About diabetes

Introduction
The term diabetes mellitus describes a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both. The effects of diabetes mellitus include longterm damage, dysfunction and failure of various organs. (WHO 1999) There are two main types of diabetes. Type 1 diabetes (T1B) usually develops in childhood and adolescence and patients require lifelong insulin injections for survival. Type 2 diabetes (T2B) usually develops in adulthood and is related to obesity, lack of physical activity, and unhealthy diets. This is the more common type of diabetes (representing 90% of diabetic cases worldwide) and treatment may involve lifestyle changes and weight loss alone, or oral medications or even insulin injections. Other categories of diabetes include gestational diabetes (a state of hyperglycemia which develops during pregnancy) and "other" rarer causes (genetic syndromes, acquired processes such as pancreatitis, diseases such as cystic fibrosis, exposure to certain drugs, viruses, and unknown causes). As well, intermediate states of hyperglycemia (impaired fasting glucose or impaired glucose tolerance) have been defined. These states are significant in that they can progress to diabetes, but with weight loss and lifestyle changes, this progression can be prevented or delayed. In the short term, hyperglycemia causes symptoms of increased thirst, increased urination, increased hunger, and weight loss . However, in the long-term, it causes damage to eyes (leading to blindness), kidneys (leading to renal failure), and nerves (leading to impotence and foot disorders/ possibly amputation). As well, it increases the risk of heart disease, stroke, and insufficiency in blood flow to legs. Studies have shown that good metabolic control prevents or delays these complications. Thus, the primary goal of treatment is to bring the elevated blood sugars down to a normal range, both to improve symptoms of diabetes as well as to prevent or delay diabetic complications. Achieving this goal requires a comprehensive, coordinated, patient-centred approach on the part of the health care system.

Type 1 Diabetes (T1B )

Description

formerly known as Insulin-Dependent Diabetes Mellitus (IDDM).

characterized by hyperglycemia due to an absolute deficiency of the insulin hormone produced by the pancreas. patients require lifelong insulin injections for survival. usually develops in children and adolescents (although can occur later in life). may present with severe symptoms such as coma or ketoacidosis. patients are usually not obese with this type of diabetes, but obesity is not incompatible with the diagnosis. patients are at increased risk of developing microvascular and macrovascular complications.

Etiology

usually (but not always) caused by autoimmune destruction of the beta cells of the pancreas, with the presence of certain antibodies in blood. a complex disease caused by mutations in more than one gene, as well as by environmental factors.

Symptoms

increased urinary frequency (polyuria), thirst (polydipsia), hunger (polyphagia), and unexplained weight loss. numbness in extremities, pain in feet (disesthesias), fatigue, and blurred vision. recurrent or severe infections. loss of consciousness or severe nausea/vomiting (ketoacidosis) or coma. Ketoacidosis more common in T1D than in T2D.

Diagnosis

diagnosis is made by the presence of classic symptoms of hyperglycemia and an abnormal blood test. a plasma glucose concentration >=7 mmol/L (or 126 mg/dL) or >=11.1mmol/L ( or 200mg/dL) 2 hours after a 75g glucose drink. in a patient without classic symptoms, diagnosis can also be made by two abnormal blood tests on separate days. in most settings (although not always available in resource-poor countries), another test called HgbA1C is done to approximate metabolic control over previous 2-3 months and to guide treatment decisions.

Treatment

overall aim of treatment is symptom relief and prevention or delay of complications by targeting normal blood glucose levels lifelong insulin injections in different combinations: short-acting/long-acting, intensive management with multiple injections prior to meals, once or twice daily injections, insulin pump consistent supply of insulin essential (however, insulin is unavailable and unaffordable in many poor countries) glucometers to self-monitor blood glucose

early detection and treatment of complications (at intervals recommended by national and international guidelines): eye exam, urine test, foot care, and specialist referral as needed patient education about self-monitoring for sign/symptoms of hypoglycemia (such as hunger, palpitations, shakiness, sweating, drowsiness and dizziness) and hyperglycemia patient education about diet, exercise, and foot care where possible, patient-led support groups and community involvement Read more about Type 1 diabetes

Type 2 diabetes T2D

Description

formerly named non-insulin-dependent diabetes mellitus (NIDDM). characterized by hyperglycemia due to a defect in insulin secretion usually with a contribution from insulin resistance. patients usually do not require lifelong insulin but can control blood glucose with diet and exercise alone, or in combination with oral medications, or with the addition of insulin. usually (but not always) develops in adulthood (and is on the rise in children and adolescents). is related to obesity, decreased physical activity and unhealthy diets. as in T1D, patients are at a higher risk of microvascular and macrovascular complications.

Etiology

associated with obesity, decreased physical activity and unhealthy diets (and involves insulin resistance in nearly all cases). occurs more frequently in individuals with hypertension, dyslipidemia (abnormal cholesterol profile), and central obesity, and is a component of "metabolic syndrome". often runs in families but is a complex disease caused by mutations in more than one gene, as well as by environmental factors.

Symptoms

patients may have no symptoms at all or minimal symptoms for years before being diagnosed. may have increased urinary frequency (polyuria), thirst (polydipsia), hunger (polyphagia), and unexplained weight loss. may also experience numbness in extremities, pain in feet (disesthesias), and blurred vision. may have recurrent or severe infections. patients may present with loss of consciousness or coma but this is less common than in T1D.

Diagnosis

diagnosis is made by the presence of classic symptoms of hyperglycemia and an abnormal blood test.

a plasma glucose concentration >=7 mmol/L (or 126 mg/dL) or >=11.1mmol/L ( or 200mg/dL) 2 hours after a 75g glucose drink. in a patient without classic symptoms, diagnosis can also be made by two abnormal blood tests on separate days. in most settings (although it may not be available in some resource-poor settings), another test called HgbA1C is done to approximate metabolic control over previous 2-3 months and to guide treatment decisions. some asymptomatic patients are diagnosed through "opportunistic screening" of high risk groups (at a routine medical visit, the health care provider may identify the patient as being at higher risk of diabetes and recommend a screening test). for example, age >45 years of age, a BMI >25 kg/m2 may, being of certain ethnic group or being hypertensive may prompt a screening test. in some cases, the patient him/herself requests screening.

Treatment

overall aim of treatment is symptom relief and prevention or delay of complications by targeting normal blood glucose levels. patients treated with diet/exercise, or with addition of one or more categories of oral medications, with a combination of oral medications and insulin, or with insulin alone. glucometers to self-monitor blood glucose (with less frequency than with T1D). early detection and treatment of complications (at intervals recommended by national and international guidelines): eye exam, urine test, foot care, and specialist referral as needed. self-monitoring for signs/symptoms of hypoglycemia (such as hunger, palpitations, shakiness, sweating, drowsiness and dizziness) and hyperglycemia. patient education about diet, exercise, and foot care. Read more about Type 2 diabetes

Gestational diabetes (GDM)

Description

characterized by hyperglycemia of varying severity diagnosed during pregnancy (without previously known diabetes) and usually (but not always) resolving within 6 weeks of delivery. risks to the pregnancy itself include congenital malformations, increased birth weight and an elevated risk of perinatal mortality. increased risk to woman of developing diabetes (T2D) later in life.

Etiology

the mechanism is not completely well understood but hormones of pregnancy appear to interfere with insulin action.

Symptoms

increased thirst (polydipsia) and increased urination (polyuria) are more commonly noted (although other symptoms can be present). because pregnancy itself causes increased urination, these symptoms are difficult to recognize as abnormal. a larger than normal baby during pregnancy (noted on routine prenatal exam) may prompt diabetic screening.

Diagnosis

standard OGTT is done at 24-28 weeks after an overnight fast (fasting plasma glucose and a plasma glucose 2 hours after 75g glucose drink is done). a 2 hour level >=7.8 mmol/L (or 140 mg/dL) is diagnostic of gestational diabetes. If fasting and postprandial blood sugars are elevated in the first trimester, this may indicate preexisting diabetes mellitus (which is considered a different condition, with different implications).

Treatment

strict metabolic control of blood glucose to lower obstetrical risks.. patients treated with diet/exercise, with addition of oral medications, or with the addition of insulin. glucometers to self-monitor blood glucose. patient education about diet and exercise. patient education after delivery regarding weight loss/exercise to prevent future diabetes. lifelong screening for T2D as patient will be in high risk category.

Intermediate States of Hyperglycemia

Description

IFG, IGT, and diabetes mellitus are seen as progressive stages of the same disease process, and treatment at earlier stages has been shown to prevent progression to later stages (by diet, exercise and lifestyle management). Not all patients with IGT have IFG, so it is considered a separate category. As well, the implications of the two states are slightly different. Impaired Fasting Hyperglycemia (IFG) is a state of higher than normal fasting blood (or plasma) glucose concentration, but lower than the diagnostic cut-off for diabetes. Impaired Glucose Intolerance (IGT) is a state of higher than normal blood (or plasma) glucose concentration 2 hours after 75 gram oral glucose load but less than the diagnostic cut-off for diabetes.

Symptoms

Patients usually have no symptoms and are diagnosed because a test is done upon patient request or because he/she falls into a high risk category.
Diagnosis

IFG: fasting plasma glucose >=6.1 mmol/L (110 mg/dL) and <7 mmol/L (126 mg/dL) per WHO 1999 criteria. (ADA has chosen a lower cutoff of 5.6mmol/L or 100mg/dL). IGT: fasting plasma glucose (if available) <7.0 mmol/L (126 mg/dL) AND 2 hour post 75g glucose drink of >= 7.8 mmol/L (140 mg/dL) and <11.1 mmol/L (200 mg/dL).

Treatment

lifestyle modifications (diet, physical activity, weight loss) are the mainstay of treatment, although sometimes medications are used. large, population-based studies in China , Finland and USA have recently demonstrated the feasibility of preventing, or delaying, the onset of diabetes in overweight subjects with mild glucose intolerance (IGT). studies suggest that even moderate reduction in weight and only half an hour of walking each day reduces the incidence of diabetes by more than one half.

Complications of Diabetes
Diabetes complications are divided into microvascular (due to damage to small blood vessels) and macrovascular (due to damage to larger blood vessels). Microvascular complications include damage to eyes (retinopathy) leading to blindness, to kidneys (nephropathy) leading to renal failure and to nerves (neuropathy) leading to impotence and diabetic foot disorders (which include severe infections leading to amputation). Macrovascular complications include cardiovascular diseases such as heart attacks, strokes and insufficiency in blood flow to legs. There is evidence from large randomized-controlled trials that good metabolic control in both type 1 and 2 diabetes can delay the onset and progression of these complications.

Diabetic retinopathy (eye disease)

Etiology

Diabetic retinopathy is a leading cause of blindness and visual disability. It is caused by small blood vessel damage to the back layer of the eye, the retina, leading to progressive loss of vision, even blindness.

Symptoms

Usually the patient complains of blurred vision, although other visual symptoms may also be present.
Diagnosis

Diagnosis of early changes in the blood vessels of the retina can be made through regular eye examinations.
Treatment

Good metabolic control can delay the onset and progression of diabetic retinopathy. As well, early detection and treatment of vision-threatening retinopathy can prevent or delay blindness. This involves regular eye examinations and timely intervention

Read more about retinopathy

Nephropathy (kidney disease)

Etiology

Diabetic kidney disease is also caused by damage to small blood vessels in the kidneys. This can cause kidney failure, and eventually lead to death. In developed countries, this is a leading cause of dialysis and kidney transplant.
Symptoms

Patients usually have no symptoms early on, but as the disease progresses, they may feel tired, become anemic, not think clearly, and even develop dangerous electrolyte imbalances.
Diagnosis

Early diagnosis can be made by a simple urine test for protein as well as a blood test for kidney function.
Treatment

If diagnosed at an early stage, several measures can retard the progression to kidney failure. These include control of high blood glucose, control of high blood pressure, intervention with medication in the early stage of kidney damage, and restriction of dietary protein.

Read more about nephropathy

Neuropathy (nerve disease)

Etiology

Diabetes causes nerve damage through different mechanisms, including direct damage by the hyperglycemia and decreased blood flow to nerves by damaging small blood vessels. This nerve damage can lead to sensory loss, damage to limbs, and impotence in diabetic men. It is the most common complication of diabetes.
Symptoms

The symptoms are many, depending on which nerves are affected: for example, numbness in extremities, pain in extremities, and impotence. Decreased sensation to feet can lead to patients not recognizing cuts and developing foot infections. If not treated early, these can lead to amputation (more about diabetic foot disease below).
Diagnosis

Early diagnosis is made by early recognition of symptoms by patients and health care providers as well as by careful examination by health care providers at regular intervals.
Treatment

If detected early, and blood glucose brought under control, these complications can also be prevented or delayed. Diabetic foot disease, due to changes in blood vessels and nerves, often leads to ulceration and subsequent limb amputation. It is one of the most costly complications of diabetes, especially in communities with inadequate footwear. It results from both vascular and neurological disease processes. Regular inspection and good care of the foot can prevent amputations. Comprehensive foot programs can reduce amputation rates by 45-85%.

Read more about neuropathy

Cardiovascular Disease
Etiology

Hyperglycemia damages blood vessels through a process called atherosclerosis, or clogging of arteries. This narrowing of arteries can lead to decreased blood flow to heart muscle (causing a

heart attack), or to brain (leading to stroke), or to extremities (leading to pain and decreased healing of infections).
Symptoms

The symptoms of these different conditions are varied: ranging from chest pain to leg pain, to confusion and paralysis.
Diagnosis

While early detection of these complications can delay progression, early detection of other risk factors such as smoking, high blood pressure, high serum cholesterol and obesity is even more important.
Treatment

Controlling these other risk factors along with blood glucose can prevent or delay cardiovascular complications.

Values for diagnosis of diabetes mellitus and other categories of hyperglycaemia (WHO, 1999)
Impaired Fasting Glucose

Diabetes Mellitus Fasting plasma glucose of >=7.0 mmol/L (126 mg/dL) or 2 hour post 75g glucose load* of >=11.1 (200 mg/dL) OR Whole blood glucose of >=6.1 mmol/L (110 mg/dL) or >=10.0 mmol/L (180 mg/dL) 2 hours after 75g glucose load

Impaired Glucose Tolerance

Fasting plasma glucose Fasting Glucose of <=7.0 mmol/L of 6.1-7.0 mmol/L (110 (126 mg/dL) mg/dL - 126 mg/dL) OR Whole blood glucose of 5.6 mmol/L (100 mg/dL) - 6.1 mg/dL (110 mg/dL) AND Plasma and whole blood glucose of >=7.8 mmol/L (>=140 mg/dL) 2 hours post glucose load of 75 g but < 11.1 mmol/L (200mg/dL)

* An OGTT (oral glucose tolerance test) is a measurement of blood (or plasma) glucose concentration 2 hours after ingesting a 75 gram glucose drink (glucose load) The diagnostic criteria developed by WHO and the American Diabetes Association (ADA) are currently the most frequently used standards for identifying diabetes among populations. The ADA has recently released new guidelines in January 2006, while the World Health Organization is reviewing its criteria which will be ready later in 2006.