

Type 2 diabetes (non–insulin-dependent diabetes mellitus [NIDDM]) is a heterogeneous disorder. Most patients with NIDDM have
previously uncommon in children, in some, countries 20% or more of new patients with diabetes in childhood and adolescence ha
release leading to maturity onset diabetes of the young (MODY).

This chapter addresses only IDDM.

Pathophysiology: Insulin is essential to process carbohydrates, fat, and protein. Insulin reduces blood glucose levels by allowing
store. Insulin also inhibits the release of stored glucose from liver glycogen (glycogenolysis) and slows the breakdown of fat to trig
protein and fat for glucose production (gluconeogenesis) in both liver and kidneys.

Hyperglycemia (ie, random blood glucose concentration more than 200 mg/dL or 11 mmol/L) results when insulin deficiency leads
the excess glucose load, causing glycosuria, osmotic diuresis, thirst, and dehydration. Increased fat and protein breakdown leads
ketoacidosis (DKA).

An excess of insulin prevents the release of glucose into the circulation and results in hypoglycemia (blood glucose concentration

Frequency:

 In the US: Overall incidence is approximately 15 cases per 100,000 individuals annually a
years.
  Internationally: DM exhibits wide geographic variation in incidence and prevalence. Annu
100,000 in Finland. Substantial variations exist between nearby countries with differing life
those in Iceland and Norway. Even more striking are the differences in incidence between
strongly support the importance of environmental factors in the development of IDDM. Mos
Incidence appears to increase with distance from the equator.

Mortality/Morbidity: Information on mortality rates is difficult to ascertain without complete national registers of childhood diabete
1-4 years who may die with DKA at the time of diagnosis. Adolescents are also a high-risk group. Most deaths result from delayed
hypoglycemia also causes some deaths. Unexplained death during sleep may also occur.

IDDM complications are comprised of 3 major categories: acute complications, long-term complications, and complications cause

 Acute complications reflect the difficulties of maintaining a balance between insulin therapy
and DKA.

 Long-term complications arise from the damaging effects of prolonged hyperglycemia and
complications are rare in childhood, maintaining good control of diabetes is important to pr
appears to depend on the interaction of factors such as metabolic control, genetic suscept
complications include the following:
o Retinopathy
o Cataracts
o Hypertension
o Progressive renal failure
o Early coronary artery disease
o Peripheral vascular disease
o Neuropathy, both peripheral and autonomic
o Increased risk of infection

 Associated autoimmune diseases are common with IDDM, particularly in children who hav
development of diabetes; others may develop later. As many as 20% of children with diabe

Race:

 Different environmental effects on IDDM development complicate the influence of race, bu

 Whites have the highest reported incidence of IDDM; Chinese have the lowest.

 IDDM is 1.5 times more likely to develop in American whites than in American blacks or Hi
 Current evidence suggests that when immigrants from an area with low incidence move to

Sex:

 The influence of sex varies with the overall incidence rates.

 Males are at greater risk in regions of high incidence, particularly older males, whose incid

 Females appear to be at a greater risk in low-incidence regions.

Age:

 Generally, incidence rates increase with age until mid-puberty then decline after puberty, b
 must be considered in any infant or toddler, because these children have the greatest risk
o Severe monilial diaper/napkin rash
o Unexplained malaise
o Poor weight gain or weight loss
o Increased thirst
o Vomiting and dehydration, with a constantly wet napkin/diaper

 Where prevalence rates are high, a bimodal variation of incidence has been reported that
incidence during early puberty (ie, 10-14 y).

CLINICAL
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

History:

 The most easily recognized symptoms are secondary to hyperglycemia, glycosuria, and ke

 Hyperglycemia: Hyperglycemia alone may not cause obvious symptoms, although some c
and become ill-tempered. The main symptoms of hyperglycemia are secondary to osmotic

 Glycosuria: This condition leads to increased urinary frequency and volume (eg, polyuria),
previously continent child. These symptoms are easy to overlook in infants because of the

 Polydipsia: Increased thirst, which may be insatiable, is secondary to the osmotic diuresis

 Weight loss: Insulin deficiency leads to uninhibited gluconeogenesis, causing breakdown o

remains good. Failure to thrive and wasting may be the first symptoms noted in an infant o

 Nonspecific malaise: While this condition may be present before symptoms of hyperglycem

 Symptoms of ketoacidosis

o Severe dehydration
o Smell of ketones
o Acidotic breathing (ie, Kussmaul respiration), masquerading as respiratory distress
o Abdominal pain
o Vomiting
o Drowsiness and coma

 Other nonspecific findings

o Hyperglycemia impairs immunity and renders a child more susceptible to recurrent

 o Candidiasis may develop, especially in groin and flexural areas.

Physical:

 Apart from wasting and mild dehydration, children with early diabetes have no specific clin

 Physical examination may reveal findings associated with other autoimmune endocrinopat
symptoms of overactivity or underactivity and possibly a palpable goiter).

 Cataract is a rare presenting problem, typically occurring in girls with a long prodrome of m

 Necrobiosis lipoidica usually, but not exclusively, occurs in people with diabetes. Necrobios
area. The condition is associated with injury to dermal collagen, granulomatous inflammati
manage.

Causes: Most cases (95%) of IDDM are the result of environmental factors interacting with a genetically susceptible person. This
islets of Langerhans. These cells are progressively destroyed, with insulin deficiency usually developing after the destruction of 9

 Genetic issues

o Clear evidence exists for a genetic component to IDDM.

o Monozygotic twins have a 60% lifetime concordance for developing IDDM, although
have only an 8% risk of concordance, which is similar to the risk among other siblin

o The frequency of diabetes developing in children with a diabetic mother is 2-3% and
diabetic.
o HLA class II molecules DR3 and DR4 are associated strongly with IDDM. More than
the general population.
o Patients expressing DR3 also risk developing other autoimmune endocrinopathies a
have positive islet cell antibodies, and to appear to have a longer period of residual
o Patients expressing DR4 are usually younger at diagnosis and more likely to have p
endocrinopathies.
o The expression of both DR3 and DR4 carries the greatest risk of IDDM; these patie

 Environmental factors

o Environmental factors are important because even identical twins have only a 30-60
populations under different living conditions.
o No single factor has been identified, but infections and diet are considered the 2 mo

o Viral infections may be the most important environmental factor in the development
reported of a direct toxic effect of infection in congenital rubella. A recent survey sug
offspring. Paradoxically, IDDM's incidence is higher in areas where the overall burde

o Dietary factors are also relevant. Breastfed infants have a lower risk for IDDM, and
diabetes. Some cow's milk proteins (eg, bovine serum albumin) have antigenic simi
water supplies, are known to cause IDDM in animal models; however, no definite lin
  Chemical causes: Streptozotocin and RH-787, a rat poison, selectively damage islet cells

 Other causes

o Congenital absence of the pancreas or islet cells

o Pancreatectomy

o IDDM secondary to pancreatic damage (ie, cystic fibrosis, chronic pancreatitis, thala

o Wolfram syndrome (diabetes insipidus, DM, optic atrophy, deafness [DIDMOAD])

o Chromosomal disorders such as Down syndrome, Turner syndrome, Klinefelter syn

syndromes.)

DIFFERENTIALS
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Diabetes Insipidus
Hyperthyroidism
Pheochromocytoma
Renal Glucosuria
Toxicity, Salicylate

Other Problems to be Considered:

Type 2 diabetes (NIDDM)

Maturity onset diabetes of the young (MODY)
Psychogenic polydipsia
Nephrogenic diabetes insipidus
High-output renal failure
Transient hyperglycemia with illness and other stress
Steroid therapy
Factitious illness (Münchhausen syndrome by proxy)
 WORKUP
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Lab Studies:

 The need for and extent of laboratory studies vary, depending upon the general state of the child's health. For most children, only urine testin
diabetes require several tests at diagnosis and at later review. (See Diabetic Ketoacidosis for information on laboratory studies needed to ma

 Urine glucose

o A positive urine glucose test suggests but is not diagnostic for IDDM. Diagnosis must be confirmed by test results showing elevated b
o Test urine of ambulatory patients for ketones at the time of diagnosis.

 Urine ketones

o Ketones in the urine confirm lipolysis and gluconeogenesis, which are normal during periods of starvation.
o With hyperglycemia and heavy glycosuria, ketonuria is a marker of insulin deficiency and potential DKA.

 Blood glucose

o Apart from transient illness- or stress-induced hyperglycemia, a random whole-blood glucose concentration more than 200 mg/dL (11
the absence of symptoms, the physician must confirm these results on a different day. Most children with diabetes detected because o
o Blood glucose tests using capillary blood samples, reagent sticks, and blood glucose meters are the usual methods for monitoring day

 Glycated hemoglobin

o Glycosylated hemoglobin derivatives (HbA1a, HbA1b, HbA1c) are the result of a nonenzymatic reaction between glucose and hemog
proportion of glycated hemoglobin. The percentage of HbA1c is more commonly measured. Normal values vary according to the labo
 children unmistakably have results above the upper limit of the reference range.

o Measurement of HbA1c levels is the best method for medium- to long-term diabetic control monitoring. The Diabetes Control and Com
long-term complications. Check HbA1c levels every 3 months. Most clinicians aim for HbA1c values of 7-9%. Values less than 7% are
complications.

 Renal function tests: If the child is otherwise healthy, renal function tests are typically not required.

 Islet cell antibodies

o Islet cell antibodies may be present at diagnosis but are not needed to diagnose IDDM.
o Islet cell antibodies are nonspecific markers of autoimmune disease of the pancreas and have been found in as many as 5% of unaffe
against islet cells are known (eg, those against glutamate decarboxylase [GAD antibodies]), but these are generally unavailable for ro

 Thyroid function tests

o Because early hypothyroidism has few easily identifiable clinical signs in children, children with IDDM may have undiagnosed thyroid
o Untreated thyroid disease may interfere with diabetes management. Check thyroid function regularly (every 2-5 years or annually if th

 Antithyroid antibodies: This test indicates risk of present or potential thyroid disease.

 Antigliadin antibodies

o Some children with IDDM may have or develop celiac disease. Positive antigliadin antibodies, especially specific antibodies (eg, antie
o If antibody tests are positive, a jejunal biopsy is required to confirm or refute a diagnosis of celiac disease.

Imaging Studies:
  No routine imaging studies are required.

Other Tests:

 Oral glucose tolerance test (OGTT)

o While unnecessary to diagnose IDDM, an OGTT can exclude the diagnosis of diabetes when hyperglycemia or glycosuria are recogn
renal glucosuria.

o Obtain a fasting blood sugar level, then administer a PO glucose load (2 g/kg for children aged <3 y, 1.75 g/kg for children aged 3-10
whole-blood glucose level higher than 120 mg/dL (6.7 mmol/L) or a 2-hour value higher than 200 mg/dL (11 mmol/L) indicates diabete
antibodies.
o A modified OGTT can also be used to identify cases of MODY that often present as type 1 diabetes, if, in addition to blood glucose lev
cannot produce more than tiny amounts of insulin. People with MODY or type 2 diabetes show variable and substantial insulin produc

 Lipid profile

o Lipid profiles are usually abnormal at diagnosis because of increased circulating triglycerides caused by gluconeogenesis.

o Apart from hypertriglyceridemia, primary lipid disorders rarely result in diabetes.

o Hyperlipidemia with poor metabolic control is common.

 Urinary albumin: Beginning at age 12 years, perform an annual urinalysis to test for a slightly increased albumin excretion rate (AER), referre

TREATMENT
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Medical Care:

 All children with IDDM require insulin therapy.

 Only children with significant dehydration, persistent vomiting, or metabolic derangement, or with serious intercurrent illness, require inpatien

 A well-organized diabetes care team can provide all necessary instruction and support in an outpatient setting. The only immediate requirem
hypoglycemia. The patient and/or family should have 24-hour access to advice and know how to contact the team.

Consultations:

 Always involve an experienced dietitian in the patient's care, typically as a regular member of the diabetes care team.

 Ophthalmology review may be needed at diagnosis if a cataract is suspected. All children with diabetes aged 12 years and older need a care
necessary, treat diabetes-related eye complications.

 Access to psychological counseling and support is desirable, preferably from a member of the diabetes care team.

Diet: Dietary management is an essential component of diabetes care. Diabetes is an energy metabolism disorder, and before insulin was discovered, children with diabetes could be kept alive by
recent dietary management of diabetes emphasizes a healthy, balanced diet, high in carbohydrates and fiber and low in fat.

 The following are universal recommendations:

o Carbohydrates should provide 50-60% of daily energy intake. (No more than 10% of carbohydrates should be from sucrose or other r
o Fat should provide less than 30%.
o Protein should provide 10-20%.
o View these recommendations in the patient's cultural context.

 The aim of dietary management is to balance the child's food intake with insulin dose and activity and to keep blood glucose concentrations
  The ability to estimate the carbohydrate content of food (carb counting) is particularly useful for those children who give fast-acting insulin at

o Adequate intake of complex carbohydrates (eg, cereals) is important before bedtime to avoid nocturnal hypoglycemia, especially for c

o The dietitian should develop a diet plan for each child to suit individual needs and circumstances. Regularly review and adjust the plan

o Low-carbohydrate diets as a management option for diabetes control have regained popularity in recent years. Logic dictates that the
diabetes have been reported, and such diets cannot be recommended at the present.

Activity:

 IDDM requires no restrictions on activity; exercise has real benefits for a child with diabetes.

 Most children can adjust their insulin dosage and diet to cope with all forms of exercise.

 Children and their caretakers must be able to recognize and treat symptoms of hypoglycemia.

o Hypoglycemia following exercise is most likely after prolonged exercise involving the legs, such as walking, running or cycling. It may
o A large presleep snack is advisable following intensive exercise.
 MEDICATION
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Insulin is always required to treat IDDM. Attempts are being made to develop alternative routes to subcutaneous administration. Recently, a human insulin (rDNA origin) inhalant powder (Exubera)
insulin analogues are now most commonly used.
Insulin has 3 basic formulations: short-acting (eg, regular, soluble, lispro, aspart, glulisine), medium- or intermediate-acting (eg, isophane, lente, detemir), and long-acting (eg, ultralente, glargine).

Regular or soluble insulin is bound to either protamine (eg, isophane) or zinc (eg, lente, ultralente) in order to prolong the duration of action. Combinations of isophane and regular, lispro or aspart i
mixtures.

The recent development of insulin analogues have attempted to address some of the shortcomings of traditional insulin. Insulins lispro and aspart have a more rapid onset of action and shorter dur
profile of action to isophane but is more pharmacologically predictable, while glargine has a relatively flat profile of action, lasting some 18-26 hours and seems especially suitable as a once-daily b
metabolic control or complication rates.

With so many various insulins and mixtures available, a wide range of possible injection regimens exist. These can be broadly categorized into 4 types, as follows:

 Twice-daily combinations of short- and intermediate-acting insulin.

 Multiple injection regimens, using once- or twice-daily injections of long- or intermediate-acting insulin and short-acting insulins given at each
 A combination of the above 2 regimens, with a morning injection of mixed insulin, an afternoon premeal injection of short-acting insulin and a
 Continuous subcutaneous insulin infusion (CSII) using an insulin pump

While controlled clinical trials suggest improved short-term metabolic control in children using multiple injections or CSII, international comparisons do not support any particular insulin regimen, an

A wide variety of insulin-injection devices exist, including a simple syringe and needle, semiautomatic pen injector devices, and needle-free jet injectors. Increasing numbers of young people use in

Tailor the insulin dose to the individual child's needs. For instance, if using a twice-daily regimen, then, as a rule of thumb, prepubertal children require between 0.5 and 1 U/kg/d, with between 60-7
one third of the administered insulin is a short-acting formulation and the remainder is a medium- to long-acting formulation. Basal bolus regimens have a higher proportion of short-acting insulin. T

Drug Category: Antidiabetic agents -- These agents are used for treatment of insulin-dependent DM and also for NIDDM unresponsive to treatment with diet and/or PO hypoglyce

Drug Name Insulin lispro (Humalog) -- Onset of action is 10-30 min, peak activity is 1-2 h, and dura
Adult Dose 0.5-1 U/kg/d SC initially; adjust doses to achieve premeal and bedtime blood glucose le
Pediatric Dose 0.5-1 U/kg/d SC initially
Adjust doses to achieve premeal and bedtime blood glucose levels of:
<5 years: 100-200 mg/dL (5.5-10 mMol/L)
 >5 years: 80-140 mg/dL (4-7.5 mMol/L)
Contraindications Documented hypersensitivity; hypoglycemia
Medications that may decrease hypoglycemic effects of insulin include acetazolamide,
isoniazid, diltiazem, diuretics, corticosteroids, thiazide diuretics, thyroid estrogens, etha
diazoxide, dobutamine phenothiazines, cyclophosphamide, dextrothyroxine, lithium car
Interactions
medications that may increase hypoglycemic effects of insulin include calcium, ACE inh
carbonate, anabolic steroids, pyridoxine, salicylates, MAOIs, mebendazole, sulfonamid
fenfluramine, guanethidine, octreotide, pentamidine, and sulfinpyrazone
Pregnancy B - Usually safe but benefits must outweigh the risks.
Due to prompt onset of action, administer within 15 min before or immediately after a m
Precautions
may be necessary in renal and hepatic dysfunction
Drug Name Regular insulin (Humulin R, Novolin R) -- Onset of action is 0.25-1 h, peak activity is 1.
Adult Dose Adjust to needs
Pediatric Dose Adjust to needs
Contraindications Documented hypersensitivity; hypoglycemia
Medications that may decrease hypoglycemic effects of insulin include acetazolamide,
isoniazid, diltiazem, diuretics, corticosteroids, thiazide diuretics, thyroid estrogens, etha
diazoxide, dobutamine phenothiazines, cyclophosphamide, dextrothyroxine, lithium car
Interactions
medications that may increase hypoglycemic effects of insulin include calcium, ACE inh
carbonate, anabolic steroids, pyridoxine, salicylates, MAOIs, mebendazole, sulfonamid
fenfluramine, guanethidine, octreotide, pentamidine, and sulfinpyrazone
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Dose adjustments may be necessary in renal and hepatic dysfunction
Drug Name Insulin NPH (Humulin N, Novolin N) -- Onset of action is 3-4 h, peak effect is in 8-14 h,
 Adult Dose Adjust to needs
Pediatric Dose Adjust to needs
Contraindications Documented hypersensitivity; hypoglycemia
Medications that may decrease hypoglycemic effects of insulin include acetazolamide,
isoniazid, diltiazem, diuretics, corticosteroids, thiazide diuretics, thyroid estrogens, etha
diazoxide, dobutamine phenothiazines, cyclophosphamide, dextrothyroxine, lithium car
Interactions
medications that may increase hypoglycemic effects of insulin include calcium, ACE inh
carbonate, anabolic steroids, pyridoxine, salicylates, MAOIs, mebendazole, sulfonamid
fenfluramine, guanethidine, octreotide, pentamidine, and sulfinpyrazone
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Dose adjustments may be necessary in renal and hepatic dysfunction
Drug Name Protamine zinc (Ultralente) -- Onset of action is 2-3 h, peak activity is 4-8 h, and duratio
Adult Dose Adjust to needs
Pediatric Dose Adjust to needs
Contraindications Documented hypersensitivity; hypoglycemia
Medications that may decrease hypoglycemic effects of insulin include acetazolamide,
isoniazid, diltiazem, diuretics, corticosteroids, thiazide diuretics, thyroid estrogens, etha
diazoxide, dobutamine phenothiazines, cyclophosphamide, dextrothyroxine, lithium car
Interactions
medications that may increase hypoglycemic effects of insulin include calcium, ACE inh
carbonate, anabolic steroids, pyridoxine, salicylates, MAOIs, mebendazole, sulfonamid
fenfluramine, guanethidine, octreotide, pentamidine, and sulfinpyrazone
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Dose adjustments may be necessary in renal and hepatic dysfunction
Drug Name Insulin aspart (NovoLog) -- Onset of action is 10-30 min, peak activity is 1-2 h, and dur
 human insulin, with the exception of single substitution of amino acid proline by asparti
DNA technology. Insulin lowers blood glucose levels by stimulating peripheral glucose u
inhibiting hepatic glucose production. Inhibits lipolysis in the adipocyte. Inhibits proteoly
principal hormone required for proper glucose use in normal metabolic processes.
Adult Dose 0.5-1 U/kg/d SC initially; adjust doses to achieve premeal and bedtime blood glucose le
0.5-1 U/kg/d SC initially
Adjust doses to achieve premeal and bedtime blood glucose levels of:
Pediatric Dose
<5 years: 100-200 mg/dL (5.5-10 mMol/L)
>5 years: 80-140 mg/dL (4-7.5 mMol/L)
Contraindications Documented hypersensitivity; hypoglycemia
Medications that may decrease hypoglycemic effects of insulin include acetazolamide,
isoniazid, diltiazem, diuretics, corticosteroids, thiazide diuretics, thyroid hormone, estro
contraceptives, diazoxide, dobutamine, phenothiazines, cyclophosphamide, dextrothyr
Interactions sulfate, and niacin
Medications that may increase hypoglycemic effects of insulin include calcium, ACE inh
carbonate, anabolic steroids, pyridoxine, salicylates, MAO inhibitors, mebendazole, sul
fenfluramine, guanethidine, octreotide, pentamidine, and sulfinpyrazone
Pregnancy B - Usually safe but benefits must outweigh the risks.
Hyperthyroidism may increase renal clearance of insulin and may need more insulin to
Precautions insulin turnover, requiring less insulin to treat hyperkalemia; due to prompt onset of act
after a meal; monitor glucose carefully; dose adjustments may be necessary in renal an
Drug Name Insulin glargine (Lantus) -- Long-acting insulin analogue. Typical onset of action from 1
Adult Dose Usually 50% of total daily dose of insulin (0.25-0.5 U/kg); adjust to needs
Pediatric Dose Licensed age varies between nations (2-6 y); adjust dose as indicated but similar to ad
Contraindications Documented hypersensitivity; hypoglycemia
 Medications that may decrease hypoglycemic effects of insulin include acetazolamide,
isoniazid, diltiazem, diuretics, corticosteroids, thiazide diuretics, thyroid hormone, estro
contraceptives, diazoxide, dobutamine, phenothiazines, cyclophosphamide, dextrothyr
Interactions sulfate, and niacin
Medications that may increase hypoglycemic effects of insulin include calcium, ACE inh
carbonate, anabolic steroids, pyridoxine, salicylates, MAO inhibitors, mebendazole, sul
fenfluramine, guanethidine, octreotide, pentamidine, and sulfinpyrazone
Pregnancy C - Safety for use during pregnancy has not been established.
Administer at the same time each day; use only if solution is clear and colorless; admin
solution; hyperthyroidism may increase renal clearance of insulin and may need more i
Precautions
delay insulin turnover, requiring less insulin; monitor glucose carefully; dose adjustmen
with renal and hepatic dysfunction
Insulin glulisine (Apidra) -- Human insulin analog produced by rDNA technology using a
Differs from human insulin by replacement of asparagine at B3 position with lysine, and
glutamic acid.
Drug Name Insulin regulates glucose metabolism by stimulating peripheral glucose uptake by skele
production.
Glucose lowering is equipotent to regular human insulin when administered IV. After SC
onset and shorter duration of action compared to regular human insulin. Useful to regu
Adult Dose Individualize dose; intended for intermittent SC injection with meals or use by external
0.5-1 U/kg/d SC initially;
Adjust doses to achieve premeal and bedtime blood glucose levels of:
Pediatric Dose
<5 years: 100-200 mg/dL (5.5-10 mMol/L)
>5 years: 80-140 mg/dL (4-7.5 mMol/L)
Contraindications Documented hypersensitivity; hypoglycemia
Interactions Corticosteroids, danazol, diazoxide, diuretics, sympathomimetic agents (eg, epinephrin
phenothiazines, growth hormone, thyroid hormone, estrogen, progestogens, protease i
 olanzapine, clozapine) may increase blood glucose and reduce glucose lowering effect
disopyramide, fibrates, fluoxetine, MAOIs, pentoxifylline, propoxyphene, salicylates, an
cause additive effects to insulin
Pregnancy C - Safety for use during pregnancy has not been established.
Hyperthyroidism may increase renal clearance of insulin and may need more insulin to
Precautions insulin turnover, requiring less insulin to treat hyperkalemia; due to prompt onset of act
after a meal; monitor glucose carefully; dose adjustments may be necessary in renal an
FOLLOW-UP
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Further Inpatient Care:

 Where a diabetes care team is available, admission is usually required only for children with DKA.

Further Outpatient Care:

 Regular outpatient review with a specialized diabetes team improves both short- and long-term outcomes. Most teams have a nurse speciali
social worker, and an exercise specialist. Involvement with the team is intense over the first few weeks after diagnosis while family members

 Conduct a structured examination and review at least once annually to examine the patient for possible complications. Examination and revi

o Growth assessment
o Injection site examination
o Retinoscopy or other retinal screening such as photography
o Examination of hands, feet, and peripheral pulses for signs of limited joint mobility, peripheral neuropathy, and vascular disease
o Evaluation for signs of associated autoimmune disease
o Blood pressure
 o Urine examination for microalbuminuria

In/Out Patient Meds:

 Insulin

 Blood glucose testing strips

 Urine ketone testing tablets or strips

 Blood ketone testing strips (also available)

Deterrence/Prevention:

 Actively discourage patients from smoking because it markedly increases the risk of developing cardiovascular complications.

 Discuss issues of sexual health with older children. Provide young women with information on pregnancy planning to ensure the best possib

 For older adolescents, discuss the effects of alcohol and illegal substance use on diabetic control.

Complications:

 Hypoglycemia
o Hypoglycemia is probably the most disliked and feared complication of diabetes, from the point of view of the child and the family. Chi
o Insulin inhibits glucogenesis and glycogenolysis, while stimulating glucose uptake. In nondiabetic individuals, insulin production by the
treated diabetic child who has not eaten adequate amounts of carbohydrates, blood glucose levels progressively fall.
o The brain depends upon glucose as a fuel. As glucose levels drop below 65 mg/dL (3.2 mmol/L) counterregulatory hormones (eg, gluc
shaking, confusion, behavioral changes, and, eventually, coma when blood glucose levels fall below 30-40 mg/dL. The glucose level a
depending in part on the duration of diabetes, frequency of hypoglycemic episodes, rate of fall of glycemia, and overall control.
o Manage mild hypoglycemia by giving rapidly absorbed PO carbohydrate or glucose; for a comatose patient, administer an intramuscu
 circulation. Where appropriate, an alternative therapy is intravenous glucose (preferably no more than a 10% glucose solution). All tre
o Occasionally, a child with hypoglycemic coma may not recover within 10 minutes, despite appropriate therapy. Under no circumstance
found subnormal. Overtreatment of hypoglycemia can lead to cerebral edema and death. If coma persists, seek other causes.
o Hypoglycemia is a particular concern in children younger than 4 years because the condition may lead to possible intellectual impairm

 Hyperglycemia
o In an otherwise healthy individual, blood glucose levels usually do not rise above 180 mg/dL (9 mmol/L). In a child with diabetes, bloo
exceeded when blood glucose levels exceed 180 mg/dL (10 mmol/L), causing glycosuria with the typical symptoms of polyuria and po
o All children with diabetes experience episodes of hyperglycemia.

 Diabetic ketoacidosis
o DKA is much less common than hypoglycemia, but it is potentially far more serious, creating a life-threatening medical emergency.
o Ketosis usually does not occur when insulin is present. In its absence, however, severe hyperglycemia, dehydration, and ketone prod
 DKA usually follows increasing hyperglycemia and symptoms of osmotic diuresis. Users of insulin pumps, by virtue of absent reservoirs of su
nausea, vomiting, and abdominal pain, symptoms similar to food poisoning.

 Injection-site hypertrophy
o If children persistently inject their insulin into the same area, subcutaneous tissue swelling may develop, causing unsightly lumps and
o Fat atrophy can also occur, possibly in association with insulin antibodies. This condition is much less common but more disfiguring.

 Diabetic retinopathy
o The most common cause of acquired blindness in many developed nations, diabetic retinopathy is rare in the prepubertal child or with
o Prevalence and severity of retinopathy increases with age and is greatest in patients whose diabetic control is poor. Prevalence rates
o Diabetic retinopathy's first symptoms are dilated retinal venules and the appearance of capillary microaneurysms, a condition known a
control, although some patient's conditions may worsen initially.
o Subsequent changes in background retinopathy are characterized by increased vessel permeability and leaking plasma that form har
unless the macula is involved. Laser therapy may be required at this stage to prevent further visual loss. Proliferative retinopathy follo
progressing to hemorrhage, scarring, retinal detachment, and blindness. Prompt retinal laser therapy may prevent blindness in the lat
 Diabetic nephropathy and hypertension
o Diabetic nephropathy's exact mechanism is unknown. Peak incidence is in postadolescents, 10-15 years after diagnosis, and may inv
o Microalbuminuria is the first evidence of nephropathy. The exact definition varies slightly between nations but an increased AER is com
a timed overnight AER of more than 20 mcg/min but less than 200 mcg/min. Early microalbuminuria may resolve. Glomerular hyperfilt
o In a patient with nephropathy, AER increases until frank proteinuria develops, and this may progress to renal failure. Blood pressure ri
o Progression may be delayed or halted by improved diabetes control, by administration of angiotensin-converting enzyme inhibitors (A
o Regular urine screening for microalbuminuria provides opportunities for early identification and treatment to prevent renal failure.
 A child younger than 15 years with persistent proteinuria may have a nondiabetic cause and should be referred to a pediatric nephrologist fo

 Diabetic neuropathy affects both the peripheral and autonomic nerves. Hyperglycemic effects on axons and microvascular changes in endon
 Autonomic changes involving cardiovascular control (eg, heart rate, postural responses) have been described in as many as 40% of children
 In adults, peripheral neuropathy usually occurs as a distal sensory loss.

 Macrovascular disease
o While this complication is not seen in pediatric patients, it is a significant cause of morbidity and premature mortality in adults with diab
o People with IDDM have twice the risk of fatal myocardial infarction (MI) and stroke than people unaffected with diabetes; for women, t
o The combination of peripheral vascular disease and peripheral neuropathy can cause serious foot pathology.
o Smoking, hypertension, hyperlipidemia, and poor diabetic control greatly increase the risk of vascular disease.

 Associated autoimmune diseases are relatively common in children and include the following:
o Hypothyroidism affects 2-5% of children with diabetes.
o Hyperthyroidism affects 1% of children with diabetes; the condition is usually discovered at the time of diabetes diagnosis.
o Although Addison disease is uncommon, affecting fewer than 1% of children with diabetes, it is a life-threatening condition that may re
unrecognized hypothyroidism.)
o Celiac disease, associated with an abnormal sensitivity to gluten in wheat products, is probably a form of autoimmune disease and m
o Necrobiosis lipoidica is probably another form of autoimmune disease. This condition is usually, but not exclusively, found in patients w

 Limited joint mobility, primarily affecting hands and feet, is believed to be associated with poor diabetic control.
o Originally described in approximately 30% of patients with IDDM, limited joint mobility occurs in 50% of patients older than 10 years w
 against each other. The skin of patients with severe joint involvement has a thickened and waxy appearance.
o Limited joint mobility is associated with increased risks for diabetic retinopathy and nephropathy. Improved diabetes control over the p
factor. More recent patients also have markedly fewer severe joint mobility limitations.

Prognosis:

 Apart from severe DKA or hypoglycemia, IDDM has little immediate morbidity.

 The risk of complications relates to diabetic control. With good management, patients can expect to lead full, normal, and healthy lives. Neve
reduced by 13-19 years, compared with their nondiabetic peers.

Patient Education:

 Education is a continuing process involving the child, family, and all members of the diabetes team. The following strategies may be used:

o Formal education sessions in a clinic setting

o Opportunistic teaching at clinics or at home in response to crises or difficulties such as acute illness
o Therapeutic camping or other organized events
o Patient-organized meetings
o Information from national organizations and patient groups, including the following:
 Children with Diabetes (This "online community for kids, families, and adults with diabetes" is an excellent resource with good l
 International Society for Pediatric and Adolescent Diabetes
 International Diabetes Federation
 Diabetes UK
 American Diabetes Association
 Juvenile Diabetes Foundation International

 Children should wear some form of medical identification such as a medic alert bracelet or necklace.
  For excellent patient education resources, see eMedicine's Diabetes Center. Also, visit eMedicine's patient education article Diabetes.

MISCELLANEOUS
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Medical/Legal Pitfalls:

 Diabetes is easily missed in an infant or pre-school child. If in doubt, check the urine for glucose.

 DKA may manifest as respiratory distress.

 Overzealous or inadequate treatment of hypoglycemia can lead to serious consequences.

 Addison disease rarely develops but is easily missed and potentially fatal.

 Failure to examine regularly for complications, especially renal and ophthalmic, can be detrimental.

Special Concerns:

 Pregnancies should be planned and carefully managed to achieve healthy outcomes for mother and infant. Preconceptual normalization of b
defects. Blood sugar control during pregnancy must be strict to avoid hypoglycemia, which may damage the fetus, and persistent hyperglyce
pregnancy may result in fetal death.

 Awareness of hypoglycemia becomes impaired over time, and severe hypoglycemia can occur without warning. Hypoglycemia is more likely

 Children with MODY may present as having type 1 diabetes. As they may respond better to oral hypoglycemic agents, recognizing MODY as

Always consider the diagnosis of MODY in the following circumstances:

  A strong family history of diabetes across 2 or more generations (The age of diagnosis usually falls with each successive generation.)

 Persistently low insulin requirements, particularly with good blood glucose control
http://www.emedicine.com/ped/topic581.htm
Diabetes mellitus
Nurse Chat
Chat now with a
live nurse to
Definition
answer all of your
Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is
health questions!
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. The treatment includes changes in diet, oral medications, and in some cases, daily injections of insulin. Nurse Chat Policy
Description
Health Exclusive
Diabetes mellitus is a chronic disease that causes serious health complications including renal (kidney) failure, heart disease, stroke,
Can You Still Be
and blindness. Approximately 17 million Americans have diabetes. Unfortunately, as many as one-half are unaware they have it. Fertile After
Vasectomy?
Background Did you know
you can still be
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
fertile for
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 months after a
behind the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through vasectomy?
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
Learn why
the blood rather entering the cells. follow-up
testing is so
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 important.
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.
continued...
This creates high levels of glucose in the urine.
Health Exclusive Archive
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
Health Headlines
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.
 Distraction
Types of diabetes mellitus Can Defuse
Drunken
Type I 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 Violence
Northern European countries (Finland, Scotland, Scandinavia) than in those from Southern European countries, the Middle East, or Scans During
Asia. In the United States, approximately three people in 1,000 develop Type I diabetes. This form also is called insulin-dependent Radiation
diabetes because people who develop this type need to have daily injections of insulin.
Treatment
Brittle diabetics are a subgroup of Type I where patients have frequent and rapid swings of blood sugar levels between hyperglycemia
Help Lung
(a condition where there is too much glucose or sugar in the blood) and hypoglycemia (a condition where there are abnormally low Cancer
levels of glucose or sugar in the blood). These patients may require several injections of different types of insulin during the day to Patients
keep the blood sugar level within a fairly normal range.
New Drug
The more common form of diabetes, Type II, occurs in approximately 3-5% of Americans under 50 years of age, and increases to 10-
Combo Fights
15% in those over 50. More than 90% of the diabetics in the United States are Type II diabetics. Sometimes called age-onset or adult- High Blood
onset diabetes, this form of diabetes occurs most often in people who are overweight and who do not exercise. It is also more common Pressure
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 II diabetes than those who remain in their original
Studies Track
countries. Treatment
Outcomes for
Type II is considered a milder form of diabetes because of its slow onset (sometimes developing over the course of several years) and Kids With
because it usually can be controlled with diet and oral medication. The consequences of uncontrolled and untreated Type II diabetes,
however, are the just as serious as those for Type I. This form is also called noninsulin-dependent diabetes, a term that is somewhat
ADHD
misleading. Many people with Type II diabetes can control the condition with diet and oral medications, however, insulin injections are Clinical Trials
sometimes necessary if treatment with diet and oral medication is not working. Update: July
20, 2007
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
more...
gestational diabetes were 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 Interactive Tools
injections may be required. These women who have diabetes during pregnancy are at higher risk for developing Type II diabetes within
5-10 years.
Trackers
Arthritis
-
Diabetes also can develop as a result of pancreatic disease, alcoholism, malnutrition, or other severe illnesses that stress the body. Tracker
Osteoporosis
-
Tracker
Causes and symptoms Tools
BMI
Causes -
Calculator
Waist
The causes of diabetes mellitus are unclear, however, 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 I Calculator
diabetes, the immune system, the body's defense system against infection, is believed to be triggered by a virus or another Healthy
microorganism that destroys cells in the pancreas that produce insulin. In Type II diabetes, age, obesity, and family history of diabetes
play a role.
- Weight
Calculator
In Type II 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 II diabetes can begin so gradually that a person may not know that he or she has it. Early Quizzes
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 II diabetes to be detected while a patient is seeing a
- Bladder
doctor about another health concern that is actually being caused by the yet undiagnosed diabetes. - Colon
- Leukemia
Individuals who are at high risk of developing Type II diabetes mellitus include people who:

 are obese (more than 20% above their ideal body weight)
 have a relative with diabetes mellitus
 belong to a high-risk ethnic population (African-American, Native American, Hispanic, or Native
Hawaiian)
 have been diagnosed with gestational diabetes or have delivered a baby weighing more than 9 lbs (4 kg)
 have high blood pressure (140/90 mmHg or above)
 have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL and/or a triglyceride
level greater than or equal to 250 mg/dL
 have had impaired glucose tolerance or impaired fasting glucose on previous testing

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 glucocorticorids), 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

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 I 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 II 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.

Diagnosis

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 can also detect ketones and protein in the urine 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.

Urine tests

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 in Type I diabetics, 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.

Blood 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 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.

Treatment
There is currently no cure for diabetes. The condition, however, can be managed so that patients can live a relatively normal life.
Treatment of diabetes focuses on two goals: keeping blood glucose within normal range and preventing the development of long-term
complications. Careful monitoring of diet, exercise, and blood glucose levels are as important as the use of insulin or oral medications
in preventing complications of diabetes. In 2003, the American Diabetes Association updated its Standards of Care for the
management of diabetes. These standards help manage health care providers in the most recent recommendations for diagnosis and
treatment of the disease.

Dietary changes

Diet and moderate exercise are the first treatments implemented in diabetes. For many Type II diabetics, 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 American Dietetic Association 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.

For many Type II diabetics, weight loss is an important factor in controlling their condition. The food exchange system, along with a
plan of moderate exercise, can help them lose excess weight and improve their overall health.

Oral medications

Oral medications are available to lower blood glucose in Type II diabetics. In 1990, 23.4 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 II 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,
glimeperide, 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 troglitizone. 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 but increased risk in other situations. While these medications are an important aspect of
treatment for Type II diabetes, they are not a substitute for a well planned diet and moderate exercise. Oral medications have not been
shown effective for Type I diabetes, in which the patient produces little or no insulin.

Constant advances are being made in development of new oral medications for persons with diabetes. In 2003, a drug called Metaglip
combining glipizide and metformin was approved in a dingle 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.

Insulin

Patients with Type I 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 II 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.

Purified human insulin is most commonly used, however, insulin from beef and pork sources also are available. Insulin may be given
as an injection of a single dose of one type of insulin once a day. Different types of insulin can be mixed and given in one dose or split
into two or more doses during a day. Patients who require multiple injections over the course of a day may be able to use an insulin
pump that administers small doses of insulin on demand. The small battery-operated pump is worn outside the body and is connected
to a needle that is inserted into the abdomen. Pumps can be programmed to inject small doses of insulin at various times during the
day, or the patient may be able to adjust the insulin doses to coincide with meals and exercise.

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.

Surgery

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.

Alternative treatment

Since diabetes can be life-threatening if not properly managed, patients should not attempt to treat this condition without medicial
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 cetain 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:

 fenugreek (Trigonella foenum-graecum) has been shown in some studies to reduce blood insulin and
glucose levels while also lowering cholesterol
 bilberry (Vaccinium myrtillus) may lower blood glucose levels, as well as helping to maintain healthy
blood vessels
 garlic (Allium sativum) may lower blood sugar and cholesterol levels
 onions (Allium cepa) may help lower blood glucose levels by freeing insulin to metabolize them
 cayenne pepper (Capsicum frutescens) can help relieve pain in the peripheral nerves (a type of diabetic
neuropathy)
 gingko (Gingko biloba) may maintain blood flow to the retina, helping to prevent diabetic retinopathy

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.

Prognosis

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 diabetics.

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.

Prevention

Research continues on diabetes prevention and improved detection of those at risk for developing diabetes. While the onset of Type I
diabetes is unpredictable, the risk of developing Type II 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 II diabetes and preventing further complications of the disease.

Key Terms

Cataract
A condition where the lens of the eye becomes cloudy.
Diabetic peripheral neuropathy
A condition where the sensitivity of nerves to pain, temperature, and pressure is dulled, particularly in
the legs and feet.
Diabetic retinopathy
A condition where the tiny blood vessels to the retina, the tissues that sense light at the back of the eye,
are damaged, leading to blurred vision, sudden blindness, or black spots, lines, or flashing lights in the
field of vision.
Glaucoma
A condition where pressure within the eye causes damage to the optic nerve, which sends visual images
to the brain.
Hyperglycemia
A condition where there is too much glucose or sugar in the blood.
Hypoglycemia
A condition where there is too little glucose or sugar in the blood.
Insulin
A hormone or chemical produced by the pancreas, insulin is needed by cells of the body in order to use
glucose (sugar), the body's main source of energy.
Ketoacidosis
A condition due to starvation or uncontrolled Type I 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 tiredness, and drowsiness.
Kidney dialysis
A process where blood is filtered through a dialysis machine to remove waste products that would
normally be removed by the kidneys. The filtered blood is then circulated back into the patient. This
process also is called renal dialysis.
Pancreas
A gland located behind the stomach that produces insulin.

For Your Information

Resources

Periodicals

 Crutchfield, Diane B. "Oral Antidiabetic Agents: Back to the Basics." Geriatric Times, May 1, 2003: 20.
 "Gestational Diabetes Increases 35% in 10 Years." Health &amp; Medicine Week, March 22, 2004: 220.
 Kordella, Terri. "New Combo Pills." Diabetes Forecast, March 2003: 42.
  "New Drugs." Drug Topics, November 18, 2002: 73.
 "Research: Lower Chromium Levels Linked to Increased Risk of Disease." Diabetes Week, March 29,
2004: 21.
 "Standards of Medical Care for Patients with Diabetes Mellitus: American Diabetes Association."
Clinical Diabetes, Winter 2003: 27.
 "Wider Metformin Use Recommended." Chemist &amp; Druggist, January 11, 2003: 24.

Organizations
 American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 342-2383.
http://www.diabetes.org.
 American Dietetic Association. 216 W. Jackson Blvd., Chicago, IL 60606-6995. (312) 899-0040.
http://www.eatright.org.
 Juvenile Diabetes Foundation. 120 Wall St., 19th Floor, New York, NY 10005. (800) 533-2873.
http://www.jdf.org.
 National Diabetes Information Clearinghouse. 1 Information Way, Bethesda, MD 20892-3560. (800)
860-8747. Ndic@info.niddk.nih.gov. http://www.niddk.nih.gov/health/diabetes/ndic.htm.

Other
 Centers for Disease Control. http://www.cdc.gov/nccdphp/ddt/ddthome.htm.
 "Insulin-Dependent Diabetes." National Institute of Diabetes and Digestive and Kidney Diseases.
National Institutes of Health, NIH Publication No.94-2098.
 "Noninsulin-Dependent Diabetes." National Institute of Diabetesand Digestive and Kidney Diseases.
National Institutes of Health, NIH Publication No.92-241.
Source: Gale Encyclopedia of Medicine, Published December, 2002 by the Gale Group

The Essay Author is Altha Roberts Edgren.

This article was updated on 08-14-2006

http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/ency/diabetes_mellitus.jsp
What is diabetes mellitus?

There are two forms of diabetes in dogs: diabetes insipidus and diabetes mellitus. Diabetes insipidus is a very rare disorder that results in failure
to regulate body water content. Your dog has the more common type of diabetes: diabetes mellitus. This is a fairly common disorder and is
most often seen in dogs five years of age or older. There is a congenital form that occurs in puppies, but this is not common.

Diabetes mellitus is a disease of the pancreas. This is a small but vital organ that is located near the stomach. It has two significant populations
of cells. One group of cells produces the enzymes necessary for proper digestion. The other group, called beta-cells, produces the hormone
called insulin. Simply put, diabetes mellitus is a failure of the pancreas to regulate blood sugar.

Some people with diabetes take insulin shots, and others take oral medication. Is this true for dogs?

In humans, two types of diabetes mellitus have been discovered. Both types are similar in that there is a failure to regulate blood sugar, but the
basic mechanisms of disease differ somewhat between the two groups.

Type I, or Insulin Dependent Diabetes Mellitus, results from total or near-complete destruction of the beta-cells. This is the only type of diabetes
known in dogs. As the name implies, dogs with this type of diabetes require insulin injections to stabilize blood sugar.

Type II, or Non-Insulin Dependent Diabetes Mellitus, is different because some insulin-producing cells remain. However, the amount produced
is insufficient, there is a delayed response in secreting it, and the tissues of the dogs body are relatively resistant to it. People with this form may
be treated with an oral drug that stimulates the remaining functional cells to produce or release insulin in an adequate amount to normalize blood
sugar. Because Type II diabetes does not occur in dogs, oral medications are not appropriate for treating diabetic dogs.

Why is insulin so important?

The role of insulin is much like that of a gatekeeper: it stands at the surface of body cells and opens the door, allowing glucose to leave the
blood stream and pass inside the cells. Glucose is a vital substance that provides much of the energy needed for life, and it must work inside the
cells. Without an adequate amount of insulin, glucose is unable to get into the cells. It accumulates in the blood, setting in motion a series of
events which can ultimately prove fatal.
When insulin is deficient, the cells become starved for a source of energy. In response to this, the body starts breaking down stores of fat and
protein to use as alternative energy sources. As a consequence, the dog eats more; thus, we have weight loss in a dog with a ravenous appetite.
The body tries to eliminate the excess glucose by excreting it in the urine. However, glucose (blood sugar) attracts water; thus, urine glucose
takes with it large quantities of the body's fluids, resulting in the production of a large amount of urine. To avoid dehydration, the dog drinks
more and more water. Thus, we have the four classical signs of diabetes:

Weight loss
Increased water consumption
Ravenous appetite
Increased urination

How is diabetes mellitus diagnosed?

The diagnosis of diabetes mellitus is based on three criteria: the four classical clinical signs, the presence of a persistently high level of glucose
in the blood stream, and the presence of glucose in the urine.

The normal level of glucose in the blood is 80-120 mg/dl (4.4-6.6 mmol/L). It may rise to 250-300 mg/dl (13.6-16.5 mmol/L) following a meal.
However, diabetes is the only common disease that will cause the blood glucose level to rise above 400 mg/dl (22 mmol/L). Some diabetic dogs
will have a glucose level as high as 800 mg/dl (44 mmol/L), although most will be in the range of 400-600 mg/dl (22-33 mmol/L).

To keep the body from losing its needed glucose, the kidneys do not allow glucose to be filtered out of the blood stream until an excessive level
is reached. This means that dogs with a normal blood glucose level will not have glucose in the urine. Diabetic dogs, however, have excessive
amounts of glucose in the blood, so it will be present in the urine.

What are the implications for me and my dog?

For the diabetic dog, one reality exists: blood glucose cannot be normalized without treatment. Although the dog can go a day or so without
treatment and not get into a crisis, treatment should be looked upon as part of the dog's daily routine. Treatment almost always requires some
dietary changes and administration of insulin.
As for you, the owner, there are two implications: financial commitment and personal commitment.

When your dog is well regulated, the maintenance costs are minimal. The special diet, insulin, and syringes are not expensive. However, the
financial commitment is significant during the initial regulation process and if complications arise.

Initially, your dog will be hospitalized for a few days to deal with the immediate crisis and to begin the regulation process. The "immediate
crisis" is only great if your dog is so sick that it has quit eating and drinking for several days. Dogs in this state, called ketoacidosis, may require
a week or more of hospitalization with quite a bit of laboratory testing. Otherwise, the initial hospitalization may be only for a day or two to get
some testing done and to begin treatment. At that point, your dog goes home for you to administer medication. At first, return visits are required
every 3-7 days to monitor progress. It may take a month or more to achieve good regulation.

The financial commitment may again be significant if complications arise. We will work with you to try and achieve consistent regulation, but a
few dogs are difficult to keep regulated. It is important that you pay close attention to our instructions related to administration of medication, to
diet, and to home monitoring. Another complication that can arise is hypoglycemia, or low blood sugar; if severe, it may be fatal. This may
occur due to inconsistencies in treatment. This will be explained in subsequent paragraphs.

Your personal commitment to treating this dog is very important in maintaining regulation and preventing crises. Most diabetic dogs require
insulin injections once or twice daily. They must be fed the same food in the same amount on the same schedule every day. If you are out of
town, your dog must receive proper treatment while you are gone. These factors should be considered carefully before deciding to treat a
diabetic dog.

What is involved in treatment?

Consistency is vital to proper management of the diabetic dog. Your dog needs consistent administration of medication, consistent feeding, and
a stable, stress-free lifestyle. To best achieve this, it is preferred that your dog live indoors most of the time. Although that is not essential,
indoor living removes many uncontrollable variables that can disrupt regulation.

The first step in treatment is to alter your dog's diet. Diets that are high in fiber are preferred because they are generally lower in sugar and
slower to be digested. This means that the dog does not have to process a large amount of sugar at one time. The preferred diets are Prescription
Diet Canine w/d( and CNM OM(. If your dog is overweight, Prescription Diet Canine r/d( or CNM OM( is fed until the proper weight is
achieved, then your dog is switched to one of the others.

Your dog's feeding routine is also important. Some dogs prefer to eat several times per day. This means that food is left in the bowl at all times
for free choice feeding. However, this is not the best way to feed a diabetic dog. The preferred way is to feed twice daily, just before each
insulin injection. If your dog is currently eating on a free choice basis, please try to make the change. However, if your dog will not change or if
you have several dogs that eat in a free choice fashion, you may find that this change is not practical. If a two-meals-per-day feeding routine will
not work for you, it is still very important that you find some way to accurately measure the amount of food that is consumed.

The foundation for regulating blood glucose is the administration of insulin by injection. Many people are initially fearful of giving insulin
injections. If this is your initial reaction, consider these points:

A. Insulin does not cause pain when it is injected.

B. The injections are made with very tiny needles that your dog hardly feels.

C. The injections are given just under the skin in areas in which it is almost impossible to cause damage toany vital organ.

Please do not decide whether to treat your dog with insulin until we have demonstrated the injection technique. You will be pleasantly surprised
at how easy it is.

The injection technique is as follows:

About Insulin. Insulin comes in an airtight bottle that is labeled with the insulin type and the concentration. Before using, mix the contents. It
says on the label to roll it gently, not shake it. The reason for this is toprevent foam formation which will make accurate measuring difficult.
Some of the types of insulin used in dogs have a strong tendency to settle out of suspension. If it is not shaken properly, it will not mix well, and
dosing will not be accurate. Therefore, the trick is to shake it vigorously enough to mix it without creating foam. Since bubbles can be removed
(as described later), it is more important to mix it well than to worry about foam formation. When you have finished shaking it, turn the bottle
upside down to see if any white powder adheres to the bottle. If so, more shaking is needed.

Insulin is a hormone that will lose its effectiveness if exposed to direct sunlight or high temperatures. It should be kept in the refrigerator, but it
should not be frozen. It is not ruined if left out of the refrigerator for a day or two and not exposed to direct sunlight, although this is not
advisable. Insulin is safe as long as it is used as directed, but it should be kept out of the reach of children.

Drawing up the Insulin. Have the syringe and needle, insulin bottle, and dog ready. Then, follow these steps:

1) Remove the guard from the needle, and draw back the plunger to the appropriate dose level.

2) Carefully insert the needle into the insulin bottle.

3) Inject air into the bottle; this prevents a vacuum from forming within the bottle.

4) Withdraw the correct amount of insulin into the syringe.

Before injecting your dog with the insulin, check that there are no air bubbles in the syringe. If you get an air bubble, draw twice as much
insulin into the syringe as you need. Then withdraw the needle from the insulin bottle and tap the barrel of the syringe with your fingernail to
make the air bubble rise to the nozzle of the syringe. Gently and slowly expel the air bubble by moving the plunger upward.

When this has been done, check that you have the correct amount of insulin in the syringe. The correct dose of insulin can be assured if you
measure from the needle end, or "0" on the syringe barrel, to the end of the plunger nearest the needle.

Injecting the Insulin. The steps to follow for injecting insulin are:

1. Hold the syringe in your right hand (switch hands if you are left-handed).

2. Have someone hold your dog while you pick up a fold of skin from somewhere along your dog's back with your free hand (pick up a different
spot each day).

3. Quickly push the very sharp, very thin needle through your dog's skin. This should be easy and painless. However, take care to push the
needle through only one layer of skin and not into your finger or through two layers of skin. The latter will result in injecting the insulin onto
your dog's haircoat or onto the floor. The needle should be directed parallel to the backbone or angled slightly downward.
4. To inject the insulin, place your thumb on the plunger and push it all the way into the syringe barrel.

5. Withdraw the needle from your dog's skin. Immediately place the needle guard over the needle anddiscard the needle and syringe.

6. Stroke your dog to reward it for sitting quietly.

7. Be aware that some communities have strict rules about disposal of medical waste material so don't throw the needle/syringe into the trash
until you know if this is permissible. If it is not, we can dispose of them for you.

It is neither necessary nor desirable to swab the skin with alcohol to "sterilize" it. There are four reasons:

1. Due to the nature of the thick hair coat and the type of bacteria that live near the skin of dogs, briefswabbing with alcohol or any other
antiseptic is not effective.

2. Because a small amount of alcohol can be carried through the skin by the needle, it may actually carry bacteria with it into the skin.

3. The sting caused by the alcohol can make your dog dislike the injections.

4. If you have accidentally injected the insulin on the surface of the skin, you will not know it. If you do not use alcohol and the skin or hair is
wet following an injection, the injection was not done properly.

5. Although the above procedures may at first seem complicated and somewhat overwhelming, they will very quickly become second nature.
Your dog will soon learn that once or twice each day it has to sit still for a few minutes. In most cases, a reward of stroking results in a fully
cooperative dog that eventually may not even need to be held.

Is continual or periodic monitoring needed?

It is necessary that your dog's progress be checked on a regular basis. Monitoring is a joint project on which owners and veterinarians must
work together.
Home Monitoring

Your part consists of two forms of monitoring. First, you need to be constantly aware of your dog's appetite, weight, water consumption, and
urine output. You should be feeding a constant amount of food each day, which will allow you to be aware of days that your dog does not eat all
of it or is unusually hungry after the feeding. You should weigh your dog at least once monthly. It is best to use the same scales each time.

You should develop a way to measure water consumption. The average dog should drink no more than 7 1/2 oz. (225 ml) of water per 10
pounds (4.5 kg) of body weight per 24 hours. Since this is highly variable from one dog to another, keeping a record of your dog's water
consumption for a few weeks will allow you to establish what is normal for your dog. Another way to measure water consumption is based on
the number of times it drinks each day. When properly regulated, it should drink no more than six times per day. If this is exceeded, you should
take steps to make an actual measurement.

Any significant change in your dog's food intake, weight, water intake, or urine output is an indicator that the diabetes is not well controlled. We
should see your dog at that time for blood testing.

The second method of home monitoring is to determine the presence of glucose in the urine. If your dog is properly regulated, there should be
no glucose present in the urine.

There are several ways to detect glucose in urine. You may purchase urine glucose test strips in any pharmacy. They are designed for use in
humans with diabetes, but they will also work in the dog. A fresh urine sample should be collected and tested with the test strip. If glucose is
detected, the test should be repeated the next two days. If it is present each time, we should see your dog for a blood test.

You should keep a small container to catch urine as the dog voids. A large amount of urine is not needed to test for urine glucose; it is not
necessary to catch the entire amount of urine. Because the female dog usually squats to urinate, a shallow pan or dish may be placed under the
hindquarters when she begins to urinate. For male dogs, urine can be collected as soon as the dog lifts the leg to void. Male dogs often urinate
small amounts in several different places and most often urinate on vertical objects, such as bushes and trees.

Monitoring of Blood
There are two blood tests that can be used to monitor your dog. One of these should be performed about every 3-4 months if your dog seems to
be well regulated. Testing should also be done at any time the clinical signs of diabetes are present or if glucose is detected in the urine for two
consecutive days.

Determining the level of glucose in the blood is the most commonly used blood test. Timing is important when the blood glucose is determined.
Since eating will elevate the blood sugar for several hours, it is best to test the blood at least 6 hours after eating.

When testing the blood we want to know the highest and lowest glucose readings for the day. The highest reading should occur just before an
injection of insulin is given. The lowest should occur at the time of peak insulin effect. This is usually 5-8 hours after an insulin injection, but it
should have been determined during the initial regulation process. Therefore, the proper procedure is as follows:

1. Feed your dog its normal morning meal then bring it to hospital immediately. If you cannot a get it to the hospital within 30 minutes, do not
feed it. In that situation, bring its food with you.

2. Bring your dog to the hospital early in the morning without giving it insulin.

3. A blood sample will be taken immediately, then we will give insulin and feed your dog if it did not eat at home.

4. A second blood sample will be taken at the time of peak insulin effect.

If your dog gets excited or very nervous when riding in the car or being in the hospital, the glucose readings may be falsely elevated. If this
occurs, it is best to admit your dog to the hospital the morning (or afternoon) before testing so it can settle down for testing the next day.
Otherwise, the tests give us limited information.

The alternative test is called a fructosamine test. This test is an average of the blood glucose levels for the last two weeks. It is less influenced
by stress and inconsistencies in diet and exercise. For some dogs, this is the preferred test. It does not require fasting and can be performed at
any time of the day.

Does hypoglycemia occur in dogs?

Hypoglycemia means low blood sugar. If it is below 40 mg/dl, it can be life-threatening. Hypoglycemia occurs under two conditions:

1. If the insulin dose is too high. Although most dogs will require the same dose of insulin for long periods of time, it is possible for the dog's
insulin requirements to change. However, the most common causes for change are a reduction in food intake and an increase in exercise or
activity. The reason for feeding before the insulin injection is for the purpose of knowing when the appetite changes. If your dog does not eat,
skip that dose of insulin. If only half of the food is eaten just give a half dose of insulin. Always remember that it is better for the blood sugar to
be too high than too low.

2. If too much insulin is given. This can occur because the insulin was not properly measured in the syringe or because two doses were given.
You may forget that you gave it and repeat it, or two people in the family may each give a dose. A chart to record insulin administration will
help to prevent the dog being treated twice.

The most likely time that a dog will become hypoglycemic is the time of peak insulin effect (5-8 hours after an insulin injection). When the
blood glucose is only mildly low, the dog will be very tired and unresponsive. You may call it and get no response. Within a few hours, the
blood glucose will rise, and your dog will return to normal. Since many dogs sleep a lot during the day, this important sign is easily missed.
Watch for it. It is the first sign of impending problems. If you see it, please bring your dog in for blood testing.

If your dog is slow to recover from this period of lethargy, you should give it corn syrup (1 tablespoon by mouth). If there is no response in 15
minutes, repeat the corn syrup. If there is still no response, contact us immediately for further instructions.

If severe hypoglycemia occurs, a dog will have seizures or lose consciousness. This is an emergency that can only be reversed with intravenous
administration of glucose. If it occurs during office hours, come in immediately. If it occurs at night or on the weekend, call our emergency
phone number for instructions.

SUMMARY OF INSTRUCTIONS

1. Read and reread this material so that you understand the specifics of proper regulation and how to recognize and treat hypoglycemia.

2. Purchase the supplies for treatment. Your prescription will specify the type of insulin and syringes. If you will be using urine glucose tests
strips, they should be purchased at a pharmacy.
3. Give the first injection of insulin of _____units at about _________ AM/PM.

4. Return for a glucose curve, no later than 8:00 a.m., on ____________. Feed your dog that morning and immediately bring it to the hospital.
Do not give insulin, but bring it with you. (If it will take more than 30minutes to drive to the hospital, call for instructions on feeding.)

5. Following regulation in the hospital, measure the urine glucose two consecutive days, then twice weekly for thenext two weeks. If glucose is
not detected, measure the glucose two consecutive days every other week.

6. If you are unable to test the urine for glucose, return to our hospital in 2-4 days for a blood glucose test. This should be done about 5-8 hours
after an injection of insulin. If two injections are given each day, be sure the test is done before the evening injection.

7. Return to our hospital for a blood glucose test in 1 month. This should be done about 5-8 hours after an injection of insulin. If two injections
are given each day, be sure the test is done before the evening injection.

8. Return to our hospital for a blood glucose test in 1 month. Since we will be determining the fructosamine level, the time of day is not
important, and fasting is not necessary.
http://www.purebredlabs.com/what_is_diabetes_mellitus.htm
 Diabetes Mellitus
Encyclopedia Article
Find | Print | E-mail | Blog It
Multimedia

3 items
Article Outline
Introduction; Type 1 Diabetes; Type 2 Diabetes; Complications; Diagnosis and Treatment; Current Research

INTRODUCTIO
I N
Print this section

Diabetes Mellitus, disease in which the pancreas produces insufficient amounts of insulin, or in which the body’s cells fail to
respond appropriately to insulin. Insulin is a hormone that helps the body’s cells absorb glucose (sugar) so it can be used as a source of
energy. In people with diabetes, glucose levels build up in the blood and urine, causing excessive urination, thirst, hunger, and problems
with fat and protein metabolism. Diabetes mellitus differs from the less common diabetes insipidus, which is caused by lack of the
hormone vasopressin, which controls the amount of urine secreted.

In the United States, some 21 million people (7 percent of the population) suffer from diabetes mellitus. Every year, some 1.5 million
people learn they have the disease. Diabetes mellitus kills more than 73,000 U.S. residents each year, making it the sixth leading cause
of all deaths resulting from disease. In addition, diabetes is a contributing factor in many deaths from heart disease, kidney failure, and
other conditions. Overall, experts estimate that diabetes contributes to about 225,000 deaths annually in the United States. In Canada,
approximately 2.5 million residents (about 6 percent of the population) have diabetes mellitus. The disease ranks as the seventh leading
cause of death in Canada, where it kills about 6,000 people a year. Diabetes and its complications contribute to about 25,000 deaths in
Canada annually.
 Diabetes is most common in adults over 45 years of age; in people who are overweight or physically inactive; in individuals who have an
immediate family member with diabetes; and in people of African, Hispanic, and Native American descent. The highest rate of diabetes in
the world occurs in Native Americans. More women than men have been diagnosed with the disease.

In diabetes mellitus low insulin levels or poor response to insulin prevent cells from absorbing glucose. As a result, glucose builds up in
the blood. When glucose-laden blood passes through the kidneys, the organs that remove blood impurities, the kidneys cannot absorb all
of the excess glucose. This excess glucose spills into the urine, accompanied by water and electrolytes—ions required by cells to regulate
the electric charge and flow of water molecules across the cell membrane. This causes frequent urination to get rid of the additional water
drawn into the urine; excessive thirst to trigger replacement of lost water; and hunger to replace the glucose lost in urination. Additional
symptoms may include blurred vision, dramatic weight loss, irritability, weakness and fatigue, and nausea and vomiting.

Sponsored Sites
A new market for job shoppers
Find out which industries are most eager for help.
Read on.
Financing your study abroad experience
Have a plan before you embark.
Get started.
Constellations Quiz
Think you know your stars?
Test your knowledge!

TYPE 1
II DIABETES
Print this section

Diabetes is classified into two types. In Type 1 diabetes, formerly called insulin-dependent diabetes mellitus (IDDM) and juvenile-onset
diabetes, the body does not produce insulin or produces it only in very small quantities. Symptoms usually appear suddenly, typically in
individuals under 20 years of age. Most cases occur around puberty—around age 10 to 12 in girls and age 12 to 14 in boys. In the United
States Type 1 diabetes accounts for 5 to 10 percent of all diabetes cases. In Canada, Type 1 diabetes accounts for about 10 percent of all
diabetes cases.
 Type 1 diabetes is a disease in which the body produces too little insulin or no insulin at all. In most cases, Type 1 diabetes is an
autoimmune disease, that is, a condition in which the body’s disease-fighting immune system goes awry and attacks healthy tissues. In
the case of Type 1 diabetes, the immune system mistakenly attacks and destroys insulin-producing cells, known as beta cells, in the
pancreas. Scientists believe that a combination of genetic and environmental factors somehow triggers the immune system to destroy
these cells. Scientists have so far identified 20 genes that play a role in Type 1 diabetes, although the exact function of these genes is
still under investigation. Environmental factors, such as certain viruses, may also contribute to the development of the disease,
particularly in people who already have a genetic predisposition for the disease. Type 1 diabetes also can result from surgical removal of
the pancreas.

In addition to causing a buildup of glucose in the blood, untreated Type 1 diabetes affects the metabolism of fat. Because the body cannot convert glucose
into energy, it begins to break down stored fat for fuel. This produces increasing amounts of acidic compounds in the blood called ketone bodies, which
interfere with cellular respiration, the energy-producing process in cells.

TYPE 2
III DIABETES
Print this section

In Type 2 diabetes, formerly known as non-insulin-dependent diabetes mellitus (NIDDM) and adult-onset diabetes, the body’s delicate
balance between insulin production and the ability of cells to use insulin goes awry. Symptoms characteristic of Type 2 diabetes include
those found in Type 1 diabetes, as well as repeated infections or skin sores that heal slowly or not at all, generalized tiredness, and
tingling or numbness in the hands or feet.

Of the nearly 21 million people in the United States with diabetes, 90 to 95 percent have Type 2 diabetes. About 90 percent of all diabetes cases in Canada
are Type 2. The onset of Type 2 diabetes usually occurs after the age of 45, although the incidence of the disease in younger people is growing rapidly.
Because symptoms develop slowly, individuals with the disease may not immediately recognize that they are sick. A number of genes are involved in Type 2
diabetes. In addition, there is a strong relationship between obesity and Type 2 diabetes. About 80 percent of diabetics with this form of the disease are
significantly overweight.

COMPLICATION
IV
 S

Print this section

If left untreated, diabetes mellitus may cause life-threatening complications. Type 1 diabetes can result in diabetic coma (a state of
unconsciousness caused by extremely high levels of glucose in the blood) or death. In both Type 1 and Type 2 diabetes, complications
may include blindness, kidney failure, and heart disease. Diabetes can cause tiny blood vessels to become blocked; when this occurs in
blood vessels of the eye, it can result in retinopathy (the breakdown of the lining at the back of the eye), causing blindness. Diabetes
mellitus is the leading cause of new cases of blindness in people aged 20 to 74. In the kidneys, diabetes can lead to nephropathy (the
inability of the kidney to properly filter toxins from the blood). About 40 percent of new cases of end-stage renal disease (kidney failure)
are caused by diabetes mellitus. Blockages of large blood vessels in diabetics can lead to many cardiovascular problems, including high
blood pressure, heart attack, and stroke. Although these conditions also occur in nondiabetic individuals, people with diabetes are two to
four times more likely to develop cardiovascular disorders.

Diabetes mellitus may also cause loss of feeling, particularly in the lower legs. This numbness may prevent a person from feeling the pain or irritation of a
break in the skin or of foot infection until after complications have developed, possibly necessitating amputation of the foot or leg. Burning pain, sensitivity to
touch, and coldness of the foot, conditions collectively known as neuropathy, can also occur. Other complications include higher-risk pregnancies in diabetic
women and a greater occurrence of dental disease.

DIAGNOSIS AND
V TREATMENT
Print this section

Diabetes is detected by measuring the amount of glucose in the blood after an individual has fasted (abstained from food) for about eight
hours. In some cases, physicians diagnose diabetes by administering an oral glucose tolerance test, which measures glucose levels before
and after a specific amount of sugar has been ingested.

Once diabetes is diagnosed, treatment consists of controlling the amount of glucose in the blood and preventing complications.
Depending on the type of diabetes, this can be accomplished through regular physical exercise, a carefully controlled diet, and
medication.
 Individuals with Type 1 diabetes must receive insulin, often two to four times a day, to provide the body with the hormone it does not
produce. Insulin cannot be taken orally, because it is destroyed in the digestive system. Consequently, insulin-dependent diabetics have
historically injected the drug using a hypodermic needle or a beeper-sized pump connected to a needle inserted under the skin. In 2006
the United States Food and Drug Administration approved a form of insulin that can be inhaled and then is absorbed by blood in the
lungs.

The amount of insulin needed varies from person to person and may be influenced by factors such as a person’s level of physical activity,
diet, and the presence of other health disorders. Typically, individuals with Type 1 diabetes use a meter several times a day to measure
the level of glucose in a drop of their blood obtained by pricking a fingertip. They can then adjust the dosage of insulin, physical exercise,
or food intake to maintain the blood sugar at a normal level. People with Type 1 diabetes must carefully control their diets by distributing
meals and snacks throughout the day so as not to overwhelm the ability of the insulin supply to help cells absorb glucose. They also need
to eat foods that contain complex sugars, which break down slowly and cause a slower rise in blood sugar levels.

Sponsored Sites
A new market for job shoppers
Find out which industries are most eager for help.
Read on.
Financing your study abroad experience
Have a plan before you embark.
Get started.
Constellations Quiz
Think you know your stars?
Test your knowledge!

Although most persons with Type 1 diabetes strive to lower the amount of glucose in their blood, levels that are too low can also cause
health problems. For example, if a person with Type 1 diabetes takes too much insulin, it can produce low blood sugar levels. This may
result in hypoglycemia, a condition characterized by shakiness, confusion, and anxiety. A person who develops hypoglycemia can combat
symptoms by ingesting glucose tablets or by consuming foods with high sugar content, such as fruit juices or hard candy.

In order to control insulin levels, people with Type 1 diabetes must monitor their glucose levels several times a day. In 1983 a group of
1,441 Type 1 diabetics aged 13 to 39 began participating in the Diabetes Control and Complications Trial (DCCT), the largest scientific
study of diabetes treatment ever undertaken. The DCCT studied the potential for reducing diabetes-related complications, such as nerve
 or kidney disease or eye disorders, by having patients closely monitor their blood sugar levels four to six times a day, maintaining the
levels as close to normal as possible. The results of the study, reported in 1993, showed a 50 to 75 percent reduction of diabetic
complications in people who aggressively monitored and controlled their glucose levels. Although the study was performed on people with
Type 1 diabetes, researchers believe that close monitoring of blood sugar levels would also benefit people with Type 2 diabetes.

For persons with Type 2 diabetes, treatment begins with diet control, exercise, and weight reduction, although over time this treatment
may not be adequate. People with Type 2 diabetes typically work with nutritionists to formulate a diet plan that regulates blood sugar
levels so that they do not rise too swiftly after a meal. A recommended meal is usually low in fat (30 percent or less of total calories),
provides moderate protein (10 to 20 percent of total calories), and contains a variety of carbohydrates, such as beans, vegetables, and
grains. Regular exercise helps body cells absorb glucose—even ten minutes of exercise a day can be effective. Diet control and exercise
may also play a role in weight reduction, which appears to partially reverse the body’s inability to use insulin.

For some people with Type 2 diabetes, diet, exercise, and weight reduction alone may work initially, but eventually this regimen does not help control high
blood sugar levels. In these cases, oral medication may be prescribed. If oral medications are ineffective, a person with Type 2 diabetes may need insulin
doses or a combination of oral medication and insulin. About 50 percent of individuals with Type 2 diabetes require oral medications, 40 percent require
insulin or a combination of insulin and oral medications, and 10 percent use diet and exercise alone.

CURRENT
VI RESEARCH
Print this section

At present no cure exists for diabetes, and scientists are unsure of the exact cause, although researchers are investigating a combination
of genetic and environmental factors. So far researchers have identified 20 genes involved in Type 1 diabetes, and they are working to
determine each gene’s role in causing the disease. The inheritance patterns of Type 1 diabetes are complicated, with many different
genes influencing a person’s risk. For instance, a gene known as DR plays a role in Type 1 diabetes. Two forms of this gene, called DR3
and DR4, are present in 95 percent of people with Type 1 diabetes. People who inherit DR3 alone develop diabetes at an older age and
have antibodies that destroy insulin-producing beta cells. Those who inherit DR4 tend to develop diabetes earlier in life and have
antibodies that destroy insulin. A person with both DR3 and DR4 typically develops diabetes at a very young age and has the highest
level of insulin-destroying antibodies.
 In 2000 researchers were surprised to find that a variation of a gene called Caplain-10, which is not involved in glucose metabolism, is
associated with the development of Type 2 diabetes. One form of this gene produces a small amount of protein, and researchers are
studying how this decrease in protein increases a person’s risk for diabetes. Other genetic studies indicate that certain genes cause a
variation of Type 2 diabetes called maturity onset diabetes of the young (MODY), which develops in people under the age of 25. Although
scientists do not yet understand how these genes cause MODY, the genes are known to be active in the liver, intestine, kidney, and
pancreas.

Other scientists hope to identify the environmental factors that trigger Type 1 diabetes in people with a genetic predisposition for the
disease. If they can determine what causes the immune system to attack the cells that produce insulin, they may discover how to
prevent the condition from developing. For instance, studies suggest that certain viruses, such as coxsackie B, rubella, and mumps, may
trigger an immune reaction against beta cells or in some cases directly infect and destroy these cells.

Researchers attribute most cases of Type 2 diabetes to obesity. Studies show that the risk for developing Type 2 diabetes increases by 4
percent for every pound of excess weight a person carries. Researchers are investigating the exact role that extra weight plays in
preventing the proper utilization of insulin and why some overweight people develop the disease while others do not.

Research also focuses on transplanting a healthy pancreas or its insulin-producing beta cells into a person with Type 1 diabetes to provide
a natural source of insulin. Some patients who have received pancreas transplants have experienced considerable improvements in their
health, but positive, long-term results with beta-cell transplants have not yet occurred. In both types of transplants recipients must take
drugs that suppress their immune systems so the body will not reject the new pancreas or cells. These drugs can cause life-threatening
side effects because the patient’s body can no longer protect itself from other harmful substances. In most people with diabetes, these
drugs pose a greater risk to health than living with diabetes. Scientists are also studying the development of an artificial pancreas and
ways to genetically manipulate non-insulin-producing cells into making insulin.

New methods for accurately measuring blood glucose levels may improve the quality of life for many individuals with diabetes. New
techniques include the use of laser beams and infrared technology. For example, a tiny computer using infrared light can be used to
measure a person’s blood sugar level. The computer automatically delivers the reading to an insulin pump carried on the diabetic’s body
that injects the appropriate amount of insulin.

Other advances include new drugs that control blood sugar. In April 2000 the United States Food and Drug Administration (FDA)
approved glargine, an insulin drug that needs to be injected only once a day. Sold under the brand name Lantus, this drug can be used
by people with Type 1 diabetes, as well as by those with Type 2 diabetes who require insulin injections. And, as mentioned earlier, in
2006 the FDA approved a form of insulin that can be inhaled. Physicians have long known that some insulin-dependent diabetics fail to
take the drug as often as needed because of the discomfort of injections. Doctors hoped the inhalant form of insulin would lead to better
patient compliance.

A number of drugs have been developed to help people with Type 2 diabetes. Examples include acarbose, (sold under the brand name
Precose), which controls blood sugar by slowing the digestion of carbohydrates; and metformin (sold under the brand name Glucophage),
which controls liver production of sugar, causes weight loss, and reduces total cholesterol. Pioglitazone (brand name, Actos) and
rosiglitazone (brand name, Avandia) are drugs that make the cells more sensitive to insulin. A study published in 2007 found that
Avandia increases the risk of heart attacks. Soon afterward the FDA told the manufacturers of Avandia and Actos, which had also been
shown to carry a heart risk, to add prominent safety warnings to the drugs’ labels.

http://encarta.msn.com/encyclopedia_761576931_2/Diabetes_Mellitus.html
Diabetes Related links

WHAT IS DIABETES? :: Department of Chronic

Diseases and Health Promotion

Diabetes is a chronic disease that occurs when the pancreas does not produce enough insulin, or alternatively, when the body cannot :: WHO’s diabetes programme
effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. Hyperglycaemia, or raised blood sugar, is a
common effect of uncontrolled diabetes and over time leads to serious damage to many of the body's systems, especially the nerves and :: WHO Global Strategy on Diet,
blood vessels. Physical Activity and Health

 Type 1 diabetes (previously known as insulin-dependent or childhood-onset) is characterized by a lack of insulin :: WHO global report Preventing
production. Without daily administration of insulin, Type 1 diabetes is rapidly fatal.
chronic diseases: a vital
investment
 Symptoms include excessive excretion of urine (polyuria), thirst (polydipsia), constant hunger, weight loss,
vision changes and fatigue. These symptoms may occur suddenly.
:: Zahida’s story: living with
 Type 2 diabetes (formerly called non-insulin-dependent or adult-onset) results from the body’s ineffective use of diabetes
insulin. Type 2 diabetes comprises 90% of people with diabetes around the world, and is largely the result of excess
body weight and physical inactivity. :: 7-minute video on common
 Symptoms may be similar to those of Type 1 diabetes, but are often less marked. As a result, the disease may misunderstandings surrounding
be diagnosed several years after onset, once complications have already arisen. chronic disease
 Until recently, this type of diabetes was seen only in adults but it is now also occurring in obese children.
 Gestational diabetes is hyperglycaemia which is first recognized during pregnancy.
 Symptoms of gestational diabetes are similar to Type 2 diabetes. Gestational diabetes is most often diagnosed through prenatal screening, rather
than reported symptoms.

Impaired Glucose Tolerance (IGT) and Impaired Fasting Glycaemia (IFG) are intermediate conditions in the transition between normality and diabetes. People with IGT or IFG
are at high risk of progressing to type 2 diabetes, although this is not inevitable.

DIABETES FACTS
 The World Health Organization (WHO) estimates that more than 180 million people worldwide have diabetes. This number is likely to more than double
by 2030.
 In 2005, an estimated 1.1 million people died from diabetes. 1
 Almost 80% of diabetes deaths occur in low and middle-income countries.
  Almost half of diabetes deaths occur in people under the age of 70 years; 55% of diabetes deaths are in women.
 WHO projects that diabetes deaths will increase by more than 50% in the next 10 years without urgent action. Most notably, diabetes deaths are
projected to increase by over 80% in upper-middle income countries between 2006 and 2015.

WHAT ARE COMMON CONSEQUENCES OF DIABETES?

Over time, diabetes can damage the heart, blood vessels, eyes, kidneys, and nerves.

 Diabetic retinopathy is an important cause of blindness, and occurs as a result of long-term accumulated damage to the small blood vessels in the retina.
After 15 years of diabetes, approximately 2% of people become blind, and about 10% develop severe visual impairment.
 Diabetic neuropathy is damage to the nerves as a result of diabetes, and affects up to 50% of people with diabetes. Although many different problems
can occur as a result of diabetic neuropathy, common symptoms are tingling, pain, numbness, or weakness in the feet and hands.
 Combined with reduced blood flow, neuropathy in the feet increases the chance of foot ulcers and eventual limb amputation.
 Diabetes is among the leading causes of kidney failure. 10-20% of people with diabetes die of kidney failure.
 Diabetes increases the risk of heart disease and stroke. 50% of people with diabetes die of cardiovascular disease (primarily heart disease and stroke).
 The overall risk of dying among people with diabetes is at least double the risk of their peers without diabetes.

WHAT IS THE ECONOMIC BURDEN OF DIABETES?

Diabetes and its complications impose significant economic consequences on individuals, families, health systems and countries.

WHO estimates that over the next 10 years (2006-2015), China will lose $ 558 billion in foregone national income due to heart disease, stroke and diabetes alone.

HOW CAN THE BURDEN OF DIABETES BE REDUCED?

Without urgent action, diabetes-related deaths will increase by more than 50% in the next 10 years.

To help prevent type 2 diabetes and its complications, people should:

 Achieve and maintain healthy body weight.

 Be physically active - at least 30 minutes of regular, moderate-intensity activity on most days. More activity is required for weight control.
Early diagnosis can be accomplished through relatively inexpensive blood testing.

Treatment of diabetes involves lowering blood glucose and the levels of other known risk factors that damage to blood vessels. Tobacco cessation is also important to avoid
complications.

Interventions that are both cost saving and feasible in developing countries include:

 Moderate blood glucose control. People with type 1 diabetes require insulin; people with type 2 diabetes can be treated with oral medication, but may
also require insulin;
 Blood pressure control;
 Foot care.

Other cost saving interventions include:

 Screening for retinopathy (which causes blindness);

 Blood lipid control (to regulate cholesterol levels);
 Screening for early signs of diabetes-related kidney disease.

These measures should be supported by a healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use.

WHO ACTIVITIES TO PREVENT AND CONTROL DIABETES

WHO aims to stimulate and support the adoption of effective measures for the surveillance, prevention and control of diabetes and its complications, particularly in low and
middle-income countries. To this end, WHO:

 Provides scientific guidelines for diabetes prevention;

 Develops norms and standards for diabetes care;
 Builds awareness on the global epidemic of diabetes; including partnership with the International Diabetes Federation in the celebration of World Diabetes
Day (14 November);
 Conducts surveillance of diabetes and its risk factors.

The WHO Global Strategy on Diet, Physical Activity and Health complements WHO's diabetes work by focusing on population-wide approaches to promote healthy diet and
regular physical activity, thereby reducing the growing global problem of overweight and obesity. The Strategy calls upon all stakeholders to take action at the global, regional
and local levels and aims to lead to a significant reduction in the prevalence of diabetes and other chronic diseases.
WHO's work on diabetes is integrated into the overall WHO chronic disease prevention and control framework of the Department of Chronic Diseases and Health Promotion.
The strategic objectives of the Department are to raise awareness about the global epidemic of chronic diseases; create healthy environments, especially for poor and
disadvantaged populations; slow and reverse trends in common chronic disease risk factors such as unhealthy diet and physical inactivity; and prevent premature deaths and
avoidable disability due to major chronic diseases.

http://www.who.int/mediacentre/factsheets/fs312/en/