Diabetes Mellitus: Causes and Treatment

Diabetes Mellitus (DM) refers to the groups of conditions that are associated with elevated blood glucose (hyperglycemia). The exact cause for this uncontrolled blood sugar depends on the underlying type. The two major types are well known: the Type 1 and Type 2 DM. Currently, DM is one of the fastest-growing disease epidemics with a 10-fold increase in global prevalence between 1985 and 2013, from 30 million to 382 million cases! More than 8% of the population is believed to have DM and many are unaware of their condition. This is very concerning as it is associated with many life-threatening complications which will be discussed below.

Not only are diabetes complications adverse for your overall health, but they will also impact your options for various insurance products. Says Melissa Thompson of Diabetes 365 “Life insurance for diabetics, as well as health insurance will be more expensive if you have severe complications from diabetes. For some individuals with significant diabetes complications they may not even be able to obtain coverage from insurance providers.”

• Glucose regulation in the body

  The carbohydrates in our food predominantly gets broken down into glucose in our guts and is absorbed into the blood stream. In response to elevated glucose after a meal, the pancreas (a gland in the abdomen) is stimulated to produce the hormone insulin. Insulin is responsible for uptake of glucose into cells and its storage. At the other extreme, a fall in blood sugars below a critical point triggers the release of another hormone from the pancreas called glucagon which draws out the stored glucose into the blood.

  The Different Causes of Diabetes Mellitus

  • Type 1 DM: This type is associated with a complete absence of insulin production by the pancreas. This is believed to occur from an auto-immune mediated destruction of the cells producing insulin (B-cells). This generally presents earlier in life usually the teens and requires insulin for survival.
  • Type 2 DM: This type is associated with insulin resistance. This occurs when higher and higher levels of insulin are required for the body’s cells to take up glucose, eventually becoming insensitive. This is the more common type of DM which is associated with obesity and unhealthy eating practises.
  • Gestational Diabetes Mellitus: This is a condition involving high blood sugars in pregnant women. This occurs due to abnormal metabolism of glucose with development of insulin resistance. Generally, the hyperglycemia resolves after child birth, but these women have a higher risk of developing DM later in life.
  • Chronic Steroid Use: Long term use of steroids like prednisone are associated with breakdown and release of stored glucose within the cell leading to hyperglycemia.
  • Glucagon excess: A tumor of the cells producing glucagon in the pancreas, called glucagonoma, can lead to excess breakdown of stored glucose to cause hyperglycemia. This is a relative rare condition and is associated with other systemic manifestations such as skin rash and anemia.

Symptoms of Diabetes

There are three classic symptoms which have been described. These are

• Polyphagia or increased appetite and intake of food
• Polyuria or increased quantity and frequency of urine
• Polydipsia or increased intake of water and other fluids to quench the thirst resulting from urinary loss.

While these symptoms are often experienced by patients with type 1 DM, most people, especially those with type 2 DM do not have any symptoms in the early stages and only experience symptoms from complications developing later.

• Complications of Diabetes Mellitus

  Vascular complications: These are complications which result from longstanding uncontrolled DM. The excess glucose damages the blood vessels all over the body. These are classified as follows

  Macrovascular (Affecting large blood vessels) complications:

  • Coronary Artery Disease: This confers increased risk of heart attacks
  • Stroke: This occurs from damage to the large vessels supplying the brain
  • Peripheral arterial disease: This occurs from involvement of the vessels supplying the arms and legs. The poor blood supply increase the risk of ulcers with high chance of infection

  Microvascular (affecting small blood vessels) complications:

  • Retinopathy: This involves the small vessels and capillaries supplying the retina in the back of the eye. Damage causes decreased vision and risk of bleed into the eye which can cause blindness
  • Neuropathy: Direct damage to the nerves and to the vessels supplying them lead to this condition. The person experiences tingling, pins and needles sensation of the hands and feet at first which is then followed by numbness which includes larger areas of the limbs. Soon, they have difficulty with balance. Men may experience impotency due to damage to the nerves in the hip region
  • Nephropathy: This refers to damage to the kidney and its filtration unit (nephrons). This in the most common cause of kidney failure in the world and is a frequent reason for long term dialysis and kidney transplant.
  • Diabetic Ketoacidosis: Some patients with type 1 DM may present as an emergency with abdominal pain, nausea and vomiting and abnormal mental state, along with the finding of a highly elevated blood sugar. This occurs due to the absence of insulin leading to abnormal metabolism of glucose and fats in the body. This condition requires admission to a hospital with monitored care till recovery followed by a long term plan to manage the DM.
  • Hypoglycemia: This is a complication associated with the treatment of Diabetes following use of insulin or intake of drugs which bring down the blood sugar too much.
  • Increased risk of infections: These patients have an increased risk of urinary tract infections, respiratory infections and skin infections. They also suffer from poor wound healing.

• Diagnosis of Diabetes Mellitus

  As the symptoms of diabetes are variable and often occur only after the disease has been present for a long time, there are recommendations in place for screening individuals at high risk for Diabetes. The American Diabetes Association has recommended screening for the following groups:

  • Any person having a BMI (body mass index) over 25 (for people of Asian origin, BMI over 23) should be screened for diabetes as obesity increases the risk of insulin resistance.
  • Everyone over the age of 45 years: All individuals should be screened after the age of 45 years and if confirmed negative, should be tested every 3 years.
  • All women with history of gestational diabetes should be screened every 3 years
  • Patients who have been diagnosed with prediabetes should be tested annually. Pre-diabetes refers to when a person has high blood sugars which are however below the cut-off for diagnosing diabetes mellitus.

• Tests Performed to Diagnose Diabetes

  • Random Blood Glucose Test: This is a blood test taken at any time of the day to test for blood glucose. A value over 200 milligram/decilitre (mg/dl) at any time or over 11.1 millimoles/litre (mmol/L) is diagnostic of Diabetes
  • Fasting Blood Glucose Test: This test is performed in the morning on an empty stomach after fasting overnight. Normal blood sugar is defines as less than 100 mg/dl (5.6mmol/L). Levels between 100 and 125 mg/dl (5.6 to 6.9 mmol/L) is considered to be prediabetic. A fasting blood sugar level equal to or higher than 126 mg/dl (7 mmol/L) on 2 separate occasions is diagnostic of Diabetes Mellitus.
  • Oral Glucose Tolerance Test (OGTT): This involves measuring blood glucose levels before and after ingestion of a defined glucose load orally. The individuals has to fast overnight prior to the test. A fasting blood glucose is first obtained following which a glucose liquid is to be drunk. The blood glucose is then measured one hour and 2 hours afterwards. At 2 hours, a blood sugar over 200 mg/dl (11.1 mmol/L) is considered to be diabetic. A level less than 140 mg/dl (7.8 mmol/L) is normal. Anything in between suggests prediabetes.
  • HbA1c Testing: this is a blood test to look for glycated haemoglobin. When there is a prolonged elevation of blood glucose, it binds to the haemoglobin in red blood cells. As red cells have a life span of 120 days, the HbA1C levels can provide an estimate of blood sugar control over 3 months. Having a value less than 5.7% is normal. An A1C level over 6.5% on 2 separate occasions is suggestive of diabetes and anything in between indicates prediabetes. A person’s A1C level will be one of the main determining health factors in qualifying for life insurance with type 2 diabetes.

Management of Diabetes

Managing Diabetes involves many levels of care including lifestyle changes, blood sugar control and certain surgical options. In addition, these patients should regularly have their blood sugars checked. Especially those with type 1 DM on insulin should have a way to test blood sugars at home using a glucometer. Here, one thing that can help these patients is Klinio, a health app, presents a comprehensive choice for effectively monitoring and managing diabetes and prediabetes. It encompasses features such as a meal planner, detailed progress counter, and beginner workouts that require no equipment, all aimed at facilitating lifestyle changes crucial in managing or preventing diabetes.

Lifestyle Modification

• Changes in Diet: A low carbohydrate diet is recommended with intake of more fruits and vegetables. Food with trans-fat is to be avoided completely.
• Physical Exercise: Moderate exercise such as brisk walking or aerobic exercise) of a minimum of 150 minutes per week or intensive exercise of 75 minutes per week is recommended and has been shown to control insulin resistance.
• Weight reduction: Weight loss through exercise and diet changes can help to control sugars even without medication in early stages

Medications

• Insulin: Many different formulations of the insulin hormone have been developed with different duration of action. These are all injected into the subcutaneous tissue. Patients with type 1 DM require lifelong insulin to stay healthy.
• Oral medications: Many classes of drugs are available to take orally to control blood sugars and work through many different ways. Metformin is usually the first line drug prescribed for patients newly diagnosed with type 2 DM and it helps control insulin resistance.

Surgery

• Pancreatic transplantation: Patients with type 1 DM may benefit from transplantation of the pancreas or of the islet cells (including beta cells). However, there are many risks associated with it and the treatment may not prove to be successful all the time.
• Bariatric Surgery: This is a surgery done for weight reduction where the size of the stomach is reduced, either through bypassing it or by partially removing it. Patients with type 2 DM who are obese (BMI over 35) may benefit from it, occasionally even showing return of blood sugar to normal levels. However, patients often frequently revert to having elevated blood sugars despite control of weight and diet.

Management of Hypoglycemia

Patients with DM are at a risk of falls in glucose when on therapy. It is important to be aware of the symptoms of low blood glucose such as sweating, tremors, racing heartbeat and feeling faint. The sugars should be tested immediately if possible. The person should always carry some sugary drink or snacks with them to take in the case of suspected hypoglycemia.

Prognosis of Diabetes

Diabetes is a chronic disease which lasts lifelong. It can be managed very well with proper care and control of diet, regular exercise and disciplined intake of medications or insulin. Failure to control sugars can lead to progression of DM to life threatening complications, the most common one being Heart attacks and stroke.

References:

• Kasper DL, et al., eds. Diabetes mellitus: Diagnosis, classification and pathophysiology. In: Harrison’s Principles of Internal Medicine. 19th ed. New York, N.Y.: McGraw-Hill Education; 2015.

• Symptoms & Causes of Diabetes | NIDDK [Internet]. National Institute of Diabetes and Digestive and Kidney Diseases. [cited 2018 Aug 2].
• Drive ADA 2451 C, Arlington S 900, Va 22202 1-800-Diabetes. Diagnosing Diabetes and Learning About Prediabetes [Internet]. American Diabetes Association. [cited 2018 Aug 2].