Diabetes Mellitus (DM)

Blue circle for diabetes[1]

Diabetes mellitus is a common metabolic disorder of multiple etiology, characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism due to defects in insulin secretion, insulin action, or both. There are four main types of diabetes mellitus: type 1 diabetes mellitus, type 2 diabetes mellitus, gestational diabetes and other specific types (genetic syndromes, pancreatitis, cystic fibrosis, exposure to certain drugs, etc.).

The disease is caused by this process: metabolic.

Presentation

Patients with type 1 diabetes mellitus usually present with classic acute symptoms of hyperglycemia. These include:

  • Polyuria (due to osmotic diuresis when blood glucose level exceeds renal threshold)
  • Thirst (as a consequence of loss of fluids and electrolytes by osmotic diuresis)
  • Postural hypotension (due to reduction of plasma volume by osmotic diuresis)
  • Loss of weight (due to depletion of glycogen stores by glycogenolysis and triglyceride stores by lipolysis; and the reduction of muscle mass as a consequence of the diversion of amino acids for gluconeogenesis)
  • Blurring of vision (because of the exposure of the lens and retina to hyperosmolar fluids)

Around 25% of the cases of diabetes mellitus present with the acute complication of ketoacidosis.

In contrast, most of the patients of type 2 diabetes mellitus do not have acute symptoms. The disease may be present for an average of 4 to 7 years before it is detected. The patients have a history of increased urination and thirst but most are asymptomatic initially. The presenting complaints of the patients include lack of energy, delayed wound healing, visual blurring and fungal infections such as pruritis vulvae or balanitis [5].

In addition, the following complications may be the initial presenting feature in chronically undetected cases.

Jaw & Teeth
Liver, Gall & Pancreas
Entire body system
  • Coronary Artery Disease Diabetes doubles the risk of cardiovascular disease and about 75% of deaths in diabetics are due to coronary artery disease. [source]
  • Fatigue In addition to the known ones above, they include blurry vision, headache, fatigue, slow healing of cuts, and itchy skin. [source]
  • Weight Loss Weight loss surgery in those with obesity is sometimes an effective measure in those with type 2 DM. [source] Weight loss surgery in those with obesity and type two diabetes is often an effective measure. [source] The classic symptoms of untreated diabetes are weight loss, polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger). [source]
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neurologic
Skin
  • Delayed Wound Healing The presenting complaints of the patients include lack of energy, delayed wound healing, visual blurring and fungal infections such as pruritis vulvae or balanitis. [source]
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respiratoric
gastrointestinal
  • Abdominal Pain People (usually with type 1 DM) may also experience episodes of diabetic ketoacidosis, a metabolic disturbance characterized by nausea, vomiting and abdominal pain, the smell of acetone on the breath, deep breathing known as Kussmaul breathing, and in [source]
  • Diarrhea Galen named the disease "diarrhea of the urine" (diarrhea urinosa). [source]
  • Increased Appetite Effects can range from feelings of unease, sweating, trembling, and increased appetite in mild cases to more serious issues such as confusion, changes in behavior such as aggressiveness, seizures, unconsciousness, and (rarely) permanent brain damage or [source]
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musculoskeletal
cardiovascular
urogenital
  • Polyuria These include: Polyuria (due to osmotic diuresis when blood glucose level exceeds renal threshold) Thirst (as a consequence of loss of fluids and electrolytes by osmotic diuresis) Postural hypotension (due to reduction of plasma volume by osmotic diuresis [source] The symptoms may relate to fluid loss and polyuria, but the course may also be insidious. [source] The classic symptoms of untreated diabetes are weight loss, polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger). [source]
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Eyes

Workup

The following investigations are helpful in establishing the diagnosis of diabetes mellitus.

  • Random blood sugar: Diabetes is labelled if the random blood sugar is found to be greater than 200 mg/dL. It is not sufficient for diagnosing diabetes and fasting blood sugar should always be checked subsequently.
  • Fasting blood sugar: Diabetes is confirmed if the fasting blood sugar is more than 126 mg/dL on more than one occasion.
  • Glucose tolerance test: Glucose tolerance test is required for the confirmation of diabetes when the fasting blood sugar is more than normal but less than the diabetic range.
  • Glycosylated hemoglobin: Level of glycosylated hemoglobin reflects the state of glycemia over the preceding 8 to 12 weeks.
  • Serum fructosamine: Serum fructosamine reflects the state of glycemic control for the preceding 2 weeks.

Laboratory

Serum
Urine
  • Glycosuria When the glucose concentration in the blood remains high over time, the kidneys will reach a threshold of reabsorption, and glucose will be excreted in the urine (glycosuria). [source] It was Thomas Willis who in 1675 added "mellitus" to the word "diabetes" as a designation for the disease, when he noticed the urine of a diabetic had a sweet taste (glycosuria). [source]
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Cerebrospinal Fluid
HLA Type
  • HLA-DR3 There is around 30 to 35% concordance in monozygotic twins. 95% of the patients carry HLA-DR3, HLD-DR4 or both genes. [source]
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Imaging

X-ray

Treatment

The treatment methods available for diabetes mellitus include:

  • Diet alone
  • Diet and insulin
  • Diet and oral hypoglycemic drugs

Diet

Around 60% of the patients can be treated adequately with diet alone. A proper diet regimen should be prepared based upon the age, sex, weight and caloric requirements of the patient. Readily absorbable carbohydrates such as sugars should be avoided. Non-nutritive sweeteners such as asparmate, saccharine or sucramate should be used if needed.

Oral hypoglycemic drugs

Oral hypoglycemic agents are useful for the treatment of type 2 diabetes mellitus. A wide number of oral hypoglycemic agents are available. They are prescribed individually or in combinations according to the patient. Common oral hypoglycemic agents include sulphonylureas (e.g. glimepride and glipizide), biguanides (e.g. metformin), alpha glucosidase inhibitors (e.g. acarbose and migitol), thiazolidinedions (e.g. pioglitazone and rosiglitazone), D-phenylalanine derivatives (e.g. nateglinide) and insulin stimulators (e.g. repaglinide) [7][8].

Insulin

Insulin is used in the treatment of all patients of type 1 diabetes mellitus and in those patients of type 2 diabetes whose hyperglycemia is not controlled by diet and oral hypoglycemic agents. Various preparations of insulin are available and are selected according to each patient.

Prognosis

Diabetes mellitus is a chronic disease that disturbs the quality of life of all the patients [4]. The patients are forced to take daily insulin injections and/or oral hypoglycemic drugs. Lifestyle and diet modifications also become essential. However, with early diagnosis and proper control of the disease, the risk of development of associated diseases and complications can be reduced and the patients enjoy a life expectancy that approaches those without the disease. Untreated diabetes mellitus is associated with a high mortality and morbidity rate.

Complications

  • Dehydration A rare but equally severe possibility is hyperosmolar hyperglycemic state, which is more common in type 2 DM and is mainly the result of dehydration. [source] Lost blood volume will be replaced osmotically from water held in body cells and other body compartments, causing dehydration and increased thirst (polydipsia). [source]
  • Diabetic Nephropathy Damage to the kidneys, known as diabetic nephropathy, can lead to tissue scarring, urine protein loss, and eventually chronic kidney disease, sometimes requiring dialysis or kidney transplantation. [source]
  • Hyperglycemia As a result, hyperglycemia develops. [source] Patients with type 1 diabetes mellitus usually present with classic acute symptoms of hyperglycemia. [source] These cells are responsible for the production of insulin and their destruction causes the level of insulin to fall leading to hyperglycemia. [source]
  • Obesity Even those who are not obese often have a high waist–hip ratio. [source] Weight loss surgery in those with obesity is sometimes an effective measure in those with type 2 DM. [source] Weight loss surgery in those with obesity and type two diabetes is often an effective measure. [source]
  • Peripheral Vascular Disease vascular disease) Myocardial infarction (because of atherosclerosis) The following investigations are helpful in establishing the diagnosis of diabetes mellitus. [source] infections, tuberculosis and skin infections) Deterioration of vision (owing to diabetic retinopathy) Paresthesia, pain and atrophy of the leg muscles (due to neuropathy) Ulcerations of the foot/feet (caused by a combination of neuropathy, infection and peripheral [source]
  • Retinopathy Infections (such as urinary tract infections, tuberculosis and skin infections) Deterioration of vision (owing to diabetic retinopathy) Paresthesia, pain and atrophy of the leg muscles (due to neuropathy) Ulcerations of the foot/feet (caused by a combination [source] Damage to the eyes, known as diabetic retinopathy, is caused by damage to the blood vessels in the retina of the eye, and can result in gradual vision loss and blindness. [source]
  • Skin Infection Infections (such as urinary tract infections, tuberculosis and skin infections) Deterioration of vision (owing to diabetic retinopathy) Paresthesia, pain and atrophy of the leg muscles (due to neuropathy) Ulcerations of the foot/feet (caused by a combination [source]
  • Stroke Other "macrovascular" diseases are stroke, and peripheral artery disease. [source] Serious long-term complications include cardiovascular disease, stroke, chronic kidney disease, foot ulcers, and damage to the eyes. [source] However, evidence supports less than or equal to somewhere between 140/90 mmHg to 160/100 mmHg; the only additional benefit found for blood pressure targets beneath this range was an isolated decrease in stroke risk, and this was accompanied by an increased [source]
  • Tuberculosis Infections (such as urinary tract infections, tuberculosis and skin infections) Deterioration of vision (owing to diabetic retinopathy) Paresthesia, pain and atrophy of the leg muscles (due to neuropathy) Ulcerations of the foot/feet (caused by a combination [source]
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Etiology

Diabetes mellitus may be primary or secondary.
Primary diabetes mellitus has two types [2].

  • Insulin dependent diabetes mellitus (Type 1)
  • Non-insulin dependent diabetes mellitus (Type 2)

Type 1 diabetes mellitus usually results from an autoimmune disease process. It is associated with a positive family history. The child of a patient having type 1 diabetes has a greater risk of developing the disease. The risk is greater with diabetic father as compared to the diabetic mother. There is around 30 to 35% concordance in monozygotic twins. 95% of the patients carry HLA-DR3, HLD-DR4 or both genes. Infection with coxsackievirus B4

Type 2 diabetes mellitus has a 100% concordance in identical twins, implying a much stronger genetic association. Around 25% of the patients have a first degree relative suffering from this disease. Overeating combined with obesity acts as a diabetogenic factor.

Epidemiology

Type 1 diabetes mellitus is the most common metabolic disease in childhood. It is present in around 1 in every 500 child or adolescent.

Type 2 diabetes mellitus is very common worldwide, particularly the US because of the high caloric diet. Its incidence is on the rise and it is said that type 2 diabetes is rapidly becoming a global “epidemic”. It is estimated that around 552 million people worldwide will be suffering from it by the year 2030.

Sex distribution
Age distribution

Pathophysiology

Type 1 diabetes mellitus is caused by an autoimmune process in which there is lymphocytic infiltration and subsequent destruction of the beta cells in the pancreas. These cells are responsible for the production of insulin and their destruction causes the level of insulin to fall leading to hyperglycemia.

In type 2 diabetes mellitus, there is both reduced secretion of insulin as well as insulin resistance in the peripheral tissues [3]. As a result, hyperglycemia develops.

Prevention

There is no effective preventive measure against type 1 diabetes mellitus as it is an autoimmune disease that occurs early in childhood.

Type 2 diabetes mellitus can be prevented by adopting a healthy lifestyle. Eating a healthy diet, avoiding overeating, controlling obesity and performing daily exercise greatly reduce the risk of development of type 2 diabetes mellitus [9] [10].

Summary

Diabetes mellitus is a clinical syndrome that is characterized by chronic hyperglycemia along with disturbances in the metabolism of carbohydrates, lipids and proteins [1]. It is of two main types, type 1 and type 2 diabetes mellitus. The former is also referred to as insulin dependent diabetes mellitus while the latter is also known as non-insulin dependent diabetes mellitus.

Patient Information

Diabetes mellitus is a disease in which the level of sugar in the blood is raised. It is of two types, one usually affecting people since childhood and the other appearing late in adulthood. Diabetes is associated with many diseases and complications and should be diagnosed and treated early to ensure better expectancy and quality of life.

Self-assessment

References

  1. Hoogwerf BJ, Sferra J, Donley BG. Diabetes mellitus--overview. Foot and ankle clinics. Dec 2006;11(4):703-715.
  2. Avery L. Diabetes mellitus types 1 and 2: an overview. Nursing standard. Nov 11-17 1998;13(8):35-38.
  3. Ostenson CG. The pathophysiology of type 2 diabetes mellitus: an overview. Acta physiologica Scandinavica. Mar 2001;171(3):241-247.
  4. Ionova TI, Odin VI, Nikitina TP, Kurbatova KA, Shablovskaia NE. [Quality of life and problems posed by hypoglycemia in type 2 diabetes mellitus during oral hypoglycemic therapy]. Klinicheskaia meditsina. 2013;91(9):34-40.
  5. Ratner RE. Type 2 diabetes mellitus: the grand overview. Diabetic medicine : a journal of the British Diabetic Association. 1998;15 Suppl 4:S4-7.
  6. Bustos-Saldana R, Prieto-Miranda S, Grupo de Estudio de Factores de Riesgo de Ulceraciones en los Pies de los Pacientes Diabeticos T. [Foot ulceration risk factors in type 2 diabetes mellitus]. Revista medica del Instituto Mexicano del Seguro Social. Sep-Oct 2009;47(5):467-476.
  7. McAvoy KH. Oral hypoglycemic agents in the management of non-insulin-dependent diabetes mellitus among the elderly. The Diabetes educator. Sep-Oct 1991;17(5):411-413.
  8. Lubbos H, Miller JL, Rose LI. Oral hypoglycemic agents in type II diabetes mellitus. American family physician. Nov 15 1995;52(7):2075-2078.
  9. Olmsted WH. Obesity: key to the prevention of diabetes. Journal - Michigan State Medical Society. Oct 1953;52(10):1057-1061.
  10. Boulin R, Rambert P. [Prevention of diabetes mellitus]. La Semana medica. Oct 22 1952;28(38):429-430.

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