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Published: Tuesday 29th of October 2013
Diabetes mellitus is a metabolic disorder with chronic hyperglycemia (high blood sugar) and impaired carbohydrate, protein and fat metabolism resulting from insufficient secretion of insulin or from the resistance of target tissue to insulin. Insulin is a hormone that is secreted by the beta cells of the pancreas which acts as a gate-keeper allowing only a certain amount of glucose to enter the cells. Glucose is a source of energy for body cells. It is plain sugar resulting from the digestion of food containing carbohydrates. When beta cells do not produce enough insulin or when insulin resistance develops, meaning that the cells can longer use the insulin circulating in the blood, glucose is not being used by body cells, it stays in the blood, which results in hyperglycemia. There are several types of diabetes, with the most common ones being insulin dependent Type 1 and non-insulin dependent Type 2 diabetes.
The occurrence of diabetes is increasing at a staggering pace. Over the past 40 years, there has been a six-fold increase in diabetes incidence. It is currently the third most common chronic illness in the United States, and it is predicted to enter the top seven causes of death worldwide by 2030. Globally, more than 6% of the population between the ages of 20 and 80 are living with diabetes. Additionally, a great many cases, as many 5.4 million in the US remain undiagnosed. The increase is most notable in Type 2 diabetes, which accounts for 90% of all cases of diabetes, and it occurs along with the obesity epidemic accompanying rapid urbanization, tendency to consume high-energy fast food and lifestyle characterized by lack of physical activity and high exposure to stress.
When a person has an increased risk for diabetes, he or she is said to have pre-diabetes, which implies impaired fasting glucose levels (IFG) and impaired glucose tolerance (IGT). If the following plasma glucose levels get surpassed, the diagnosis of pre-diabetes can be made: fasting glucose levels 100-125 mg/dl (5.6-6.9 mmol/L), 2h glucose measurement 140-199 mg/dl (7.8-11 mmol/L). This diagnosis represents an intermediate stage between normalcy and diabetes. Persons with pre-diabetes are at an increased risk for developing diabetes, but this does not happen in all cases. Indeed a significant number of persons once diagnosed with pre-diabetes go on to have healthy sugar levels later on. Others eventually require treatment for diabetes.
Type 1 diabetes is a severe chronic life-threatening condition which accounts for 5-10% of all persons with diabetes. It was previously referred to as juvenile- or childhood-onset diabetes, or insulin-dependent diabetes. It results from autoimmune destruction of specialized cells in the pancreas, called beta cells. The actual rate of beta cell destruction is highly variable, being the most rapid in infants and children and slowest in older adults. It is even possible for some patients, most commonly children to present with ketoacidosis as the first manifestation of the condition. Diabetic ketoacidosis represents a metabolic state with high concentrations of ketone bodies, resulting from the breakdown of fatty acids and the deamination of amino acids. It is a medical emergency usually requiring in-patient treatment. Its symptoms include marked polyuria and polydipsia, nausea and vomiting, dehydration, impaired consciousness and labored and gasping breathing known as acidotic respiration. If left untreated, it results in coma and possible death.
Type 1 diabetes may result from a viral infection, autoimmune reactions, as well as various genetic factors. Viral infections implicated in the onset of Type 1 diabetes include rubella virus, Coxsackie virus, hepatitis B virus, cytomegalovirus, influenza virus, etc. There is evidence of a significant rise of Type 1 diabetes diagnoses in months of the year when the viral infections are most present, in autumn and winter. Cold weather is another contributing factor. As to the genetic factors, Type 1 diabetes has been shown to be a polygenic disease, with specific variants of the HLA-DQA1, HLA-DQB1, and HLA-DRB1 genes implicated in its etiology. These genes belong to the family of human leukocyte antigen (HLA) complex which helps the body`s immune system to distinguish its own proteins from those originating from foreign invaders, such as bacteria or viruses. Type 1 diabetes is considered to be an autoimmune disorder in which the immune system falsely identifies pancreatic cells as invaders and damages or destroys them, leaving them unable to produce insulin. Persons predisposed to developing diabetes are also at risk for other autoimmune disorders like Graves’ disease, Addison’s disease, Hashimoto’s thyroiditis, coeliac disease, vitiligo, autoimmune hepatitis, etc.
Type 1 diabetes typically develops relatively early in life, in childhood or early adulthood. It is treated with direct injections of insulin. Persons living with this condition are vulnerable to two types of events in connection with blood sugar levels, namely hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). Hypoglycemia occurs when too much insulin is released into the bloodstream, causing an extreme drop in sugar levels. The affected person’s skin turns pale and gets covered in cold sweat, breathing is rapid and shallow, there is hand tremor; the person is confused or irritated. The condition requires immediate action, which will usually be consumption of high-sugar types of foods. Hyperglycemia develops more slowly, with red color and dryness of skin, drowsiness, deep and labored breathing, thirst, and sometimes abdominal pain. It is treated with injections of insulin.
About 90% of persons living with diabetes have Type 2 diabetes. It typically occurs later in life than Type 1 diabetes, although the age of onset is decreasing. It is more common among women and persons of not so well-to-do social and economic background. Initially, it is not treated with insulin, but insulin dependency can develop in the course of the disease. As to the causes of this form of diabetes, there is a reduction in islet mass with deposition of islet amyloid polypeptide which produces histological changes within the islets. The plasma levels of proinsulin-like molecules show beta cell dysfunction while the autoimmune destruction of beta cells does not occur.
Obesity is the major contributing factor to Type 2 diabetes, and it is partly responsible for insulin resistance. Even if persons with Type 2 diabetes are not obese, they tend to have fat accumulation in the abdominal region of the body, and an increased percentage of body fat. This type of diabetes is said to occur when a specific lifestyle characterized by excessive caloric intake, low caloric expenditure, and obesity get overlaid upon a genotype predisposed to this condition. The following are some of the risk factors for developing Type 2 diabetes: being overweight, leading a sedentary lifestyle, having a high blood pressure, having a close relative with diabetes, being born with excessive birth weight, being a member of susceptible ethnic groups which include African Americans, Latinos, Native Americans, Asian Americans and Pacific Islanders.
Gestational diabetes mellitus is high blood sugar that develops during pregnancy and usually resolves after giving birth. It is most common in the second half of the pregnancy. It is due to the pregnant woman’s body being unable to produce sufficient levels of insulin to meet the extra needs in pregnancy. As to the treatment, a simple diet modification sometimes suffices, but there is also a possibility of it requiring insulin injections. If a mother has had gestational diabetes during her first pregnancy, the condition is likely to reoccur in subsequent pregnancies. Also, there is a possibility of developing Type 1 or Type 2 diabetes later on in life.
The reason why diabetes is such an important public health issue lies in long-term consequences that arise from long-standing hyperglycemia. These complications can be divided into macrovascular (coronary artery disease, peripheral arterial disease, and stroke) and microvascular complications (diabetic neuropathy, nephropathy, and retinopathy). Diabetic retinopathy is responsible for 10000 new cases of blindness a year in the United States alone, with diabetes being the leading cause of blindness among adults. Patients with Type 1 diabetes usually develop retinopathy within twenty years of diagnosis, but the actual time elapsed from diagnosis to onset of retinopathy is highly dependent on glycemic control. If a person with diabetes has well-controlled blood sugar levels, he or she can delay this complication even further. Diabetic nephropathy is the principal cause of renal failure in the United States and many other First World countries, and it accounts for around 50% of all patients requiring treatment by renal dialysis. Diabetic neuropathy, defined as the presence of symptoms of peripheral nerve dysfunction in persons with diabetes, is directly proportional to the duration and severity of hyperglycemia, although some individuals can also be genetically predisposed to this type of complication. Patients can experience burning, or tingling sensations in their extremities, numbness, and foot ulcerations which, if untreated in a timely manner, can eventually lead to amputations. Pain sensation can also be impaired.
Macrovascular complications occur through the process of atherosclerosis, which is a cause of the narrowing of arterial walls throughout the body. Persons living with diabetes are at a significant risk of developing cardiovascular disease, and this is the primary cause of death in people with both major types of diabetes. Diabetes also represents a substantial independent factor in the prediction of stroke and cerebrovascular disease. The risk of stroke in persons with diabetes is 150-400% greater than in persons without diabetes. As a consequence of all these complications of long-standing hyperglycemia, persons with diabetes have a significantly shorter life expectancy than individuals without diabetes.
Stress exerts a significant influence on persons with both Type 1 and Type 2 diabetes. Stress can be a precipitating factor for the onset of Type 1 diabetes in persons with a genetic predisposition to the disease. Furthermore, people at high risk for diabetes have abnormal glycemic reactions to stress. Stress also aggravates both types of diabetes possibly through the action of stress hormones, such as cortisol, which when present in high doses, decreases the efficacy of insulin in facilitating glucose storage. When you combine this constellation of factors with high blood pressure often accompanying high insulin production and add obesity (especially if manifested with excess fat around the waist), elevated cholesterol and triglyceride levels and physical inactivity, you get even higher insulin resistance and a further increase in insulin secretion. This combination of factors is commonly referred to as the metabolic syndrome which is a significant health risk factor.
The diagnosis of diabetes puts a heavy burden on the affected person as well as those close to him or her. It has a profound psychological impact on the whole family and requires significant adjustments in lifestyle, eating habits, etc. In children diagnosed with diabetes, a successful adaptation to the condition and achieving adequate diabetes control depends on several aspects of family functioning, including family cohesiveness and openness, but also the presence or absence of psychological problems within a family, such as depression, anxiety, eating disorders or behavioral problems. In adults with diabetes, problems with diabetes control can be expected if the affected person shows signs of clinical depression, anxiety or eating disorders.
Overall the adherence to self-management programs in persons with diabetes seems to be somewhat low. A high percentage of individuals with diabetes administer insulin incorrectly, or in the wrong dosage, they test their glucose levels infrequently or inaccurately or fail to adhere to dietary recommendations. They do not take medical advice seriously or find it hard to follow them since they usually require self-control, dietary restrictions, exercising regularly, and other lifestyle modifications. People with diabetes are often unaware of the health risks they face. The fact that the consequences of non-adherence to medical recommendations and poor glycemic control are not visible immediately, and are usually evident only years after the onset of diabetes, makes people less frightened of them. Therefore, education about diabetes and its health implications is of utmost importance. Comprehensive care for persons with diabetes includes interventions aimed at improving adherence, training in social skills specific to diabetes (resisting to social pressures and temptations, etc.) and problem-solving skills.