Diabetes Mellitus

Overview Treatment Options

Definition Treatment Strategy

Etiology Drug Therapies

Risk Factors Complementary and Alternative Therapies

Signs and Symptoms Patient Monitoring

Differential Diagnosis Other Considerations

Diagnosis Prevention

Physical Examination Complications/Sequelae

Laboratory Tests Prognosis

Pathology/Pathophysiology Pregnancy

Other Diagnostic Procedures References

Overview
Definition

Diabetes mellitus results from the body's failure to regulate blood glucose levels adequately. It
is a common endocrine disease, with more than 600,000 new cases diagnosed in the United
States each year. It affects men and women of all ages, races, and income levels. Among
those over 40, it affects 1:15 Caucasians and 1:10 to 1:8 African-Americans and Hispanics.
Among those over 65, 1 of every 5 persons has diabetes and up to 50% of patients are
undiagnosed. There is a strong familial susceptibility to the condition. Two major forms are
seen:

 Type I (insulin-dependent diabetes mellitus [IDDM]): usually occurs before age 30,
most likely between ages 11 and 13; accounts for about 10% of cases.
 Type II (non-insulin-dependent diabetes mellitus [NIDDM]): usually occurs in those
over age 40; accounts for about 90% of cases; 30% to 40% need insulin.

Gestational diabetes (GDM) can occur in pregnant women. Diabetes can be secondary to
pancreatic disease, the use of chemicals or drugs, various genetic syndromes (Turner's
syndrome, myotonic dystrophy, or Prader-Willi syndrome), rare abnormalities in the cellular
receptor for insulin, or an autosomal dominant inherited disorder.

Etiology

Unknown, but most likely a combination of genetic predisposition, viral infection, lifestyle,
nutrition and diet, obesity, autoimmune disorders, and exposure to toxic agents. Type I
probably results when pancreatic beta cells are attacked and destroyed by an autoimmune
process triggered by a viral infection in a genetically susceptible individual. Type II develops in
older, overweight individuals whose insulin production is insufficient to meet body needs or
whose response to insulin is diminished by a loss of insulin receptors on the surface
membranes of target cells.

Risk Factors

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Type I:

 Family history of diabetes, thyroid disease, or other endocrinopathies

 Family history of autoimmune diseases such as Hashimoto's thyroiditis, Graves'
disease, myasthenia gravis, or pernicious anemia
 Cow's milk consumption in infancy

Type II:

 Obesity and age over 40 years

 Family history of diabetes, thyroid disease, or other endocrinopathies
 Sedentary lifestyle with diet high in fats and calories
 African-American, Hispanic, American Indian, or Asian or Pacific Island-American

Signs and Symptoms

 Polyuria, polydipsia, rapid weight loss, and hyperglycemia
 Glycosuria
 Increased susceptibility to infection
 Dehydration
 Polyphagia
 Fatigue or weakness
 Blurred vision
 Stiffness in the shoulder and upper back
 Pruritus, numbness, and tingling in the hands and feet
 Leg cramps
 Hyperlipidemia
 Ketoacidosis

Differential Diagnosis
 Polydipsia—medication side effect, psychogenic factors, diabetes insipidus
 Polyuria—hypercalcemia, medication side effect, renal wasting, urologic or prostate
conditions
 Blurred vision—myopia, presbyopia
 Fatigue or weakness—thyroid disorder, anemia, adrenal insufficiency, depression
 Pruritus—allergy, renal failure
 Cushing's disease
 Corticosteroid use

Diagnosis
Physical Examination

Patient may present with fatigue, lethargy, poor concentration, and atypical thirst for liquids.

Laboratory Tests
 Two or more fasting plasma glucose levels over 140 mg/dL or one level over 200
mg/dL plus other signs and symptoms.

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  Oral glucose tolerance test values 120 to 140 mg/dL
 Glycosylated hemoglobin test showing consistently elevated values.
 Glycosylated hemoglobin is used to track treatment efficacy, not to diagnose DM.

Pathology/Pathophysiology

Elevated blood sugar levels with weight loss, decreased blood pressure, nonhealing wounds
(especially on the extremities), recurrent cutaneous infections, decreased extremity
sensation, retinal abnormalities or cataract formation, carotid bruits, abdominal tenderness,
dry skin, and hair loss over lower leg and foot.

Other Diagnostic Procedures

Blood glucose testing

Treatment Options
Treatment Strategy
 Control blood sugar levels; helps reduce complications.
 Requires patients to be self-disciplined, able to concentrate, able to maintain a
positive attitude, and honest with self and physician.
 Components are diet, exercise, blood glucose self-monitoring, oral hypoglycemic
agents (Type II), and insulin (Type I).
 Because diabetes affects so many body systems, treatment planning must include a
whole-body approach.

Treatment specific to Type I:

 Diet—consistent timing/content (same gram amount of carbohydrates, protein, and

fat at each meal); consult dietitian for meal planning.
 Exercise—daily; wear proper shoes and protective equipment; avoid extreme heat or
cold; check feet daily and after exercise; suspend exercise when blood glucose
control is poor.
 Self-monitoring—teach the patient to use a home glucose meter and make needed
adjustments in diet, exercise, and/or insulin.

Treatment specific to Type II:

 Diet—use moderation; lose weight by decreasing calories while increasing activity;

base choices on USDA Food Pyramid.
 Exercise—as for Type I; do moderate aerobic exercise (50% to 70% of VO 2 max) for
20 to 45 minutes at least three days a week; include low-intensity warm-up and cool-
down exercises.
 Self-monitoring—as for Type I, with adjustments in diet, exercise, and/or oral
hypoglycemic agent as needed.

Drug Therapies

Insulin (used for Type I and occasionally Type II [30% to 40%]). Taken subcutaneously, with
dose and type individualized to the patient's condition. Possible treatment regimens:
 Three-injections/day, doses adjusted to variations in control

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  Long-acting and short-acting preparations taken at meals for stable background
levels
 External insulin pump for tight control
 Single injection/day for those with some pancreatic function

Sulfonylureas (Type II only). Oral hypoglycemic agents used when diet and exercise are
ineffective or in conjunction with diet and exercise. Doses individualized to the patient's
condition. Side effects include hypoglycemia, nausea, heartburn, stomach fullness;
intolerance and allergy (<2% of patients). Use with caution in persons with liver or kidney
impairment and those with sulfa allergy. Approved agents:

 Acetohexamide (Dymelor)—250 to 1,500 mg; slight diuretic effect

 Chlorpropamide (Diabinese, Glucamide)—100 to 750 mg; very long duration of
action, antidiuretic effect
 Tolazamide (Tolinase)—100 to 1,000 mg; slight diuretic effect
 Tolbutamide (Orinase)—500 to 3,000 mg; usually taken in two to three doses/day
 Glipizide (Glucotrol)—5 to 40 mg; take on empty stomach
 Glipizide-extended release (Glucotrol XL)—20 mg; do not break tablet, take once/day
 Glyburide (Diabeta, Micronase)—1.25 to 30 mg
 Glyburide-micronized (Glynase)—12 mg/day; not equivalent in action to glyburide
 Glimepiride (Amaryl)—8 mg/day
 Metformin (Glucophage)—Used as a supplement to or substitute for sulfonylureas.
Side effects include weight loss, nausea, abdominal discomfort, and diarrhea. Use
with caution in persons with conditions leading to lactic acid buildup (congestive heart
failure, severe vascular disease, kidney or liver disease). Discontinue 24 to 48 hours
before surgery or radiographic dye study. Dose: 1 to 2.5 g/day in two to three doses;
available in 500 and 850 mg tablets; take before meals
 Acarbose (Precose)—Slows absorption of carbohydrate into blood, acts locally in the
intestine. Take at the beginning of a meal for immediate action. Major side effect is
increased gas production (up to 75% of users). Dose: 50 to 100 mg depending on
results and side effects
 Troglitazone (Rezulin)—In trials for use with insulin; liver damage reported
 Repaglinide (Prandin)—Meglitinide class; use in Type II disease

Complementary and Alternative Therapies

Treatments stabilize blood sugars. Also, alternative therapies have an important role in
preventing vascular damage and some of the serious complications that may be involved with
DM. A combination of herbs and nutrition, along with lifestyle changes, can be quite helpful.
Regular exercise is extrememly important. Ten minutes/day of exercise has been shown to
have an effect on glucose tolerance, although a minimum of 30 minutes three times/week is
required to see significant changes. Extended exercise is desired. Short bursts of activity may
actually increase glucose levels.

Nutrition
 Diet: the classic diet for DM is high in complex carbohydrates and fiber. Some people,
however, achieve better glucose control with a high-protein diet with very few
carbohydrates. If the classic diet does not stabilize blood sugar, a trial of high-protein
diet may be indicated.

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  Essential fatty acids: anti-inflammatory, decrease insulin resistance, and prevent
cardiovascular and neurological complications of DM. Evening primrose oil (2,000 mg
bid) or fish oil (1,200 mg bid) rather than flax or borage may be required, since a
greater percentage of diabetics are lacking enzymes required for utilization of flax
and/or borage oil.
 OPCs (oligomeric procyanidins) such as pycnogenol or grape seed extracts help to
support vascular health and prevent oxidation side effects associated with diabetes
 B-complex: biotin (300 mcg), B1 (50 to 100 mg), B2 (50 mg), B3 (100 mg), B6 (50 to
100 mg), B12 (100 to 1,000 mcg), folate (400 mcg/day) help prevent neuropathy,
control glucose levels, and prevent nephropathy
 Vitamin C (2 to 3 g/day) may prevent microangiopathy and hypertriglyceridemia
 Vitamin E (400 IU/day) may reduce insulin requirements so should start at 100 IU and
gradually increase the dose; enhances healing of ulcers, and is a cardioprotective
antioxidant
 Brewer's yeast: contains chromium, which may improve glucose tolerance, and
glutathione, an antioxidant (9 g or 3 tbsp. brewer's yeast/day and/or 200 mcg
chromium)
 Magnesium: (400 mg/day) low in diabetics, may help prevent the calcium deposition
in arterial walls
 Manganese: (500 to 1,000 mcg) low in diabetics, may help stabilize glucose levels
 Zinc: (30 mg/day) may decrease fasting glucose levels and help prevent fatty acid
oxidation
 Coenzyme Q10: (50 to 100 mg bid) depleted by oral hypoglycemic agents, prevents
fatty acid oxidation
 Vanadium: (5 to 10 mg/day) to normalize serum cholesterol and triglycerides
 Some feel that chromium picolinate (200 mcg) helps normalize sugar metabolism.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. Ascertain a
diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules,
powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered
5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day.
Tinctures may be used singly or in combination as noted.
 Garlic (Allium sativum) increases fibrolysis, inhibits platelet aggregation, lowers lipids
 Onion (Allium cepa) lowers lipids and blood pressure, inhibits thrombocyte
aggregation
 Bilberry (Vaccinium myrtillus) is a flavonoid, historic use in DM, especially to prevent
diabetic retinopathy
 Fenugreek (Trigonella foenum-graecum) historically used to stabilize blood sugar
 Garlic and onions should be consumed liberally in the diet; bilberry and fenugreek,
equal parts, can be used as 1 cup tea tid or 30 to 60 drops tincture tid
 Cayenne (Capsicum annum): 0.075% capsaicin cream topically, decreases pain in
peripheral neuropathy after two to four weeks of use

Homeopathy
An experienced homeopath should assess individual constitutional types and severity of
disease to select the correct remedy and potency. Constitutional homeopathy may be helpful.

Acupuncture
May be helpful in both symptomatic relief and increasing overall vitality.

Massage

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May be helpful in relieving stress, which decreases cortisol and stabilizes blood sugar, and for
maintaining healthy circulation in the extremities.

Patient Monitoring
 Patients taking insulin—daily fingerstick to measure blood sugar levels, weight, and
skin evaluation (redness indicating allergy to insulin, edema, or cellulitis)
 Electrocardiogram at initial visit
 Thyroid-stimulating hormone and thyroid antibody screening for high-risk patients at
initial visit and then as indicated by antibody tests and physical examination
 Lipid profile four to six weeks after beginning therapy and three months later
 Every three months: glycosylated hemoglobin or hemoglobin A, urine dipstick, LFT
 Yearly: 24-hour urine collection to measure microalbumin, protein, creatinine
clearance rate; electrolytes, BUN, dilated funduscopic examination
 Yearly: opthalmology exam, foot exam

Other Considerations
Prevention
Avoid weight gain and obesity. Maintain regular physical activity.
Complications/Sequelae
 Diabetic ketoacidosis
 Hyperosmolar coma
 Arteriosclerosis—cardiac, peripheral vascular, or cerebrovascular disease
 Diabetic eye disease—glaucoma, cataracts, blindness
 Diabetic kidney disease—nephropathy, failure
 Diabetic neuropathy—peripheral symmetrical polyneuropathy, autonomic
neuropathies, mononeuropathies
 Foot ulcers/infections
 Skin changes—bruising, hypertrophy, or lipoatrophy at injection site, dryness, fungal
infections, vitiligo, necrobiosis lipoidica diabeticorum, pruritus, alopecia, scleroderma
adultorum, xanthomas, xanthelasma, acanthosis nigricans, gangrene, skin ulcers
 Musculoskeletal problems—stiff joints, tendon contractures of the hands, bursitis
Prognosis
Prevent and/or slow development of complications by maintaining blood glucose averages
around 155 mg/dL. Complications usually begin 10 to 20 years after onset of disease.

Pregnancy
Women of child-bearing age with diabetes should consult an endocrinologist about the
benefits of tight glucose control before attempting conception. Target blood glucose
concentrations are:
 Fasting: 60 to 90 mg/dL (3.3 to 5 mmol/L)
 Preprandial: 60 to 105 mg/dL (3.3 to 5.8 mmol/L)
 Two hours postprandial: 90 to 120 mg/dL (5 to 6.7 mmol/L)

Women with gestational diabetes should be treated to normalize glucose levels and reduce
the risk of complications (developmental malformations, perinatal morbidity/mortality). Modify
diet to improve glucose values. If this fails, use insulin therapy; oral hypoglycemic agents are
contraindicated during pregnancy. Subsequent pregnancies can be affected, and risk of
developing type II diabetes is increased. If maternal glucose levels uncontrolled, infant can
suffer CNS defects, macrosomia, organomegaly, cardiac or renal anomalies, situs inversus,
stillbirth, asphyxia, respiratory distress, increased blood volume, hyperviscosity, congestive
heart failure, hypocalcemia, hypomagnesemia, hypoglycemia, or hyperbilirubinemia.