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There are many types of diabetes,[3] the most common of which are:
Type 1 diabetes: results from the body's failure to produce insulin, and presently
requires the person to inject insulin.
Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use
insulin properly, sometimes combined with an absolute insulin deficiency.
Gestational diabetes: is when pregnant women, who have never had diabetes before,
have a high blood glucose level during pregnancy. It may precede development of type 2
DM.
Other forms of diabetes mellitus include congenital diabetes, which is due to genetic defects of
insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high doses of
glucocorticoids, and several forms of monogenic diabetes.
All forms of diabetes have been treatable since insulin became medically available in 1921, and
type 2 diabetes can be controlled with tablets, but it is chronic condition that usually cannot be
cured. Pancreas transplants have been tried with limited success in type 1 DM; gastric bypass
surgery has been successful in many with morbid obesity and type 2 DM; and gestational
diabetes usually resolves after delivery. Diabetes without proper treatments can cause many
complications. Acute complications include hypoglycemia, diabetic ketoacidosis, or nonketotic
hyperosmolar coma. Serious long-term complications include cardiovascular disease, chronic
renal failure, retinal damage. Adequate treatment of diabetes is thus important, as well as blood
pressure control and lifestyle factors such as smoking cesation and maintaining a healthy body
weight.
As of 2000 at least 171 million people worldwide suffer from diabetes, or 2.8% of the
population.[4] Type 2 diabetes is by far the most common, affecting 90 to 95% of the U.S.
diabetes population.[5]
Contents
[hide]
1 Classification
o 1.1 Type 1 diabetes
o 1.2 Type 2 diabetes
o 1.3 Gestational diabetes
o 1.4 Other types
2 Signs and symptoms
3 Causes
o 3.1 Lifestyle
o 3.2 Medical conditions
o 3.3 Genetics
4 Pathophysiology
5 Diagnosis
6 Screening
7 Prevention
o 7.1 Type 1
o 7.2 Type 2
8 Management
o 8.1 Lifestyle modifications
o 8.2 Medications
o 8.3 Support
9 Prognosis
10 Epidemiology
11 History
12 Society and culture
13 References
14 External links
Classification
Most cases of diabetes mellitus fall into the three broad categories of type 1 or type 2 and
gestational diabetes. A few other types are described.
The term diabetes, without qualification, usually refers to diabetes mellitus, which roughly
translates to excessive sweet urine (known as "glycosuria"). Several rare conditions are also
named diabetes. The most common of these is diabetes insipidus in which large amounts of urine
are produced (polyuria), which is not sweet (insipidus meaning "without taste" in Latin).
The term "type 1 diabetes" has replaced several former terms, including childhood-onset
diabetes, juvenile diabetes, and insulin-dependent diabetes mellitus (IDDM). Likewise, the term
"type 2 diabetes" has replaced several former terms, including adult-onset diabetes, obesity-
related diabetes, and non-insulin-dependent diabetes mellitus (NIDDM). Beyond these two
types, there is no agreed-upon standard nomenclature. Various sources have defined "type 3
diabetes" as: gestational diabetes,[6] insulin-resistant type 1 diabetes (or "double diabetes"), type 2
diabetes which has progressed to require injected insulin, and latent autoimmune diabetes of
adults (or LADA or "type 1.5" diabetes)[7]
Type 1 diabetes
Type 1 diabetes mellitus is characterized by loss of the insulin-producing beta cells of the islets
of Langerhans in the pancreas leading to insulin deficiency. This type of diabetes can be further
classified as immune-mediated or idiopathic. The majority of type 1 diabetes is of the immune-
mediated nature, where beta cell loss is a T-cell mediated autoimmune attack.[2] There is no
known preventive measure against type 1 diabetes, which causes approximately 10% of diabetes
mellitus cases in North America and Europe. Most affected people are otherwise healthy and of a
healthy weight when onset occurs. Sensitivity and responsiveness to insulin are usually normal,
especially in the early stages. Type 1 diabetes can affect children or adults but was traditionally
termed "juvenile diabetes" because it represents a majority of the diabetes cases in children.
Type 2 diabetes
Type 2 diabetes mellitus is characterized by insulin resistance which may be combined with
relatively reduced insulin secretion. The defective responsiveness of body tissues to insulin is
believed to involve the insulin receptor. However, the specific defects are not known. Diabetes
mellitus due to a known defect are classified separately. Type 2 diabetes is the most common
type.
In the early stage of type 2 diabetes, the predominant abnormality is reduced insulin sensitivity.
At this stage hyperglycemia can be reversed by a variety of measures and medications that
improve insulin sensitivity or reduce glucose production by the liver. As the disease progresses,
the impairment of insulin secretion occurs, and therapeutic replacement of insulin may
sometimes become necessary in certain patients.[citation needed]
Gestational diabetes
Gestational diabetes mellitus (GDM) resembles type 2 diabetes in several respects, involving a
combination of relatively inadequate insulin secretion and responsiveness. It occurs in about
2%–5% of all pregnancies and may improve or disappear after delivery. Gestational diabetes is
fully treatable but requires careful medical supervision throughout the pregnancy. About 20%–
50% of affected women develop type 2 diabetes later in life.
Even though it may be transient, untreated gestational diabetes can damage the health of the fetus
or mother. Risks to the baby include macrosomia (high birth weight), congenital cardiac and
central nervous system anomalies, and skeletal muscle malformations. Increased fetal insulin
may inhibit fetal surfactant production and cause respiratory distress syndrome.
Hyperbilirubinemia may result from red blood cell destruction. In severe cases, perinatal death
may occur, most commonly as a result of poor placental perfusion due to vascular impairment.
Labor induction may be indicated with decreased placental function. A cesarean section may be
performed if there is marked fetal distress or an increased risk of injury associated with
macrosomia, such as shoulder dystocia.
A 2008 study completed in the U.S. found that more American women are entering pregnancy
with preexisting diabetes. In fact the rate of diabetes in expectant mothers has more than doubled
in the past 6 years.[8] This is particularly problematic as diabetes raises the risk of complications
during pregnancy, as well as increasing the potential that the children of diabetic mothers will
also become diabetic in the future.
Other types
Pre-diabetes indicates a condition that occurs when a person's blood glucose levels are higher
than normal but not high enough for a diagnosis of type 2 diabetes. Many people destined to
develop type 2 diabetes spend many years in a state of pre-diabetes which has been termed
"America's largest healthcare epidemic,"[9]:10–11.
Some cases of diabetes are caused by the body's tissue receptors not responding to insulin (even
when insulin levels are normal, which is what separates it from type 2 diabetes); this form is very
uncommon. Genetic mutations (autosomal or mitochondrial) can lead to defects in beta cell
function. Abnormal insulin action may also have been genetically determined in some cases.
Any disease that causes extensive damage to the pancreas may lead to diabetes (for example,
chronic pancreatitis and cystic fibrosis). Diseases associated with excessive secretion of insulin-
antagonistic hormones can cause diabetes (which is typically resolved once the hormone excess
is removed). Many drugs impair insulin secretion and some toxins damage pancreatic beta cells.
The ICD-10 (1992) diagnostic entity, malnutrition-related diabetes mellitus (MRDM or
MMDM, ICD-10 code E12), was deprecated by the World Health Organization when the current
taxonomy was introduced in 1999.[10]
The classical symptoms of DM are polyuria (frequent urination), polydipsia (increased thirst)
and polyphagia (increased hunger).[11] Symptoms may develop quite rapidly (weeks or months)
in type 1 diabetes, particularly in children. However, in type 2 diabetes symptoms usually
develop much more slowly and may be subtle or completely absent. Type 1 diabetes may also
cause a rapid yet significant weight loss (despite normal or even increased eating) and irreducible
mental fatigue. All of these symptoms except weight loss can also manifest in type 2 diabetes in
patients whose diabetes is poorly controlled, although unexplained weight loss may be
experienced at the onset of the disease. Final diagnosis is made by measuring the blood glucose
concentration.
When the glucose concentration in the blood is raised beyond its renal threshold (about
10 mmol/L, although this may be altered in certain conditions, such as pregnancy), reabsorption
of glucose in the proximal renal tubuli is incomplete, and part of the glucose remains in the urine
(glycosuria). This increases the osmotic pressure of the urine and inhibits reabsorption of water
by the kidney, resulting in increased urine production (polyuria) and increased fluid loss. Lost
blood volume will be replaced osmotically from water held in body cells and other body
compartments, causing dehydration and increased thirst.
Prolonged high blood glucose causes glucose absorption, which leads to changes in the shape of
the lenses of the eyes, resulting in vision changes; sustained sensible glucose control usually
returns the lens to its original shape. Blurred vision is a common complaint leading to a diabetes
diagnosis; type 1 should always be suspected in cases of rapid vision change, whereas with
type 2 change is generally more gradual, but should still be suspected.
Patients (usually with type 1 diabetes) may also initially present with diabetic ketoacidosis
(DKA), an extreme state of metabolic dysregulation characterized by the smell of acetone on the
patient's breath; a rapid, deep breathing known as Kussmaul breathing; polyuria; nausea;
vomiting and abdominal pain; and any of many altered states of consciousness or arousal (such
as hostility and mania or, equally, confusion and lethargy). In severe DKA, coma may follow,
progressing to death. Diabetic ketoacidosis is a medical emergency and requires immediate
hospitalization.
A rarer but equally severe possibility is hyperosmolar nonketotic state, which is more common in
type 2 diabetes and is mainly the result of dehydration due to loss of body water. Often, the
patient has been drinking extreme amounts of sugar-containing drinks, leading to a vicious circle
in regard to the water loss.
A number of skin rashes can occur in diabetes that are collectively known as diabetic
dermadromes.
Causes
Type 2 diabetes is determined primarily by lifestyle factors and genes.[12]
Lifestyle
A number of lifestyle factors are known to be important to the development of type 2 diabetes. In
one study, those who had high levels of physical activity, a healthy diet, did not smoke, and
consumed alcohol in moderation had an 82% lower rate of diabetes. When a normal weight was
included the rate was 89% lower. In this study a healthy diet was defined as one high in fiber,
with a high polyunsaturated to saturated fat ratio, and a lower mean glycemic index.[13] Obesity
has been found to contribute to approximately 55% type 2 diabetes,[14] and decreasing
consumption of saturated fats and trans fatty acids while replacing them with unsaturated fats
may decrease the risk.[12] The increased rate of childhood obesity in between the 1960s and 2000s
is believed to have lead to the increase in type 2 diabetes in children and adolescents.[15]
Environmental toxins may contribute to recent increases in the rate of type 2 diabetes. A positive
correlation has been found between the concentration in the urine of bisphenol A, a constituent
of some plastics, and the incidence of type 2 diabetes.[16]
Medical conditions
Subclinical Cushing's syndrome (cortisol excess) may be associated with DM type 2.[17] The
percentage of subclinical Cushing's syndrome in the diabetic population is about 9%.[18] Diabetic
patients with a pituitary microadenoma can improve insulin sensitivity by removal of these
microadenomas.[19]
Hypogonadism is often associated with cortisol excess, and testosterone deficiency is also
associated with diabetes mellitus type 2,[20][21] even if the exact mechanism by which testosterone
improve insulin sensitivity is still not known.
Genetics
Both type 1 and type 2 diabetes are partly inherited. Type 1 diabetes may be triggered by certain
infections, with some evidence pointing at Coxsackie B4 virus. There is a genetic element in
individual susceptibility to some of these triggers which has been traced to particular HLA
genotypes (i.e., the genetic "self" identifiers relied upon by the immune system). However, even
in those who have inherited the susceptibility, type 1 diabetes mellitus seems to require an
environmental trigger.
There is a stronger inheritance pattern for type 2 diabetes. Those with first-degree relatives with
type 2 have a much higher risk of developing type 2, increasing with the number of those
relatives. Concordance among monozygotic twins is close to 100%, and about 25% of those with
the disease have a family history of diabetes. Genes significantly associated with developing
type 2 diabetes, include TCF7L2, PPARG, FTO, KCNJ11, NOTCH2, WFS1, CDKAL1,
IGF2BP2, SLC30A8, JAZF1, and HHEX.[22] KCNJ11 (potassium inwardly rectifying channel,
subfamily J, member 11), encodes the islet ATP-sensitive potassium channel Kir6.2, and
TCF7L2 (transcription factor 7–like 2) regulates proglucagon gene expression and thus the
production of glucagon-like peptide-1.[2] Moreover, obesity (which is an independent risk factor
for type 2 diabetes) is strongly inherited.[23]
Various hereditary conditions may feature diabetes, for example myotonic dystrophy and
Friedreich's ataxia. Wolfram's syndrome is an autosomal recessive neurodegenerative disorder
that first becomes evident in childhood. It consists of diabetes insipidus, diabetes mellitus, optic
atrophy, and deafness, hence the acronym DIDMOAD.[25]
Gene expression promoted by a diet of fat and glucose as well as high levels of inflammation
related cytokines found in the obese results in cells that "produce fewer and smaller
mitochondria than is normal," and are thus prone to insulin resistance.[26]
Pathophysiology
This section does not cite any references or sources.
Please help improve this article by adding citations to reliable sources. Unsourced material may be
challenged and removed. (November 2009)
The fluctuation of blood sugar (red) and the sugar-lowering hormone insulin (blue) in humans
during the course of a day with three meals. One of the effects of a sugar-rich vs a starch-rich
meal is highlighted.
Mechanism of insulin release in normal pancreatic beta cells. Insulin production is more or less
constant within the beta cells, irrespective of blood glucose levels. It is stored within vacuoles
pending release, via exocytosis, which is primarily triggered by food, chiefly food containing
absorbable glucose. The chief trigger is a rise in blood glucose levels after eating
Insulin is the principal hormone that regulates uptake of glucose from the blood into most cells
(primarily muscle and fat cells, but not central nervous system cells). Therefore deficiency of
insulin or the insensitivity of its receptors plays a central role in all forms of diabetes mellitus.
Humans are capable of digesting some carbohydrates, in particular those most common in food;
starch, and some disaccharides such as sucrose, are converted within a few hours to simpler
forms most notably the monosaccharide glucose, the principal carbohydrate energy source used
by the body. The most significant exceptions are fructose, most disaccharides (except sucrose
and in some people lactose), and all more complex polysaccharides, with the outstanding
exception of starch. The rest are passed on for processing by gut flora largely in the colon.
Insulin is released into the blood by beta cells (β-cells), found in the Islets of Langerhans in the
pancreas, in response to rising levels of blood glucose, typically after eating. Insulin is used by
about two-thirds of the body's cells to absorb glucose from the blood for use as fuel, for
conversion to other needed molecules, or for storage.
Insulin is also the principal control signal for conversion of glucose to glycogen for internal
storage in liver and muscle cells. Lowered glucose levels result both in the reduced release of
insulin from the beta cells and in the reverse conversion of glycogen to glucose when glucose
levels fall. This is mainly controlled by the hormone glucagon which acts in the opposite manner
to insulin. Glucose thus forcibly produced from internal liver cell stores (as glycogen) re-enters
the bloodstream; muscle cells lack the necessary export mechanism. Normally liver cells do this
when the level of insulin is low (which normally correlates with low levels of blood glucose).
Higher insulin levels increase some anabolic ("building up") processes such as cell growth and
duplication, protein synthesis, and fat storage. Insulin (or its lack) is the principal signal in
converting many of the bidirectional processes of metabolism from a catabolic to an anabolic
direction, and vice versa. In particular, a low insulin level is the trigger for entering or leaving
ketosis (the fat burning metabolic phase).
If the amount of insulin available is insufficient, if cells respond poorly to the effects of insulin
(insulin insensitivity or resistance), or if the insulin itself is defective, then glucose will not have
its usual effect so that glucose will not be absorbed properly by those body cells that require it
nor will it be stored appropriately in the liver and muscles. The net effect is persistent high levels
of blood glucose, poor protein synthesis, and other metabolic derangements, such as acidosis.
Diagnosis
Main articles: Glycosylated hemoglobin and Glucose tolerance test
mmol/l(mg/dl) mmol/l(mg/dl)
Patients with fasting glucose levels from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) are considered to
have impaired fasting glucose. Patients with plasma glucose at or above 140 mg/dL
(7.8 mmol/L), but not over 200 mg/dL (11.1 mmol/L), two hours after a 75 g oral glucose load
are considered to have impaired glucose tolerance. Of these two pre-diabetic states, the latter in
particular is a major risk factor for progression to full-blown diabetes mellitus as well as
cardiovascular disease.[30]
Screening
Diabetes screening is recommended for many people at various stages of life, and for those with
any of several risk factors. The screening test varies according to circumstances and local policy,
and may be a random blood glucose test, a fasting blood glucose test, a blood glucose test two
hours after 75 g of glucose, or an even more formal glucose tolerance test. Many healthcare
providers recommend universal screening for adults at age 40 or 50, and often periodically
thereafter. Earlier screening is typically recommended for those with risk factors such as obesity,
family history of diabetes, high-risk ethnicity (Hispanic, Native American, Afro-Caribbean,
Pacific Islander, or Māori).[31][32]
Many medical conditions are associated with diabetes and warrant screening. A partial list
includes: subclinical Cushing's syndrome,[17] testosterone deficiency,[20] high blood pressure,
elevated cholesterol levels[citation needed], coronary artery disease[citation needed], past gestational diabetes,
polycystic ovary syndrome, chronic pancreatitis, fatty liver, hemochromatosis[citation needed], cystic
fibrosis, several mitochondrial neuropathies and myopathies (such as MIDD), myotonic
dystrophy, Friedreich's ataxia, some of the inherited forms of neonatal hyperinsulinism. The risk
of diabetes is higher with chronic use of several medications, including long term corticosteroids,
some chemotherapy agents (especially L-asparaginase), as well as some of the antipsychotics
and mood stabilizers (especially phenothiazines and some atypical antipsychotics).
People with a confirmed diagnosis of diabetes are tested routinely for complications. This
includes yearly urine testing for microalbuminuria and examination of the retina of the eye for
retinopathy.
Prevention
Type 1
Type 1 diabetes risk is known to depend upon a genetic predisposition based on HLA types
(particularly types DR3 and DR4), an unknown environmental trigger (suspected to be an
infection, although none has proven definitive in all cases), and an uncontrolled autoimmune
response that attacks the insulin producing beta cells.[33] Some research has suggested that
breastfeeding decreased the risk in later life;[34][35] various other nutritional risk factors are being
studied, but no firm evidence has been found.[36] Giving children 2000 IU of Vitamin D during
their first year of life is associated with reduced risk of type 1 diabetes, though the causal
relationship is obscure.[37]
Children with antibodies to beta cell proteins (i.e. at early stages of an immune reaction to them)
but no overt diabetes, and treated with vitamin B-3 (niacin), had less than half the diabetes onset
incidence in a 7-year time span as did the general population, and an even lower incidence
relative to those with antibodies as above, but who received no vitamin B3.[38]
Type 2
Lifestyle
Type 2 diabetes risk can be reduced in many cases by making changes in diet and increasing
physical activity.[39][40][41] The American Diabetes Association (ADA) recommends maintaining a
healthy weight, getting at least 2½ hours of exercise per week (several brisk sustained walks
appear sufficient), having a modest fat intake, and eating sufficient fiber (e.g., from whole
grains). The ADA does not recommend alcohol consumption as a preventive, but it is interesting
to note that moderate alcohol intake may reduce the risk (though heavy consumption absolutely
and clearly increases damage to bodily systems significantly); a similarly confused connection
between low dose alcohol consumption and heart disease is termed the French Paradox.[citation
needed]
There is inadequate evidence that eating foods of low glycemic index is clinically helpful despite
recommendations and suggested diets emphasizing this approach.[42]
Diets that are very low in saturated fats reduce the risk of becoming insulin resistant and
diabetic.[43][44] Study group participants whose "physical activity level and dietary, smoking, and
alcohol habits were all in the low-risk group had an 82% lower incidence of diabetes."[13] In
another study of dietary practice and incidence of diabetes, "foods rich in vegetable oils,
including non-hydrogenated margarines, nuts, and seeds, should replace foods rich in saturated
fats from meats and fat-rich dairy products. Consumption of partially hydrogenated fats should
be minimized."[12]
There are numerous studies which suggest connections between some aspects of Type II diabetes
with ingestion of certain foods or with some drugs. Breastfeeding may also be associated with
the prevention of type 2 of the disease in mothers.[45]
Medications
Some studies have shown delayed progression to diabetes in predisposed patients through
prophylactic use of metformin,[40] rosiglitazone,[46] or valsartan.[47] In patients on
hydroxychloroquine for rheumatoid arthritis, incidence of diabetes was reduced by 77% though
causal mechanisms are unclear.[48] Lifestyle interventions are however more effective than
metformin at preventing diabetes regardless of weightloss.[49]
Management
Main article: Diabetes management
Lifestyle modifications
There are roles for patient education, dietetic support, sensible exercise, with the goal of keeping
both short-term and long-term blood glucose levels within acceptable bounds. In addition, given
the associated higher risks of cardiovascular disease, lifestyle modifications are recommended to
control blood pressure[50] in patients with hypertension, cholesterol in those with dyslipidmia, as
well as exercising more, smoking less or ideally not at all, consuming a recommended diet[citation
needed]
. Patients with foot problems are also recommended to wear diabetic socks[citation needed], and
possibly diabetic shoes[citation needed].
Medications
Oral medications
Main article: Anti-diabetic drug
Insulin
Main article: Insulin therapy
Type 1 treatments usually include combinations of regular or NPH insulin, and/or synthetic
insulin analogs.
Support
In countries using a general practitioner system, such as the United Kingdom, care may take
place mainly outside hospitals, with hospital-based specialist care used only in case of
complications, difficult blood sugar control, or research projects. In other circumstances, general
practitioners and specialists share care of a patient in a team approach. Optometrists,
podiatrists/chiropodists, dietitians, physiotherapists, nursing specialists (e.g., DSNs (Diabetic
Specialist Nurse)), nurse practitioners, or Certified Diabetes Educators, may jointly provide
multidisciplinary expertise. In countries where patients must provide for their own health care
(e.g. in the US, and in much of the undeveloped world).
Peer support links people living with diabetes. Within peer support, people with a common
illness share knowledge and experience that others, including many health workers, do not have.
Peer support is frequent, ongoing, accessible and flexible and can take many forms—phone calls,
text messaging, group meetings, home visits, and even grocery shopping. It complements and
enhances other health care services by creating the emotional, social and practical assistance
necessary for managing disease and staying healthy.
Prognosis
Main article: Prognosis of diabetes mellitus
Patient education, understanding, and participation is vital since the complications of diabetes are
far less common and less severe in people who have well-managed blood sugar levels.[51][52]
Wider health problems may accelerate the deleterious effects of diabetes. These include
smoking, elevated cholesterol levels, obesity, high blood pressure, and lack of regular exercise.
According to one study, women with high blood pressure (hypertension) were three times more
likely to develop type 2 diabetes as compared with women with optimal BP after adjusting for
various factors such as age, ethnicity, smoking, alcohol intake, body mass index (BMI), exercise,
family history of diabetes, etc.[53] The study was conducted by researchers from the Brigham and
Women’s Hospital, Harvard Medical School and the Harvard School of Public Health, USA,
who followed over 38,000 female health professionals for ten years.
Except in the case of type 1 diabetes, which always requires insulin replacement, the way type 2
diabetes is managed may change with age. Insulin production decreases because of age-related
impairment of pancreatic beta cells. Additionally, insulin resistance increases because of the loss
of lean tissue and the accumulation of fat, particularly intra-abdominal fat, and the decreased
tissue sensitivity to insulin. Glucose tolerance progressively declines with age, leading to a high
prevalence of type 2 diabetes and postchallenge hyperglycemia in the older population.[54] Age-
related glucose intolerance in humans is often accompanied by insulin resistance, but circulating
insulin levels are similar to those of younger people.[55] Treatment goals for older patients with
diabetes vary with the individual, and take into account health status, as well as life expectancy,
level of dependence, and willingness to adhere to a treatment regimen.[56] Glycated hemoglobin is
better than fasting glucose for determining risks of cardiovascular disease and death from any
cause.[57]
Epidemiology
Prevalence of diabetes worldwide in 2000 (per 1000 inhabitants). World average was 2.8%.
no data ≤ 7.5 7.5–15 15–22.5 22.5–30 30–37.5 37.5–45 45–52.5 52.5–60 60–
67.5 67.5–75 75–82.5 ≥ 82.5
In 2000, according to the World Health Organization, at least 171 million people worldwide
suffer from diabetes, or 2.8% of the population.[4] Its incidence is increasing rapidly, and it is
estimated that by 2030, this number will almost double.[4] Diabetes mellitus occurs throughout
the world, but is more common (especially type 2) in the more developed countries. The greatest
increase in prevalence is, however, expected to occur in Asia and Africa, where most patients
will probably be found by 2030.[4] The increase in incidence of diabetes in developing countries
follows the trend of urbanization and lifestyle changes, perhaps most importantly a "Western-
style" diet. This has suggested an environmental (i.e., dietary) effect, but there is little
understanding of the mechanism(s) at present, though there is much speculation, some of it most
compellingly presented.[4]
For at least 20 years, diabetes rates in North America have been increasing substantially. In 2008
there were about 24 million people with diabetes in the United States alone, from those 5.7
million people remain undiagnosed. Other 57 million people are estimated to have pre-diabetes.
[59]
The Centers for Disease Control has termed the change an epidemic.[60] The National Diabetes
Information Clearinghouse estimates that diabetes costs $132 billion in the United States alone
every year. About 5%–10% of diabetes cases in North America are type 1, with the rest being
type 2. The fraction of type 1 in other parts of the world differs. Most of this difference is not
currently understood. The American Diabetes Association cite the 2003 assessment of the
National Center for Chronic Disease Prevention and Health Promotion (Centers for Disease
Control and Prevention) that 1 in 3 Americans born after 2000 will develop diabetes in their
lifetime.[61][62]
Indigenous populations in first world countries have a higher prevalence and increasing
incidence of diabetes than their corresponding non-indigenous populations. In Australia the age-
standardised prevalence of self-reported diabetes in Indigenous Australians is almost 4 times that
of non-indigenous Australians.[64] Preventative community health programs such as Sugar Man
(diabetes education) are showing some success in tackling this problem.
History
The term diabetes (Greek: διαβήτης, diabētēs) was coined by Aretaeus of Cappadocia. It was
derived from the Greek verb διαβαίνειν, diabaínein, itself formed from the prefix dia-, "across,
apart," and the verb bainein, "to walk, stand." The verb diabeinein meant "to stride, walk, or
stand with legs asunder"; hence, its derivative diabētēs meant "one that straddles," or specifically
"a compass, siphon." The sense "siphon" gave rise to the use of diabētēs as the name for a
disease involving the discharge of excessive amounts of urine. Diabetes is first recorded in
English, in the form diabete, in a medical text written around 1425. In 1675, Thomas Willis
added the word mellitus, from the Latin meaning "honey", a reference to the sweet taste of the
urine. This sweet taste had been noticed in urine by the ancient Greeks, Chinese, Egyptians,
Indians, and Persians. In 1776, Matthew Dobson confirmed that the sweet taste was because of
an excess of a kind of sugar in the urine and blood of people with diabetes.[65]
Diabetes mellitus appears to have been a death sentence in the ancient era. Hippocrates makes no
mention of it, which may indicate that he felt the disease was incurable. Aretaeus did attempt to
treat it but could not give a good prognosis; he commented that "life (with diabetes) is short,
disgusting and painful."[66]
Sushruta (6th century BCE) identified diabetes and classified it as Medhumeha.[67] He further
identified it with obesity and sedentary lifestyle, advising exercises to help "cure" it.[67] The
ancient Indians tested for diabetes by observing whether ants were attracted to a person's urine,
and called the ailment "sweet urine disease" (Madhumeha). The Korean, Chinese, and Japanese
words for diabetes are based on the same ideographs (糖尿病) which mean "sugar urine disease".
The endocrine role of the pancreas in metabolism, and indeed the existence of insulin, was not
further clarified until 1921, when Sir Frederick Grant Banting and Charles Herbert Best repeated
the work of Von Mering and Minkowski, and went further to demonstrate they could reverse
induced diabetes in dogs by giving them an extract from the pancreatic islets of Langerhans of
healthy dogs.[71] Banting, Best, and colleagues (especially the chemist Collip) went on to purify
the hormone insulin from bovine pancreases at the University of Toronto. This led to the
availability of an effective treatment—insulin injections—and the first patient was treated in
1922. For this, Banting and laboratory director MacLeod received the Nobel Prize in Physiology
or Medicine in 1923; both shared their Prize money with others in the team who were not
recognized, in particular Best and Collip. Banting and Best made the patent available without
charge and did not attempt to control commercial production. Insulin production and therapy
rapidly spread around the world, largely as a result of this decision. Banting is honored by World
Diabetes Day which is held on his birthday, November 14.
The distinction between what is now known as type 1 diabetes and type 2 diabetes was first
clearly made by Sir Harold Percival (Harry) Himsworth, and published in January 1936.[72]
Despite the availability of treatment, diabetes has remained a major cause of death. For instance,
statistics reveal that the cause-specific mortality rate during 1927 amounted to about 47.7 per
100,000 population in Malta.[73]
In 1980, U.S. biotech company Genentech developed human insulin. The insulin is isolated from
genetically altered bacteria (the bacteria contain the human gene for synthesizing human insulin),
which produce large quantities of insulin. Scientists then purify the insulin and distribute it to
pharmacies for use by diabetes patients.
Several countries established more and less successful national diabetes programmes to improve
treatment of the disease.[78]
A study shows that diabetic patients with neuropathic symptoms such as numbness or tingling in
feet or hands are twice as likely to be unemployed as those without the symptoms.[79]
References
1. ^ (17 March 2006)"Diabetes Blue Circle Symbol". International Diabetes Federation. 17 March
2006. http://www.diabetesbluecircle.org.
2. ^ a b c Rother KI (April 2007). "Diabetes treatment—bridging the divide". The New England
Journal of Medicine 356 (15): 1499–501. doi:10.1056/NEJMp078030. PMID 17429082.
3. ^ a b L M Tierney, S J McPhee, M A Papadakis (2002). Current medical Diagnosis & Treatment.
International edition. New York: Lange Medical Books/McGraw-Hill. pp. 1203–15. ISBN 0-07-
137688-7.
4. ^ a b c d e Wild S, Roglic G, Green A, Sicree R, King H (May 2004). "Global prevalence of
diabetes: estimates for 2000 and projections for 2030". Diabetes Care 27 (5): 1047–53.
doi:10.2337/diacare.27.5.1047. PMID 15111519.
5. ^ "Type 2 Diabetes Overview". Web MD. http://diabetes.webmd.com/guide/type-2-diabetes.
Mirror [max.1gb.ru [file /eng/learn/ib005.shtml [at Fri, 06 Feb 2009 06:38:25 GMT]]]
Keywords: a case history, an endocrinology, diabetum melitous, 1 type, the serious form,
subindemnification, an angioretinopathia, an angiopathia of the bottom extremities, a distal
sensory polyneuropatia
the DIAGNOSIS
diabetum melitous, 1 type, the serious form, subindemnification. An
angioretinopathia. An angiopathia of the bottom extremities. A distal sensory
polyneuropatia. Trophic infringements of calcaneal areas of both stop. Amputating
stump V of a finger left stops, III finger of the left arm. A nephropathy III. A
symptomatic hypertonia.
the EPICRISIS
***** ********** **************, 46 flying has acted 15.07 with complaints to pains, a
burning sensation, a pricking in ikronozhnyh muscles, presence on both legs is
long not healing purulent wounds. 5-th finger on left stop and 3-rd - on the left
brush are amputated. Marks dryness in a mouth, headaches, a giddiness, a
hymenium before eyes. Strong delicacy. It is sick of a sugar diabetes during 21-22
flying. The flying was ill at 23-25, is acute, has lost in weight *gt; 40 kg. At initial
hospitalization the level of a glucose in a blood has made 23 mmole/l. Constantly
accepts preparations of an insulin. For the last 3 years the condition has worsened:
trophic ulcers have appeared, vision has worsened, headaches and rising of a
blood pressure up to 240 and 130 have appeared. Objectively: presence on both
stops in area achille tendons of trophic ulcers with yellowish purulent separated.
The expressed tachycardia (pulse about 100-105 in one minute). The patient is
acyanotic, the plentiful diaphoresis is observed. The smell of an acetone is not
present. Level of a glucose of a blood at 11.00 (15.07) - 23,8 mmole/l.
the infection of wounds by a staphylococcal flora, sensitive to erythromycin,
Oxacillinum, Cefazolinum Is revealed. The expressed proteinuria (2,3). On an
electrocardiogram - attributes of ischemic changes of a forward wall and a septum
of heart. On the basis of an anamnesis, inquiry, the inspection, the given laboratory
and tool methods of treatment, the diagnosis is put: diabetum melitous, 1 type, the
serious form, subindemnification. An angioretinopathia. An angiopathia of the
bottom extremities. A distal sensory polyneuropatia. Trophic infringements of
calcaneal areas of both stop. Amputating stump V of a finger left stops, III finger of
the left arm. A nephropathy III. A symptomatic hypertonia. A fatty dystrophia of a
liver, a dyskinesia of biliferous ways. An ischemic disease, a stenocardia of a
strain. Normohromnaja an anemia.
Disease proceeds hardly, with a plenty of burdensome complications, the forecast
unfavourable.
the Patient received preparations of an insulin (39 ED in day), an antibiotic
erythromycin (2,5 g in day), dressings of wounds were carried out; the table №9 is
appointed. During a presence in hospital the condition of the patient by way of
correction diabetum melitous has improved (a level of a glucose has considerably
come nearer to normal), but the general condition of the patient has become
complicated by an anemia. In general treatment can be estimated as effective.
References to the local doctor: To advise the patient to carry out exercises for
conservation and improvements of a trophicity of extremities, to keep to a diet,
supervise a level of a glucose in a blood, to eat it is high-grade and it is various.
The patient should to stop smoke. To advise it to wear convenient clothes and
footwear. To supervise a blood pressure of the patient, to pick up to it
antianginalnye preparations, constantly to watch a level of a cholesterin and blood
lipids.
THE LITERATURE:
Keywords: a case history, an endocrinology, diabetum melitous, 1 type, the serious form,
subindemnification, an angioretinopathia, an angiopathia of the bottom extremities, a distal
sensory polyneuropatia
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Insulin is a hormone that is produced by specialized cells (beta cells) of the
pancreas. (The pancreas is a deep-seated organ in the abdomen located
behind the stomach.) In addition to helping glucose enter the cells, insulin is
also important in tightly regulating the level of glucose in the blood. After a
meal, the blood glucose level rises. In response to the increased glucose
level, the pancreas normally releases more insulin into the bloodstream to
help glucose enter the cells and lower blood glucose levels after a meal.
When the blood glucose levels are lowered, the insulin release from the
pancreas is turned down. It is important to note that even in the fasting state
there is a low steady release of insulin than fluctuates a bit and helps to
maintain a steady blood sugar level during fasting. In normal individuals,
such a regulatory system helps to keep blood glucose levels in a tightly
controlled range. As outlined above, in patients with diabetes, the insulin is
either absent, relatively insufficient for the body's needs, or not used
properly by the body. All of these factors cause elevated levels of blood
glucose (hyperglycemia).
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Diabetes
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There are three types of diabetes. Type 1 diabetes affects children mostly and type three or
gestational diabetes occurs during pregnancy. Type 2 diabetes is the most prevalent and also
called adult-onset or non-insulin dependent diabetes. In this case, the body produces sufficient
insulin, but the insulin and the glucose it transports cannot effectively enter into cells.
Gestational diabetes affect pregnant women.
Diabetes Symptoms
Diabetes goes undetected for a long time as they do not produce serious, obvious symptoms. Do
watch out for strong thirst, frequent urination, excessive appetite, weight loss, fatigue, irritability
and blurred vision. In diabetics, the urine maybe pale in color, with an acidic reaction and a
sweet odor. They also look pale, may suffer from secondary issues like anemia, constipation,
intense itching around the genital region, palpitations and general weakness.
Diabetes Diet
Eat foods that are rich in fiber. Fiber slows intestinal absorption of sugar and smoothes
out blood sugar levels. Pears, beans, barley, blackberries and chick-peas are some sources
of fiber.
Okra is prescribed in Ayurveda as a remedy for blood sugar. Okra is quite delicious as a
steamed or roasted vegetable.
Prickly pear cactus is available in the Mexican sections of the grocery store. The pads can
be diced and used in a salad or taco. It helps with diabetes, obesity and elevated blood
cholesterol.
Dandelion greens are hypoglycemic and they can be juiced or chopped into salads and
soups. Ingesting dandelion can improve lipid profiles, cholesterol and triglycerides in
diabetic patients.
Cinnamon, nutmeg, cashew, cayenne, ginger, turmeric, bay leaf, coriander seed, turnip,
lettuce, cabbage, cranberry, papaya fruit, millet, Jeruselam artichoke, barley, oats and
buckwheat are a few other foods helpful for a diabetic. Incorporate some of them into
your diet everyday.
One tsp of turmeric is added to some gooseberry(amla) juice and this mixture is
consumed everyday. Alternatively, turmeric extracts or capsules can be taken. This is
very effective in normalizing the blood glucose levels and reducing insulin resistance.
.Read other Turmeric home remedies.
Fenugreek is a good blood-sugar lowering herb. It is also cheap and can be easily worked
into dishes. It has a high soluble fiber content and alkaloids, which help with delayed
gastric emptying, slow carbohydrate absorption and glucose transport. Fenugreek may
also increase the number of insulin receptors in red blood cells and improve glucose
utilization in peripheral tissues, thus showing anti-diabetic properties in the pancreas and
other organs. Read other Fenugreek home remedies.
Onions and garlic are significant hypoglycemic. The allicin and diallyl disulphide
chemicals present in these lower glucose levels by competing with insulin in the liver.
Clinical studies have shown that allicin in garlic combines with Vitamin B1 and stimulate
the pancrease to release more insulin. It also arrests the chemical receptors that deactivate
insulin. Onion and garlic not only help with insulin normalization, but also provide
significant cardiovascular benefits as well. Read other Garlic home remedies .
Cinnamon is beneficial to Type 2 diabetes as it can reduce blood sugar levels and
increase the body's natural production of insulin. It can also improve cholesterol
metabolism, remove artery-damaging free radicals from the blood and improve the
functioning of the blood vessels. Try to consume half a teaspoon of cinnamon before
breakfast, for about 40 days. You can also add cinnamon in your diet by sprinkling it in
your cereal, tea or entree. .Read other Cinnamon home remedies.
Aloe juice is believed to lower blood sugar levels in people with type 2 diabetes. Aloe
contains two chemicals - mannose and glucomannon; mannose helps open up the blood
vessels and glucomannon helps in triglyceride production. Check out food grade Aloe
juice in your neighbourhood. Read other Aloe home remedies.
Chicory is very beneficial to diabetics as it contains Inulin, a fiber that has a low
glycemic index and controls blood sugar levels. It can be used as a sweetner and added to
beverages. Chicory not only helps with blood sugar, but also reduces the serum LDL
cholesterol levels in the blood. .Read other Chicory home remedies. .
Neem can reduce insulin requirements without altering blood glucose levels. Regular
consumption of neem decoction or neem tablets is an effective alternative therapy for
diabetes. Read other Neem home remedies.
One teaspoon of Amla juice mixed with a cup of bitter gourd juice is prescribed by
naturopaths as it stimulates the Pancreas and it will secrete enough insulin for reducing
blood sugar. Amla seeds or dried amla is equally invaluable for the control of
Diabetes. .Read other Amla home remedies.
Diabetics fear ripe mangoes for their high sugar content! But, mango leaves help
normalize insulin levels in the blood. Boil a few mango leaves in water and allow it to
saturate through the night. Consume the filtered decoction in the morning for diabetic
home remedy. Alternatively, dry mango leaves, powder and store. Add about a teaspoon
and boil in water and consume the filtered decoction. .Read other Mango home remedies.
Tinospora is very effective in resolving the symptoms of diabetes. Boil the stem pieces in
500 ml of water for 30 minutes. Drink 50 ml of this tinospora extract twice daily for a
month. There will be a marked improvement in the condition. Read other Tinospora
home remedies.
Bitter gourd or Karela(in Hindi) or balsam pear is a vegetable grown in Asia, Africa and
South America. It contains a hypoglycemic or insulin-like principle, termed as "plant
insulin". It has been found to lower blood and urine sugar levels. Bitter gourd contain a
lectin which links together with insulin receptors and provide a way for managing Type 2
diabetes.
Excessive usage of bitter gourd can cause diarrhea and abdominal discomfort. People
with hypoglycemia or low sugar levels should not take this.
Gurmar, another name for Gymnema, means "killer of sweet" in Sansktrit. It can lower
blood sugar, blood fats, triglycerides, and cholesterol, and repair the liver, kidney and
muscle tissues. It shows potential for fixing pancreas malfunction, raising insulin output
to normal levels. Gymnema also acts on taste buds and the surface of the intestines, and
reduces the appeal for sugary foods. It is promising herb for both Type I and Type II
diabetes.
Stevia is thirty times sweeter than sugar and yet has 1 calorie per 10 leaves, and it is
totally natural. It has a long history of use in South America and holds promise as a
sweetener for diabetics. Stevia has been found to lower blood sugar and blood pressure. It
also does not cause tooth decay like regular sugars.
Green Tea contain catechins and epicatechins, plant compounds belonging to the flavonol
category. They are powerful antioxidants and found to be beneficial for diabetes. Green
tea can be consumed as a beverage, or a decaffeinated version can be ingested as
capsules.
Apple cider vinegar has shown to reduce the raise of blood sugar after the consumption
of a high carbohydrate meal. Fermented foods like apple cider vinegar that contain acetic
acid has been shown to lower blood sugar by helping store excess glucose in the liver,
thus reducing the body's rate of glucose production and absorption. Try to purchase apple
cider vinegar that is least processed and dark. Two teaspoons of apple cider vinegar can
be diluted in a cup of water and taken before the meal. You could also add the vinegar to
your salad or main course.
Vitamin C helps prevent the sugar inside the cells from converting to sorbitol, a sugar
alcohol that cells can neither burn for energy nor move out. Vitamin C may also be
beneficial in diminishing the damage to proteins caused by free radicals. Dietary sorbitol
is not a danger to diabetics though, as it is poorly absorbed and is not transported into the
cells. Citrus fruits, guava and papaya are rich in Vitamin C. More on Vitamin C.
Vitamin E
Diabetics need more anti-oxidant protection than normal, Vitamin E helps alleviate some
of those risks to the heart. Diabetics are two to four times more vulnerable to heart
conditions. Vitamin E reduces the tendency for sugar to stick to proteins in the blood and
can lower the percentage of triglycerides. More on Vitamin E
Magnesium
Chromium
Deficiency in Chromium not only affects sugar metabolism, but worsen the secondary
symptoms of numbness, tingling and pain in the hands and legs. Chromium is a key
player in sugar metabolism and hooks up with insulin in transporting sugar through the
cell membrane and into the cell. Brewer's yeast, wheat germ, whole grains, cheese, soy
products, onions and garlic are rich in chromium.
B Complex Vitamins
Vitamin B6, B12 and Biotin have important roles to play in sugar metabolism. Vitamin
B6 deficiency can cause glucose intolerance, there is an abnormal increase in blood sugar
after eating. People with diabetes tend to be low in B Vitamins, partly because the disease
uses up most of them or they are improperly absorbed and excreted in the urine.
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DEFINITION AND DESCRIPTION OF DIABETES MELLITUS
Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from
defects in insulin secretion, insulin action, or both. The chronic hyperglycemia of diabetes is
associated with long-term damage, dysfunction, and failure of various organs, especially the eyes,
kidneys, nerves, heart, and blood vessels.
Several pathogenic processes are involved in the development of diabetes. These range from
autoimmune destruction of the β-cells of the pancreas with consequent insulin deficiency to
abnormalities that result in resistance to insulin action. The basis of the abnormalities in
carbohydrate, fat, and protein metabolism in diabetes is deficient action of insulin on target tissues.
Deficient insulin action results from inadequate insulin secretion and/or diminished tissue responses
to insulin at one or more points in the complex pathways of hormone action. Impairment of insulin
secretion and defects in insulin action frequently coexist in the same patient, and it is often unclear
which abnormality, if either alone, is the primary cause of the hyperglycemia.
Symptoms of marked hyperglycemia include polyuria, polydipsia, weight loss, sometimes with
polyphagia, and blurred vision. Impairment of growth and susceptibility to certain infections may
also accompany chronic hyperglycemia. Acute, life-threatening consequences of uncontrolled
diabetes are hyperglycemia with ketoacidosis or the nonketotic hyperosmolar syndrome.
Long-term complications of diabetes include retinopathy with potential loss of vision; nephropathy
leading to renal failure; peripheral neuropathy with risk of foot ulcers, amputations, and Charcot
joints; and autonomic neuropathy causing gastrointestinal, genitourinary, and cardiovascular
symptoms and sexual dysfunction. Patients with diabetes have an increased incidence of
atherosclerotic cardiovascular, peripheral arterial, and cerebrovascular disease. Hypertension and
abnormalities of lipoprotein metabolism are often found in people with diabetes.
The vast majority of cases of diabetes fall into two broad etiopathogenetic categories (discussed in
greater detail below). In one category, type 1 diabetes, the cause is an absolute deficiency of insulin
secretion. Individuals at increased risk of developing this type of diabetes can often be identified by
serological evidence of an autoimmune pathologic process occurring in the pancreatic islets and by
genetic markers. In the other, much more prevalent category, type 2 diabetes, the cause is a
combination of resistance to insulin action and an inadequate compensatory insulin secretory
response. In the latter category, a degree of hyperglycemia sufficient to cause pathologic and
functional changes in various target tissues, but without clinical symptoms, may be present for a
long period of time before diabetes is detected. During this asymptomatic period, it is possible to
demonstrate an abnormality in carbohydrate metabolism by measurement of plasma glucose in the
fasting state or after a challenge with an oral glucose load.
The degree of hyperglycemia (if any) may change over time, depending on the extent of the
underlying disease process (Fig. 1). A disease process may be present but may not have progressed
far enough to cause hyperglycemia. The same disease process can cause impaired fasting glucose
(IFG) and/or impaired glucose tolerance (IGT) without fulfilling the criteria for the diagnosis of
diabetes. In some individuals with diabetes, adequate glycemic control can be achieved with weight
reduction, exercise, and/or oral glucose-lowering agents. These individuals therefore do not require
insulin. Other individuals who have some residual insulin secretion but require exogenous insulin for
adequate glycemic control can survive without it. Individuals with extensive β-cell destruction and
therefore no residual insulin secretion require insulin for survival. The severity of the metabolic
abnormality can progress, regress, or stay the same. Thus, the degree of hyperglycemia reflects the
severity of the underlying metabolic process and its treatment more than the nature of the process
itself.
Previous SectionNext Section
CLASSIFICATION OF DIABETES MELLITUS AND OTHER
CATEGORIES OF GLUCOSE REGULATION
Assigning a type of diabetes to an individual often depends on the circumstances present at the time
of diagnosis, and many diabetic individuals do not easily fit into a single class. For example, a
person with gestational diabetes mellitus (GDM) may continue to be hyperglycemic after delivery and
may be determined to have, in fact, type 2 diabetes. Alternatively, a person who acquires diabetes
because of large doses of exogenous steroids may become normoglycemic once the glucocorticoids
are discontinued, but then may develop diabetes many years later after recurrent episodes of
pancreatitis. Another example would be a person treated with thiazides who develops diabetes years
later. Because thiazides in themselves seldom cause severe hyperglycemia, such individuals probably
have type 2 diabetes that is exacerbated by the drug. Thus, for the clinician and patient, it is less
important to label the particular type of diabetes than it is to understand the pathogenesis of the
hyperglycemia and to treat it effectively.
Type 1 diabetes (β-cell destruction, usually leading to absolute insulin
deficiency)
Immune-mediated diabetes.
This form of diabetes, which accounts for only 5–10% of those with diabetes, previously
encompassed by the terms insulin-dependent diabetes, type I diabetes, or juvenile-onset diabetes,
results from a cellular-mediated autoimmune destruction of the β-cells of the pancreas. Markers of
the immune destruction of the β-cell include islet cell autoantibodies, autoantibodies to insulin,
autoantibodies to glutamic acid decarboxylase (GAD 65), and autoantibodies to the tyrosine
phosphatases IA-2 and IA-2β. One and usually more of these autoantibodies are present in 85–90%
of individuals when fasting hyperglycemia is initially detected. Also, the disease has strong HLA
associations, with linkage to the DQA and DQB genes, and it is influenced by the DRB genes. These
HLA-DR/DQ alleles can be either predisposing or protective.
In this form of diabetes, the rate of β-cell destruction is quite variable, being rapid in some
individuals (mainly infants and children) and slow in others (mainly adults). Some patients,
particularly children and adolescents, may present with ketoacidosis as the first manifestation of the
disease. Others have modest fasting hyperglycemia that can rapidly change to severe hyperglycemia
and/or ketoacidosis in the presence of infection or other stress. Still others, particularly adults, may
retain residual β-cell function sufficient to prevent ketoacidosis for many years; such individuals
eventually become dependent on insulin for survival and are at risk for ketoacidosis. At this latter
stage of the disease, there is little or no insulin secretion, as manifested by low or undetectable
levels of plasma C-peptide. Immune-mediated diabetes commonly occurs in childhood and
adolescence, but it can occur at any age, even in the 8th and 9th decades of life.
Autoimmune destruction of β-cells has multiple genetic predispositions and is also related to
environmental factors that are still poorly defined. Although patients are rarely obese when they
present with this type of diabetes, the presence of obesity is not incompatible with the diagnosis.
These patients are also prone to other autoimmune disorders such as Graves’ disease, Hashimoto’s
thyroiditis, Addison’s disease, vitiligo, celiac sprue, autoimmune hepatitis, myasthenia gravis, and
pernicious anemia.
Idiopathic diabetes.
Some forms of type 1 diabetes have no known etiologies. Some of these patients have permanent
insulinopenia and are prone to ketoacidosis, but have no evidence of autoimmunity. Although only a
minority of patients with type 1 diabetes fall into this category, of those who do, most are of African
or Asian ancestry. Individuals with this form of diabetes suffer from episodic ketoacidosis and
exhibit varying degrees of insulin deficiency between episodes. This form of diabetes is strongly
inherited, lacks immunological evidence for β-cell autoimmunity, and is not HLA associated. An
absolute requirement for insulin replacement therapy in affected patients may come and go.
Type 2 diabetes (ranging from predominantly insulin resistance with relative
insulin deficiency to predominantly an insulin secretory defect with insulin
resistance)
This form of diabetes, which accounts for ∼90–95% of those with diabetes, previously referred to as
non-insulin-dependent diabetes, type II diabetes, or adult-onset diabetes, encompasses individuals
who have insulin resistance and usually have relative (rather than absolute) insulin deficiency At least
initially, and often throughout their lifetime, these individuals do not need insulin treatment to
survive. There are probably many different causes of this form of diabetes. Although the specific
etiologies are not known, autoimmune destruction of β-cells does not occur, and patients do not
have any of the other causes of diabetes listed above or below.
Most patients with this form of diabetes are obese, and obesity itself causes some degree of insulin
resistance. Patients who are not obese by traditional weight criteria may have an increased
percentage of body fat distributed predominantly in the abdominal region. Ketoacidosis seldom
occurs spontaneously in this type of diabetes; when seen, it usually arises in association with the
stress of another illness such as infection. This form of diabetes frequently goes undiagnosed for
many years because the hyperglycemia develops gradually and at earlier stages is often not severe
enough for the patient to notice any of the classic symptoms of diabetes. Nevertheless, such patients
are at increased risk of developing macrovascular and microvascular complications. Whereas patients
with this form of diabetes may have insulin levels that appear normal or elevated, the higher blood
glucose levels in these diabetic patients would be expected to result in even higher insulin values
had their β-cell function been normal. Thus, insulin secretion is defective in these patients and
insufficient to compensate for insulin resistance. Insulin resistance may improve with weight
reduction and/or pharmacological treatment of hyperglycemia but is seldom restored to normal The
risk of developing this form of diabetes increases with age, obesity, and lack of physical activity. It
occurs more frequently in women with prior GDM and in individuals with hypertension or
dyslipidemia, and its frequency varies in different racial/ethnic subgroups. It is often associated with
a strong genetic predisposition, more so than is the autoimmune form of type 1 diabetes. However,
the genetics of this form of diabetes are complex and not clearly defined.
Other specific types of diabetes
Genetic defects of the β-cell.
Several forms of diabetes are associated with monogenetic defects in β-cell function. These forms of
diabetes are frequently characterized by onset of hyperglycemia at an early age (generally before age
25 years). They are referred to as maturity-onset diabetes of the young (MODY) and are
characterized by impaired insulin secretion with minimal or no defects in insulin action. They are
inherited in an autosomal dominant pattern. Abnormalities at six genetic loci on different
chromosomes have been identified to date. The most common form is associated with mutations on
chromosome 12 in a hepatic transcription factor referred to as hepatocyte nuclear factor (HNF)-1α.
A second form is associated with mutations in the glucokinase gene on chromosome 7p and results
in a defective glucokinase molecule. Glucokinase converts glucose to glucose-6-phosphate, the
metabolism of which, in turn, stimulates insulin secretion by the β-cell. Thus, glucokinase serves as
the “glucose sensor” for the β-cell. Because of defects in the glucokinase gene, increased plasma
levels of glucose are necessary to elicit normal levels of insulin secretion. The less common forms
result from mutations in other transcription factors, including HNF-4α, HNF-1β, insulin promoter
factor (IPF)-1, and NeuroD1.
Point mutations in mitochondrial DNA have been found to be associated with diabetes mellitus and
deafness The most common mutation occurs at position 3243 in the tRNA leucine gene, leading to
an A-to-G transition. An identical lesion occurs in the MELAS syndrome (mitochondrial myopathy,
encephalopathy, lactic acidosis, and stroke-like syndrome); however, diabetes is not part of this
syndrome, suggesting different phenotypic expressions of this genetic lesion.
Genetic abnormalities that result in the inability to convert proinsulin to insulin have been identified
in a few families, and such traits are inherited in an autosomal dominant pattern. The resultant
glucose intolerance is mild. Similarly, the production of mutant insulin molecules with resultant
impaired receptor binding has also been identified in a few families and is associated with an
autosomal inheritance and only mildly impaired or even normal glucose metabolism.
Genetic defects in insulin action.
There are unusual causes of diabetes that result from genetically determined abnormalities of insulin
action. The metabolic abnormalities associated with mutations of the insulin receptor may range
from hyperinsulinemia and modest hyperglycemia to severe diabetes. Some individuals with these
mutations may have acanthosis nigricans. Women may be virilized and have enlarged, cystic ovaries.
In the past, this syndrome was termed type A insulin resistance. Leprechaunism and the Rabson-
Mendenhall syndrome are two pediatric syndromes that have mutations in the insulin receptor gene
with subsequent alterations in insulin receptor function and extreme insulin resistance. The former
has characteristic facial features and is usually fatal in infancy, while the latter is associated with
abnormalities of teeth and nails and pineal gland hyperplasia.
Alterations in the structure and function of the insulin receptor cannot be demonstrated in patients
with insulin-resistant lipoatrophic diabetes. Therefore, it is assumed that the lesion(s) must reside in
the postreceptor signal transduction pathways.
Diseases of the exocrine pancreas.
Any process that diffusely injures the pancreas can cause diabetes. Acquired processes include
pancreatitis, trauma, infection, pancreatectomy, and pancreatic carcinoma. With the exception of
that caused by cancer, damage to the pancreas must be extensive for diabetes to occur;
adrenocarcinomas that involve only a small portion of the pancreas have been associated with
diabetes. This implies a mechanism other than simple reduction in β-cell mass. If extensive enough,
cystic fibrosis and hemochromatosis will also damage β-cells and impair insulin secretion.
Fibrocalculous pancreatopathy may be accompanied by abdominal pain radiating to the back and
pancreatic calcifications identified on X-ray examination. Pancreatic fibrosis and calcium stones in
the exocrine ducts have been found at autopsy.
Endocrinopathies.
Several hormones (e.g., growth hormone, cortisol, glucagon, epinephrine) antagonize insulin action.
Excess amounts of these hormones (e.g., acromegaly, Cushing’s syndrome, glucagonoma,
pheochromocytoma, respectively) can cause diabetes. This generally occurs in individuals with
preexisting defects in insulin secretion, and hyperglycemia typically resolves when the hormone
excess is resolved.
Somatostatinoma- and aldosteronoma-induced hypokalemia can cause diabetes, at least in part, by
inhibiting insulin secretion. Hyperglycemia generally resolves after successful removal of the tumor.
Drug- or chemical-induced diabetes.
Many drugs can impair insulin secretion. These drugs may not cause diabetes by themselves, but
they may precipitate diabetes in individuals with insulin resistance. In such cases, the classification is
unclear because the sequence or relative importance of β-cell dysfunction and insulin resistance is
unknown. Certain toxins such as Vacor (a rat poison) and intravenous pentamidine can permanently
destroy pancreatic β-cells. Such drug reactions fortunately are rare. There are also many drugs and
hormones that can impair insulin action. Examples include nicotinic acid and glucocorticoids.
Patients receiving α-interferon have been reported to develop diabetes associated with islet cell
antibodies and, in certain instances, severe insulin deficiency. The list shown in Table 1 is not all-
inclusive, but reflects the more commonly recognized drug-, hormone-, or toxin-induced forms of
diabetes.
Infections.
Certain viruses have been associated with β-cell destruction. Diabetes occurs in patients with
congenital rubella, although most of these patients have HLA and immune markers characteristic of
type 1 diabetes. In addition, coxsackievirus B, cytomegalovirus, adenovirus, and mumps have been
implicated in inducing certain cases of the disease.
Uncommon forms of immune-mediated diabetes.
In this category, there are two known conditions, and others are likely to occur. The stiff-man
syndrome is an autoimmune disorder of the central nervous system characterized by stiffness of the
axial muscles with painful spasms. Patients usually have high titers of the GAD autoantibodies, and
approximately one-third will develop diabetes.
Anti-insulin receptor antibodies can cause diabetes by binding to the insulin receptor, thereby
blocking the binding of insulin to its receptor in target tissues. However, in some cases, these
antibodies can act as an insulin agonist after binding to the receptor and can thereby cause
hypoglycemia. Anti-insulin receptor antibodies are occasionally found in patients with systemic
lupus erythematosus and other autoimmune diseases. As in other states of extreme insulin
resistance, patients with anti-insulin receptor antibodies often have acanthosis nigricans. In the
past, this syndrome was termed type B insulin resistance.
Other genetic syndromes sometimes associated with diabetes.
Many genetic syndromes are accompanied by an increased incidence of diabetes mellitus. These
include the chromosomal abnormalities of Down’s syndrome, Klinefelter’s syndrome, and Turner’s
syndrome. Wolfram’s syndrome is an autosomal recessive disorder characterized by insulin-deficient
diabetes and the absence of β-cells at autopsy. Additional manifestations include diabetes insipidus,
hypogonadism, optic atrophy, and neural deafness. Other syndromes are listed in Table 1.
Gestational diabetes mellitus (GDM)
GDM is defined as any degree of glucose intolerance with onset or first recognition during
pregnancy. The definition applies regardless of whether insulin or only diet modification is used for
treatment or whether the condition persists after pregnancy. It does not exclude the possibility that
unrecognized glucose intolerance may have antedated or begun concomitantly with the pregnancy.
GDM complicates ∼4% of all pregnancies in the U.S., resulting in ∼135,000 cases annually. The
prevalence may range from 1 to 14% of pregnancies, depending on the population studied. GDM
represents nearly 90% of all pregnancies complicated by diabetes.
Deterioration of glucose tolerance occurs normally during pregnancy, particularly in the 3rd
trimester.
Impaired glucose tolerance (IGT) and impaired fasting glucose (IFG)
The Expert Committee (1,2) recognized an intermediate group of subjects whose glucose levels,
although not meeting criteria for diabetes, are nevertheless too high to be considered normal. This
group is defined as having fasting plasma glucose (FPG) levels ≥100 mg/dl (5.6 mmol/l) but <126
mg/dl (7.0 mmol/l) or 2-h values in the oral glucose tolerance test (OGTT) of ≥140 mg/dl (7.8
mmol/l) but <200 mg/dl (11.1 mmol/l). Thus, the categories of FPG values are as follows:
FPG <100 mg/dl (5.6 mmol/l) = normal fasting glucose;
FPG 100–125 mg/dl (5.6–6.9 mmol/l) = IFG (impaired fasting glucose);
FPG ≥126 mg/dl (7.0 mmol/l) = provisional diagnosis of diabetes (the diagnosis must
be confirmed, as described below).
The corresponding categories when the OGTT is used are the following:
2-h postload glucose <140 mg/dl (7.8 mmol/l) = normal glucose tolerance;
2-h postload glucose 140–199 mg/dl (7.8–11.1 mmol/l) = IGT (impaired glucose
tolerance);
2-h postload glucose ≥200 mg/dl (11.1 mmol/l) = provisional diagnosis of diabetes
(the diagnosis must be confirmed, as described below).
Patients with IFG and/or IGT are now referred to as having “pre-diabetes” indicating the relatively
high risk for development of diabetes in these patients. In the absence of pregnancy, IFG and IGT are
not clinical entities in their own right but rather risk factors for future diabetes as well as
cardiovascular disease. They can be observed as intermediate stages in any of the disease processes
listed in Table 1. IFG and IGT are associated with the metabolic syndrome, which includes obesity
(especially abdominal or visceral obesity), dyslipidemia of the high-triglyceride and/or low-HDL
type, and hypertension. It is worth mentioning that medical nutrition therapy aimed at producing 5–
10% loss of body weight, exercise, and certain pharmacological agents have been variably
demonstrated to prevent or delay the development of diabetes in people with IGT; the potential
impact of such interventions to reduce cardiovascular risk has not been examined to date.
Note that many individuals with IGT are euglycemic in their daily lives. Individuals with IFG or IGT
may have normal or near normal glycated hemoglobin levels. Individuals with IGT often manifest
hyperglycemia only when challenged with the oral glucose load used in the standardized OGTT.
Previous SectionNext Section
DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS
The criteria for the diagnosis of diabetes are shown in Table 2. Three ways to diagnose diabetes are
possible, and each, in the absence of unequivocal hyperglycemia, must be confirmed, on a
subsequent day, by any one of the three methods given in Table 2. The use of the hemoglobin A1c
(A1C) for the diagnosis of diabetes is not recommended at this time.
Diagnosis of GDM
The criteria for abnormal glucose tolerance in pregnancy are those of Carpenter and Coustan ( 3).
Recommendations from the American Diabetes Association’s Fourth International Workshop-
Conference on Gestational Diabetes Mellitus held in March 1997 support the use of the
Carpenter/Coustan diagnostic criteria as well as the alternative use of a diagnostic 75-g 2-h OGTT.
These criteria are summarized below.
Testing for gestational diabetes.
Previous recommendations included screening for GDM performed in all pregnancies. However, there
are certain factors that place women at lower risk for the development of glucose intolerance during
pregnancy, and it is likely not cost-effective to screen such patients. Pregnant women who fulfill all
of these criteria need not be screened for GDM.
This low-risk group comprises women who
are <25 years of age
are a normal body weight
have no family history (i.e., first-degree relative) of diabetes
have no history of abnormal glucose metabolism
have no history of poor obstetric outcome
are not members of an ethnic/racial group with a high prevalence of diabetes (e.g.,
Hispanic American, Native American, Asian American, African American, Pacific
Islander)
Risk assessment for GDM should be undertaken at the first prenatal visit. Women with clinical
characteristics consistent with a high risk of GDM (marked obesity, personal history of GDM,
glycosuria, or a strong family history of diabetes) should undergo glucose testing (see below) as
soon as feasible. If they are found not to have GDM at that initial screening, they should be retested
between 24 and 28 weeks of gestation. Women of average risk should have testing undertaken at
24–28 weeks of gestation.
A fasting plasma glucose level >126 mg/dl (7.0 mmol/l) or a casual plasma glucose >200 mg/dl
(11.1 mmol/l) meets the threshold for the diagnosis of diabetes. In the absence of unequivocal
hyperglycemia, the diagnosis must be confirmed on a subsequent day. Confirmation of the diagnosis
precludes the need for any glucose challenge. In the absence of this degree of hyperglycemia,
evaluation for GDM in women with average or high-risk characteristics should follow one of two
approaches.
One-step approach.
Perform a diagnostic OGTT without prior plasma or serum glucose screening. The one-step
approach may be cost-effective in high-risk patients or populations (e.g., some Native-American
groups).
Two-step approach.
Perform an initial screening by measuring the plasma or serum glucose concentration 1 h after a 50-
g oral glucose load (glucose challenge test [GCT]) and perform a diagnostic OGTT on that subset of
women exceeding the glucose threshold value on the GCT. When the two-step approach is used, a
glucose threshold value >140 mg/dl (7.8 mmol/l) identifies ∼80% of women with GDM, and the yield
is further increased to 90% by using a cutoff of >130 mg/dl (7.2 mmol/l).
With either approach, the diagnosis of GDM is based on an OGTT. Diagnostic criteria for the 100-g
OGTT are derived from the original work of O’Sullivan and Mahan (4) modified by Carpenter and
Coustan (3) and are shown in the top of Table 3. Alternatively, the diagnosis can be made using a
75-g glucose load and the glucose threshold values listed for fasting, 1 h, and 2 h (Table 2, bottom);
however, this test is not as well validated as the 100-g OGTT.
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Figure 1—
Disorders of glycemia: etiologic types and stages. ∗Even after presenting in ketoacidosis, these
patients can briefly return to normoglycemia without requiring continuous therapy (i.e.,
“honeymoon” remission); ∗∗in rare instances, patients in these categories (e.g., Vacor toxicity, type
1 diabetes presenting in pregnancy) may require insulin for survival.
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Table 1—
Etiologic classification of diabetes mellitus
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Table 2—
Criteria for the diagnosis of diabetes mellitus
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Table 3—
Diagnosis of GDM with a 100-g or 75-g glucose load
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Footnotes
The information that follows is based largely on the reports of the Expert Committee
on the Diagnosis and Classification of Diabetes ( Diabetes Care 20:1183–1197, 1997,
and Diabetes Care 26:3160–3167, 2003).
DIABETES CARE
Previous Section
References
1. ↵
The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report
of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.
Diabetes Care 20: 1183–1197, 1997
MedlineWeb of Science
2. ↵
The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Follow-
up report on the diagnosis of diabetes mellitus. Diabetes Care 26: 3160–3167, 2003
FREE Full Text
3. ↵
Carpenter MW, Coustan DR: Criteria for screening tests for gestational diabetes. Am J
Obstet Gynecol 144: 768–773, 1982
MedlineWeb of Science
4. ↵
O’Sullivan JB, Mahan CM: Criteria for the oral glucose tolerance test in pregnancy.
Diabetes 13: 278, 1964
erican Study of Kidney Disease a
Differing effects of antihypertensive drugs on the incidence of diabetes mellitus among
patients with hypertensive kidney disease. Archives of Internal Medicine April 10, 2006
166:797-805
There are three main types of diabetes that have been categorized by medical scientists.
The first type is called Type I Diabetes. Formerly known as juvenile diabetes, this type begins to
make its appearance in pre-adolescence or adolescent growth. It is an insulin dependent
autoimmune disease in which the body destroys its own beta cells. It accounts for 10% of all
diabetes types.
The second type is called Type II Diabetes. This disease generally appears after 40 years of age.
It is most likely triggered by poor diet and lack of exercise. Because of poor diets and the
availability of fast food, Type II diabetes is now showing up in teenagers. It is non-insulin
dependent, meaning insulin is used to control blood sugar levels but is not crucial to maintaining
life.
Gestational Diabetes is the third type of diabetes. Occurring during a woman’s pregnancy, the
mother has difficulty digesting carbohydrates. Gynecologists usually perform this test on all
pregnant women early in the first trimester.
There is also a condition called Pre-Diabetes. This condition is defined as someone who has elevated
blood sugar levels, but does not fall into a clearly defined category.
Syndrome X, Polycystic Ovary Disease, Hemocromatosis and Cystic Fibrosis are additional types of
insulin resistant diabetes.
As a Type I diabetic ages, the symptomatic lines begin to blur into Type II. A person can also be typed as
Type 1.5, Type 2-s or Type 2-d.
It is very important that factors such as ketones, antibodies, high triglyceride and low HDL, uric acid, and
C-peptide be taken into account for your diagnosis.
Incorrectly categorizing diabetes is very common. Conditions that worsen or don’t show improvement
should be brought to the attention of a diabetic specialist.
As aging blurs the lines of the types of diabetes, it is very important to review your symptoms often.
Like this information? Help us by sharing it with others using the social media buttons below.
The first step in managing diabetes is to commit yourself to the care of a health professional. The
healthcare professional will determine the severity of the patient’s diabetes and decide if insulin
injections are required. In some less severe cases, pills may be given to aid in the body’s use of
glucose. One of the aims of the health professional is to instruct the patient about controlling
blood glucose levels. Insulin injections or pills taken at prescribed times achieve this goal.
Beyond medical intervention, the most important method of managing diabetes is a change in
lifestyle. This change will include careful attention to diet and increased physical activity. Since
diabetes is a condition where the blood glucose levels are too high, dietary plans to manage
diabetes will include maintaining consistent levels of blood glucose throughout the day. A certified
dietician can help determine what levels are optimal for each individual. These levels will be
determined by many physical factors, including sex, age, occupation, and other health conditions.
It is important to note (and take heart) that modifying diet to manage diabetes does not mean that
any one food must be eliminated from your diet.
The key to proper diet is balance and the healthy diabetic diet is simply a healthy diet, one that all
individuals should adopt. Proper dietary management of diabetes includes eating regular meals
based on wholegrain varieties of breads, cereals and pasta. At least five portions of fruits and
vegetables should be eaten on a daily basis. Fruit intake should be spread out during the day to
maintain optimal blood glucose levels. A good diet will also have lower salt and fat intake. Sugary
foods should be cut to a minimum. If rich desserts are eaten, intake of other fats and
carbohydrates need to be drastically reduced.
Another factor in diabetic management is maintaining a safe weight. Most individuals with type 2
diabetes, the type of diabetes that occurs when the body doesn’t produce enough insulin or the
insulin produced does not work properly, are overweight. Losing weight will not only help control
diabetes but lower the risk of other health problems such as cardiovascular diseases.
Successful diabetic management will require increased physical activity. Walking is a natural
exercise that most people can do. Whenever possible, walk instead of ride, and take stairs
instead of elevators and escalators. Increased physical activity goes beyond regulating blood
sugar levels, it also benefits the heart, lungs, and joints and gives a sense of well being.
No one needs to succumb to the long-term negative side effects of diabetes. One needs to submit to the
regular care of a health professional and take prescribed medication. Adopting a new lifestyle and
mindset is a vital key to success. Eating wisely, watching your weight and increasing physical activity
bring diabetes management into the realm of the possibility. These lifestyle changes make for all around
good health.
The first step in managing diabetes is to commit yourself to the care of a health professional. The
healthcare professional will determine the severity of the patient’s diabetes and decide if insulin
injections are required. In some less severe cases, pills may be given to aid in the body’s use of
glucose. One of the aims of the health professional is to instruct the patient about controlling
blood glucose levels. Insulin injections or pills taken at prescribed times achieve this goal.
Beyond medical intervention, the most important method of managing diabetes is a change in
lifestyle. This change will include careful attention to diet and increased physical activity. Since
diabetes is a condition where the blood glucose levels are too high, dietary plans to manage
diabetes will include maintaining consistent levels of blood glucose throughout the day. A certified
dietician can help determine what levels are optimal for each individual. These levels will be
determined by many physical factors, including sex, age, occupation, and other health conditions.
It is important to note (and take heart) that modifying diet to manage diabetes does not mean that
any one food must be eliminated from your diet.
The key to proper diet is balance and the healthy diabetic diet is simply a healthy diet, one that all
individuals should adopt. Proper dietary management of diabetes includes eating regular meals
based on wholegrain varieties of breads, cereals and pasta. At least five portions of fruits and
vegetables should be eaten on a daily basis. Fruit intake should be spread out during the day to
maintain optimal blood glucose levels. A good diet will also have lower salt and fat intake. Sugary
foods should be cut to a minimum. If rich desserts are eaten, intake of other fats and
carbohydrates need to be drastically reduced.
Another factor in diabetic management is maintaining a safe weight. Most individuals with type 2
diabetes, the type of diabetes that occurs when the body doesn’t produce enough insulin or the
insulin produced does not work properly, are overweight. Losing weight will not only help control
diabetes but lower the risk of other health problems such as cardiovascular diseases.
Successful diabetic management will require increased physical activity. Walking is a natural
exercise that most people can do. Whenever possible, walk instead of ride, and take stairs
instead of elevators and escalators. Increased physical activity goes beyond regulating blood
sugar levels, it also benefits the heart, lungs, and joints and gives a sense of well being.
No one needs to succumb to the long-term negative side effects of diabetes. One needs to submit to the
regular care of a health professional and take prescribed medication. Adopting a new lifestyle and
mindset is a vital key to success. Eating wisely, watching your weight and increasing physical activity
bring diabetes management into the realm of the possibility. These lifestyle changes make for all around
good health.
“I found help through a support groups. They provided me with instruction, comfort, and peace of mind. I
also relied heavily on God to give me comfort. He did not choose to cure my physical illness but He
helped me with the daily mental struggles. I found comfort in Matthew 11:28-30, ‘Come to me, all of you
who are weary and carry heavy burdens, and I will give you rest. Take my yoke upon you. Let me teach
you, because I am humble and gentle, and you will find rest for your souls.’ As diabetics, we can
experience rest from the fears of what diabetes can do.
“If you have not experienced the peace of knowing God and would like to seek His comfort and security of
eternal life, investigate what a life of knowing Jesus as your Savior and comforter can do for you. I know
that in Him and I have found my rest.”
Scientists are still working on the cause of diabetes. Since there are different types of diabetes, each type
has a unique possible cause.
The main cause of diabetes is the body’s failure to produce enough of the insulin hormone. Another
cause could be that the body develops a resistance to insulin.
There is also gestational diabetes that only occurs in pregnant women. These are only a few of the
different types of diabetes.
It is suspected that there may be many contributors to diabetes. Genetics, environmental factors, obesity,
lack of exercise, and high fat diets are just a few causes linked to diabetes. You cannot become a diabetic
just because you eat a lot of sugars and candies, but if you are predisposed to the disease these factors
may raise your risk of becoming a diabetic.
A sedentary lifestyle can also lead to diabetes, since the body cannot perform as well as someone in
good physical condition.
Most scientists believe that you must be born predisposed to this disease. In other words, your body is
more susceptible because of the genetic make-up of your ancestors. If your parents, grandparents, or
siblings have diabetes you are at greater risk. However, this is dependant upon the type of diabetes.
The cause of diabetes may seem to be elusive, but with the direction of science and how far we’ve come
in the last 100 years, the answer could be right around the corner.
Many people find controlling diabetes difficult because it is hard to change eating habits, find the time to
exercise, or even to get the courage to use painful glucose meters. However, all of those things are
necessary when it comes to successfully controlling diabetes.
Education: Controlling diabetes begins with knowing as much as you can about the disease. The
more you know about diabetes, the more it will help you understand the need to take care of
yourself. You need to learn about the medications you take and what they do and don’t do. You
also need to learn about other complications that result from not keeping your diabetes in check.
You need to learn as much as possible about how your life has changed and what to do about it.
Food: Controlling diabetes is all about good eating habits. The amount of carbohydrates a
diabetic takes in can mean the difference between high and low blood sugar levels. So the first
step to controlling diabetes is to keep a diary of your carbohydrate intake. A diary will allow you to
see what foods you are eating and will allow you to make necessary adjustments.
Exercise: Controlling diabetes means making time for regular exercise. Exercise, added to a
program of good eating habits, will help control diabetes and keep sugar levels under control. The
more you exercise, the more sugar you will burn and the lower your blood sugar levels will be.
The level and degree of your exercise should depend upon what your doctor recommends for
you. However, most recommendations average out to about one-half hour to a full hour per day.
Remember, exercise will also help to minimize the other complications of diabetes such as heart
disease.
Sugar Levels: Controlling diabetes means you must regularly monitor your sugar levels. A useful
tool to monitoring your blood sugar levels is the glucose meter. The glucose meter allows you to
determine if your regiment of diet and exercise, in combination with your medication, is effectively
lowering your blood sugar. It can also help you determine whether your doctor needs to be
consulted.
A glucose meter should be used at the least once per day, and possibly more often, depending
upon the severity of your diabetes. This enables you to detect any drastic or sudden changes in
your blood sugar levels
You are here: Life Challenges >> Learn More About Controlling Diabetes! >> Signs Of Diabetes
Diabetes is a chronic disease in which the body does not produce enough insulin. Diabetes, when left
untreated, has been linked to other health problems such as heart disease and kidney failure. At the
present time, diabetes is not a curable disease but it is a controllable disease provided you recognize the
early warning signs of diabetes and then seek treatment immediately.
There is a long list of the warning signs of diabetes. The following are some of the ones I experienced
when I was diagnosed with Type 2 diabetes. Once these symptoms were recognized, I went to see my
family doctor who verified for me what I already suspected.
Rapid weight loss – Even though I ate the same types of food I began losing weight.
Increased Hunger – After each meal I was still very hungry and would eat more.
Thirsty – I could not drink enough water to satisfy my thirst.
Frequent urination – It seemed like I was making frequent trips to the restroom.
Tiredness – No matter how much sleep I received, I remained tired.
Tingling in the Hands and feet – My hands and feet often felt like they were numb.
Additional signs of diabetes include blurry vision, sores that do not heal, and in extreme cases spells of
unconsciousness. The warning signs of diabetes vary from person to person as well as from Type 1 to
Type 2 diabetes.
Seeking help
The best thing that you can do for yourself if you are experiencing any the signs of diabetes is to seek out
the advice of your family physician. Your family physician can administer a blood test which can indicate
what you sugar levels have been like over the last three months as well as how well your pancreas is
working. From the blood test, your physician can find out if you truly have diabetes or not.
There are three main types of diabetes that have been categorized by medical scientists.
The first type is called Type I Diabetes. Formerly known as juvenile diabetes, this type begins to
make its appearance in pre-adolescence or adolescent growth. It is an insulin dependent
autoimmune disease in which the body destroys its own beta cells. It accounts for 10% of all
diabetes types.
The second type is called Type II Diabetes. This disease generally appears after 40 years of age.
It is most likely triggered by poor diet and lack of exercise. Because of poor diets and the
availability of fast food, Type II diabetes is now showing up in teenagers. It is non-insulin
dependent, meaning insulin is used to control blood sugar levels but is not crucial to maintaining
life.
Gestational Diabetes is the third type of diabetes. Occurring during a woman’s pregnancy, the
mother has difficulty digesting carbohydrates. Gynecologists usually perform this test on all
pregnant women early in the first trimester.
There is also a condition called Pre-Diabetes. This condition is defined as someone who has elevated
blood sugar levels, but does not fall into a clearly defined category.
Syndrome X, Polycystic Ovary Disease, Hemocromatosis and Cystic Fibrosis are additional types of
insulin resistant diabetes.
As a Type I diabetic ages, the symptomatic lines begin to blur into Type II. A person can also be typed as
Type 1.5, Type 2-s or Type 2-d.
It is very important that factors such as ketones, antibodies, high triglyceride and low HDL, uric acid, and
C-peptide be taken into account for your diagnosis.
Incorrectly categorizing diabetes is very common. Conditions that worsen or don’t show improvement
should be brought to the attention of a diabetic specialist.
As aging blurs the lines of the types of diabetes, it is very important to review your symptoms often.
Injectable medications:
GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc)
Insulin, etc Rx , New Inhaled Insulin (Exubera)
Glipizide (Glucotrol)
Dose: lowest effective single dose, 5mg, Usually dose 5-10 mg 1-2 tab BID (Max 40
mg/day)
Glipizide (GI therapeutic system) Glucotrol XL 5-10mg tab once/day (Max 20
mg/day)
Dose: lowest effective single dose, 5 mg; daily max, 20 mg
Glyburide (Micronase, Diabeta) - (2nd generation)
Dose: lowest effective single dose, 1.25 mg; Usually dose 1.25-2.5-5 mg 1-2 tab BID
(Max 20 mg/day)
Micronized glyburide (Glynase)
Dose: lowest effective single dose, 1.5 mg; daily max, 6 mg
Glimepiride (Amaryl) (3rd generation)
Dose: lowest effective single dose, 0.5 mg; 1,2,4 mg tab/day. Start 1-2 mg/d, usual
maintenance dose is 1-4mg once/d (Max: 8mg/d)
Gliclazide/ Diamicron 80-160 mg daily, max 320 mg PO daily.
Modified release Diamicron MR 30 mg PO daily, mas 120 mg daily
Combination meds:
Glucovance (Glyburide and Metformin)
Avandaryl (Glimepiride and Avandia/Rosiglitazone)
Sulfonylureas (as Glipizide/Glucotrol, Glyburide/Micronase) | Biguanides (Metformin/Glucophage)
Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide,
Starlix/Nataglinide)
a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset) | GLP Analogues (Exenatide/Byetta,
Pramlintide/Symlin Subc)
DPP IV Inhibitors (Vildagliptin/Galvus, Sitagliptin/Januvia PO) | Insulin, etc Rx , New Inhaled Insulin
(Exubera)
Biguanides
- Primary action is reduction of excessive hepatic glucose output; it also has some activity on
insulin resistance in skeleton muscle, though less than troglitazone.
- Metformin may cause life-threatening lactic acidosis.
- Takes about 2 wks to work well. Do not use in renal or hepatic dysfunction, dehydrated,
or hospital patients.
- Hold this med prior to IV contrast agents and for for 48 hours after.
- Avoid if ethanol abuse, heart failure, hepatic or renal insufficiency (Cr >1.4-1.5), or
hypoxic states.
Injectable medications:
GLP Analogues (Exenatide/Byetta, Pramlintide/Symlin Subc)
Insulin, etc Rx , New Inhaled Insulin (Exubera)
Glipizide (Glucotrol)
Dose: lowest effective single dose, 5mg, Usually dose 5-10 mg 1-2 tab BID (Max 40
mg/day)
Glipizide (GI therapeutic system) Glucotrol XL 5-10mg tab once/day (Max 20
mg/day)
Dose: lowest effective single dose, 5 mg; daily max, 20 mg
Glyburide (Micronase, Diabeta) - (2nd generation)
Dose: lowest effective single dose, 1.25 mg; Usually dose 1.25-2.5-5 mg 1-2 tab BID
(Max 20 mg/day)
Micronized glyburide (Glynase)
Dose: lowest effective single dose, 1.5 mg; daily max, 6 mg
Glimepiride (Amaryl) (3rd generation)
Dose: lowest effective single dose, 0.5 mg; 1,2,4 mg tab/day. Start 1-2 mg/d, usual
maintenance dose is 1-4mg once/d (Max: 8mg/d)
Gliclazide/ Diamicron 80-160 mg daily, max 320 mg PO daily.
Modified release Diamicron MR 30 mg PO daily, mas 120 mg daily
Combination meds:
Glucovance (Glyburide and Metformin)
Avandaryl (Glimepiride and Avandia/Rosiglitazone)
Sulfonylureas (as Glipizide/Glucotrol, Glyburide/Micronase) | Biguanides (Metformin/Glucophage)
Thiazolidinediones (Pioglitazone/Actos, Rosiglitazone/Avandia) | Meglitinide (Prandin/Repaglinide,
Starlix/Nataglinide)
a-Glucosidase inhibitors (Acarbose/Precose, Miglitol/Glyset) | GLP Analogues (Exenatide/Byetta,
Pramlintide/Symlin Subc)
DPP IV Inhibitors (Vildagliptin/Galvus, Sitagliptin/Januvia PO) | Insulin, etc Rx , New Inhaled Insulin
(Exubera)
Biguanides
- Primary action is reduction of excessive hepatic glucose output; it also has some activity on
insulin resistance in skeleton muscle, though less than troglitazone.
- Metformin may cause life-threatening lactic acidosis.
- Takes about 2 wks to work well. Do not use in renal or hepatic dysfunction, dehydrated,
or hospital patients.
- Hold this med prior to IV contrast agents and for for 48 hours after.
- Avoid if ethanol abuse, heart failure, hepatic or renal insufficiency (Cr >1.4-1.5), or
hypoxic states.
The signs and symptoms of both types of diabetes include increased urine output and decreased
appetite as well as fatigue. Diabetes is diagnosed by blood glucose testing, the glucose tolerance
test, and testing of the level of glycosylated hemoglobin (glycohemoglobin or hemoglobin A1C).
The mode of treatment depends on the type of the diabetes.
The major complications of diabetes include dangerously elevated blood sugar, abnormally low
blood sugar due to diabetes medications, and disease of the blood vessels which can damage the
eye, kidneys, nerves, and heart.
Last Editorial Review: 1/6/2001
The prevalence of diabetes varies by age, gender, race, and ethnicity. In the United
States, about 0.19 percent of the population less than twenty years of age (151,000
people) have diabetes, versus 8.6 percent of the population twenty years of age and
older. In addition, adults sixty-five and older account for 40 percent of those with
diabetes, despite composing only 12 percent of the population. Considerable variations
also exist in the prevalence of diabetes among various racial and ethnic groups. For
example, 7.8 percent of non-Hispanic whites, 13 percent of non-Hispanic blacks, 10.2
percent of Hispanic/Latino Americans, and 15.1 percent of American Indians and
Alaskan Natives have diabetes. Among Asian Americans and Pacific
The standard method of measuring blood glucose level is called a fingerstick, which is a small
blood sample taken from the fingertip. Diabetics must monitor their blood glucose levels daily in
order to avoid dire complications such as kidney disease, blindness, stroke, and poor blood
circulation.
[Photograph by Tom Stewart. Corbis. Reproduced by permission.]
Islanders, the rate of diabetes varies substantially and is estimated at 15 to 20 percent. The
prevalence of diabetes is comparable for males and females—8.3 and 8.9 percent respectively.
Nevertheless, the disease is more devastating and more difficult to control among women,
especially African-American and non-Hispanic white women. In fact, the risk for death is
greater among young people (3.6 times greater for people from 25 to 44 years of age) and
women (2.7 times greater for women ages 45 to 64 than men of the same age).
Types of Diabetes
Diabetes mellitus is classified into four categories: type 1, type 2, gestational diabetes,
and other. In type 1 diabetes, specialized cells in the pancreas are destroyed, leading to a
deficiency in insulin production. Type 1 diabetes frequently develops over the course of a
few days or weeks. Over 95 percent of people with type 1 diabetes are diagnosed before
the age of twenty-five. Estimates show 5.3 million people worldwide live with type 1
diabetes. Although the diagnosis of type 1 diabetes occurs equally among men and
women, an increased prevalence exists in the white population. Type 1 diabetes in Asian
children is relatively rare.
Family history, diet , and environmental factors are risk factors for type 1 diabetes.
Studies have found an increased risk in children whose parents have type 1 diabetes, and
this risk increases with maternal age. Environmental factors such as viral infections,
toxins , and exposure to cow's milk are being contested as causing or modifying the
development of type 1 diabetes.
Genetics and environmental factors are the main contributors to type 2 diabetes.
Physical inactivity and adoption of a Western lifestyle (particularly choosing foods with
more animal protein , animal fats, and processed carbohydrates ), especially in
indigenous people in North American and within ethnic groups and migrants, have
contributed to weight gain and obesity. In fact, obesity levels increased by 74 percent
between 1991 and 2003. Increased body fat and abdominal obesity are associated with
insulin resistance, a precursor to diabetes. Impaired glucose tolerance (IGT) and
impaired fasting glucose (IFG) are two prediabetic conditions associated with insulin
resistance. In these conditions, the blood glucose concentration is above the normal
range, but below levels required to diagnose diabetes. Subjects with IGT and/or IFG are
at substantially higher risk of developing diabetes and cardiovascular disease than
those with normal glucose tolerance. The conversion of individuals with IGT to type 2
diabetes varies with ethnicity, anthropometric measures related to obesity, fasting
blood glucose (a measurement of blood glucose values after not eating for 12 to 14
hours), and the two-hour post-glucose load level (a measurement of blood glucose taken
exactly two hours after eating). In addition to IGT and IFG, higher than normal levels of
fasting insulin, called hyperinsulinemia, are associated with an increased risk of
developing type 2 diabetes. Insulin levels are higher in African Americans than in
whites, particularly African-American women, indicating their greater predisposition for
developing type 2 diabetes.
Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with
onset or first recognition during pregnancy. This definition applies regardless of
whether insulin or diet modification is used for treatment, and whether or not the
condition persists after pregnancy. GDM affects up to 14 percent of the pregnant
population—approximately 135,000 women per year in United States. GDM complicates
about 4 percent of all pregnancies in the U.S. Women at greatest risk for developing
GDM are obese , older than twenty-five years of age, have a previous history of
abnormal glucose control, have first-degree relatives with diabetes, or are members of
ethnic groups with a high prevalence of diabetes. Infants of a woman with GDM are at a
higher risk of developing obesity, impaired glucose tolerance, or diabetes at an early age.
After a pregnancy with GDM, the mother has an increased risk of developing type 2
diabetes.
Other forms of diabetes are associated with genetic defects in the specialized cells of the
pancreas, drug or chemical use, infections, or other diseases. The most notable of the
genetically linked diabetes is maturity onset diabetes of the young (MODY).
Characterized by the onset of hyperglycemia before the age of twenty-five, insulin
secretion is impaired while minimal or no defects exist in insulin action. Drugs ,
infections, and diseases cause diabetes by damaging the pancreas and/or impairing
insulin action or secretion.
Diabetes Complications
People with diabetes are at increased risk for serious long-term complications.
Hyperglycemia, as measured by fasting plasma glucose concentration or glycosylated
hemoglobin (HbA1c), causes structural and functional changes in the retina, nerves,
kidneys, and blood vessels. This damage can lead to blindness, numbness, reduced
circulation, amputations, kidney disease, and cardiovascular disease. Type 1 diabetes is
more likely to lead to kidney failure. About 40 percent of people with type 1 diabetes
develop severe kidney disease and kidney failure by the age of fifty. Nevertheless,
between 1993 and 1997, more than 100,000 people in the United States were treated for
kidney failure caused by type 2 diabetes.
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia state (HHS) are serious
diabetic emergencies and the most frequent cause of mortality. Both DKA and HHS
result from an insulin deficiency and an increase in counter-regulatory hormones (a.k.a.
hyperglycemia). Hyperglycemia leads to glycosuria (glucose in the urine), increased
urine output, and dehydration. Because the glucose is excreted in the urine, the body
becomes starved for energy . At this point, the body either continues to excrete glucose
in the urine making the hyperglycemia worse (HHS), or the body begins to break down
triglycerides causing the release of ketones (by-products of fat breakdown) into the
urine and bloodstream (DKA). The mortality rate of patients with DKA is less than 5
percent while the mortality rate of HHS patients is about 15 percent. Infection (urinary
tract infections and pneumonia account for 30 to 50 percent of cases), omission of
insulin, and increased amounts of counter-regulatory hormones contribute to DKA and
HHS. Type 1 and type 2 diabetic patients may experience DKA and HHS. However, DKA
is more common in type 1 diabetic patients, while HHS is more common in type 2
diabetic patients. Treatment of DKA and HHS involves correction of dehydration,
hyperglycemia, ketoacidosis, and electrolyte deficits and imbalances.
The World Health Organization estimates that 150 million people had diabetes
worldwide in 2002. This number is projected to double by the year 2025. Much of this
increase will occur in developing countries and will be due to population growth, aging,
unhealthful diets, obesity , and sedentary lifestyles. In the United States, diabetes is
the sixth leading cause of death. While 6.2 percent of the population has diabetes, an
estimated 5.9 million people are unaware they have the disease. In addition, about 19
percent of all deaths in the United States for those age twenty-five and older are due to
diabetes-related complications.
The prevalence of diabetes varies by age, gender, race, and ethnicity. In the United
States, about 0.19 percent of the population less than twenty years of age (151,000
people) have diabetes, versus 8.6 percent of the population twenty years of age and
older. In addition, adults sixty-five and older account for 40 percent of those with
diabetes, despite composing only 12 percent of the population. Considerable variations
also exist in the prevalence of diabetes among various racial and ethnic groups. For
example, 7.8 percent of non-Hispanic whites, 13 percent of non-Hispanic blacks, 10.2
percent of Hispanic/Latino Americans, and 15.1 percent of American Indians and
Alaskan Natives have diabetes. Among Asian Americans and Pacific
The standard method of measuring blood glucose level is called a fingerstick, which is a small
blood sample taken from the fingertip. Diabetics must monitor their blood glucose levels daily in
order to avoid dire complications such as kidney disease, blindness, stroke, and poor blood
circulation.
Islanders, the rate of diabetes varies substantially and is estimated at 15 to 20 percent. The
prevalence of diabetes is comparable for males and females—8.3 and 8.9 percent respectively.
Nevertheless, the disease is more devastating and more difficult to control among women,
especially African-American and non-Hispanic white women. In fact, the risk for death is
greater among young people (3.6 times greater for people from 25 to 44 years of age) and
women (2.7 times greater for women ages 45 to 64 than men of the same age).
Types of Diabetes
Diabetes mellitus is classified into four categories: type 1, type 2, gestational diabetes,
and other. In type 1 diabetes, specialized cells in the pancreas are destroyed, leading to a
deficiency in insulin production. Type 1 diabetes frequently develops over the course of a
few days or weeks. Over 95 percent of people with type 1 diabetes are diagnosed before
the age of twenty-five. Estimates show 5.3 million people worldwide live with type 1
diabetes. Although the diagnosis of type 1 diabetes occurs equally among men and
women, an increased prevalence exists in the white population. Type 1 diabetes in Asian
children is relatively rare.
Family history, diet , and environmental factors are risk factors for type 1 diabetes.
Studies have found an increased risk in children whose parents have type 1 diabetes, and
this risk increases with maternal age. Environmental factors such as viral infections,
toxins , and exposure to cow's milk are being contested as causing or modifying the
development of type 1 diabetes.
Genetics and environmental factors are the main contributors to type 2 diabetes.
Physical inactivity and adoption of a Western lifestyle (particularly choosing foods with
more animal protein , animal fats, and processed carbohydrates ), especially in
indigenous people in North American and within ethnic groups and migrants, have
contributed to weight gain and obesity. In fact, obesity levels increased by 74 percent
between 1991 and 2003. Increased body fat and abdominal obesity are associated with
insulin resistance, a precursor to diabetes. Impaired glucose tolerance (IGT) and
impaired fasting glucose (IFG) are two prediabetic conditions associated with insulin
resistance. In these conditions, the blood glucose concentration is above the normal
range, but below levels required to diagnose diabetes. Subjects with IGT and/or IFG are
at substantially higher risk of developing diabetes and cardiovascular disease than
those with normal glucose tolerance. The conversion of individuals with IGT to type 2
diabetes varies with ethnicity, anthropometric measures related to obesity, fasting
blood glucose (a measurement of blood glucose values after not eating for 12 to 14
hours), and the two-hour post-glucose load level (a measurement of blood glucose taken
exactly two hours after eating). In addition to IGT and IFG, higher than normal levels of
fasting insulin, called hyperinsulinemia, are associated with an increased risk of
developing type 2 diabetes. Insulin levels are higher in African Americans than in
whites, particularly African-American women, indicating their greater predisposition for
developing type 2 diabetes.
Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with
onset or first recognition during pregnancy. This definition applies regardless of
whether insulin or diet modification is used for treatment, and whether or not the
condition persists after pregnancy. GDM affects up to 14 percent of the pregnant
population—approximately 135,000 women per year in United States. GDM complicates
about 4 percent of all pregnancies in the U.S. Women at greatest risk for developing
GDM are obese , older than twenty-five years of age, have a previous history of
abnormal glucose control, have first-degree relatives with diabetes, or are members of
ethnic groups with a high prevalence of diabetes. Infants of a woman with GDM are at a
higher risk of developing obesity, impaired glucose tolerance, or diabetes at an early age.
After a pregnancy with GDM, the mother has an increased risk of developing type 2
diabetes.
Other forms of diabetes are associated with genetic defects in the specialized cells of the
pancreas, drug or chemical use, infections, or other diseases. The most notable of the
genetically linked diabetes is maturity onset diabetes of the young (MODY).
Characterized by the onset of hyperglycemia before the age of twenty-five, insulin
secretion is impaired while minimal or no defects exist in insulin action. Drugs ,
infections, and diseases cause diabetes by damaging the pancreas and/or impairing
insulin action or secretion.
Diabetes Complications
People with diabetes are at increased risk for serious long-term complications.
Hyperglycemia, as measured by fasting plasma glucose concentration or glycosylated
hemoglobin (HbA1c), causes structural and functional changes in the retina, nerves,
kidneys, and blood vessels. This damage can lead to blindness, numbness, reduced
circulation, amputations, kidney disease, and cardiovascular disease. Type 1 diabetes is
more likely to lead to kidney failure. About 40 percent of people with type 1 diabetes
develop severe kidney disease and kidney failure by the age of fifty. Nevertheless,
between 1993 and 1997, more than 100,000 people in the United States were treated for
kidney failure caused by type 2 diabetes.
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia state (HHS) are serious
diabetic emergencies and the most frequent cause of mortality. Both DKA and HHS
result from an insulin deficiency and an increase in counter-regulatory hormones (a.k.a.
hyperglycemia). Hyperglycemia leads to glycosuria (glucose in the urine), increased
urine output, and dehydration. Because the glucose is excreted in the urine, the body
becomes starved for energy . At this point, the body either continues to excrete glucose
in the urine making the hyperglycemia worse (HHS), or the body begins to break down
triglycerides causing the release of ketones (by-products of fat breakdown) into the
urine and bloodstream (DKA). The mortality rate of patients with DKA is less than 5
percent while the mortality rate of HHS patients is about 15 percent. Infection (urinary
tract infections and pneumonia account for 30 to 50 percent of cases), omission of
insulin, and increased amounts of counter-regulatory hormones contribute to DKA and
HHS. Type 1 and type 2 diabetic patients may experience DKA and HHS. However, DKA
is more common in type 1 diabetic patients, while HHS is more common in type 2
diabetic patients. Treatment of DKA and HHS involves correction of dehydration,
hyperglycemia, ketoacidosis, and electrolyte deficits and imbalances.
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Introduction
Background
Type 2 diabetes mellitus is a group of disorders characterized by hyperglycemia and associated with
microvascular (ie, retinal, renal, possibly neuropathic), macrovascular (ie, coronary, peripheral vascular), and
neuropathic (ie, autonomic, peripheral) complications. Unlike patients with type 1 diabetes mellitus, patients
with type 2 are not absolutely dependent upon insulin for life, even though many of them are ultimately treated
with insulin. See below for images on diagnosis and treatment.
The genetics of type 2 diabetes are complex and not completely understood, but presumably this disease is
related to multiple genes (with the exception of maturity-onset diabetes of the young [MODY]). Evidence
supports inherited components for pancreatic beta-cell failure and insulin resistance. Considerable debate
exists regarding the primary defect in type 2 diabetes mellitus. Most patients have insulin resistance and some
degree of insulin deficiency. However, insulin resistance per se is not the sine qua non for type 2 diabetes
mellitus because many people with insulin resistance (particularly those who are obese) do not develop
glucose intolerance. Therefore, insulin deficiency is necessary for the development of hyperglycemia. Insulin
concentrations may be high, yet inappropriately low for the level of glycemia.
MODY is associated with autosomal dominant inheritance and is characterized by onset in at least 1 family
member younger than 25 years, absence of autoantibodies, correction of fasting hyperglycemia without insulin
for at least 2 years, and absence of ketosis. At least 6 genetically different types of MODY have been
described.2 Some patients ultimately require insulin to control glycemia. Variants in 2 of the genes associated
with MODY (HNF-1alpha and, to a lesser extent, HNF-4alpha) have been shown to predict future type 2
diabetes.3
Presumably, the defects of type 2 diabetes mellitus occur when a diabetogenic lifestyle (ie, excessive caloric
intake, inadequate caloric expenditure, obesity) is superimposed upon a susceptible genotype. The body mass
index at which excess weight increases risk for diabetes varies with different racial groups. For example,
compared with persons of European ancestry, persons of Asian ancestry are at increased risk for diabetes at
lower levels of overweight.4 In addition, an in utero environment resulting in low birth weight may predispose
some individuals to develop type 2 diabetes mellitus.5,6 A simplified scheme for the pathophysiology of abnormal
glucose metabolism in type 2 diabetes mellitus is depicted in the image below.
Frequency
United States
In 2007, the estimated prevalence of diabetes in the United States was 7.8% (23.6 million people); almost one
third of cases were undiagnosed.9 More than 90% of cases of diabetes are type 2 diabetes mellitus. With
increasing obesity in the population, an older population, and an increase in the population of higher-risk
minority groups (see Race), prevalence is increasing.
International
Type 2 diabetes mellitus is less common in non-Western countries where the diet contains fewer calories and
caloric expenditure on a daily basis is higher. However, as people in these countries adopt Western lifestyles,
weight gain and type 2 diabetes mellitus are becoming virtually epidemic.
Mortality/Morbidity
Diabetes mellitus is one of the leading causes of morbidity and mortality in the United States because of its role
in the development of optic, renal, neuropathic, and cardiovascular disease. These complications, particularly
cardiovascular disease (~50-75% of medical expenditures), are the major sources of expenses for patients with
diabetes mellitus. Approximately two thirds of people with diabetes die from heart disease or stroke. Men with
diabetes face a 2-fold increased risk for coronary heart disease, and women have a 3- to 4-fold increased risk.
In 1994, 1 of every 7 health care dollars in the United States was spent on patients with diabetes mellitus. The
2002 estimate for direct medical costs due to diabetes in the United States was $92 billion, with another $40
billion in indirect costs. Approximately 20% of Medicare funds are spent on these patients.
Diabetes mellitus is the leading cause of blindness in working-age adults in the United States; diabetic
retinopathy accounts for 12,000-24,000 newly blind persons every year.9 The National Eye Institute
estimates that laser surgery and appropriate follow-up care can reduce the risk of blindness from
diabetic retinopathy by 90%.10
Diabetes mellitus is the leading cause of end-stage renal disease (ESRD), accounting for 44% of new
cases, according to the Centers for Disease Control and Prevention (CDC).11 In 2005, 46,739 people in
the United States and Puerto Rico began renal replacement therapy, and 178,689 people with
diabetes were on dialysis or had received a kidney transplant.9
Diabetes mellitus is the leading cause of nontraumatic lower limb amputations in the United States,
with a 15- to 40-fold increase in risk over that of the nondiabetic population. In 2004, about 71,000
nontraumatic lower limb amputations were performed related to neuropathy and vasculopathy.9
Race
The prevalence of type 2 diabetes mellitus varies widely among various racial and ethnic groups. The image
below shows data for various groups. Type 2 diabetes mellitus is becoming virtually pandemic in some groups
of Native Americans and Hispanic people. The risk of retinopathy and nephropathy appears to be greater in
blacks, Native Americans, and Hispanics.
Prevalence of diabetes mellitus type 2 in various racial and ethnic groups in the United
States (2007 estimates).
Sex
Type 2 diabetes mellitus is slightly more common in older women than men.
Age
While type 2 diabetes mellitus traditionally has been thought to affect individuals older than 40 years, it is being
recognized increasingly in younger persons, particularly in highly susceptible racial and ethnic groups and the
obese. In some areas, more type 2 than type 1 diabetes mellitus is being diagnosed in prepubertal children,
teenagers, and young adults. The prevalence of diabetes mellitus by age is shown in the image below. Virtually
all cases of diabetes mellitus in older individuals are type 2.
Prevalence of diabetes mellitus type 2 by age in the United States (2007 estimates).
Clinical
History
While a diagnosis of diabetes mellitus is readily entertained when a patient presents with classic
symptoms (ie, polyuria, polydipsia, polyphagia, weight loss), most patients with type 2 diabetes
mellitus are asymptomatic for years. Other symptoms that might suggest hyperglycemia include
blurred vision, lower extremity paresthesias, or yeast infections, particularly balanitis in men. However,
the asymptomatic state does not mean that hyperglycemia is not affecting the individual.
The possible presence of diabetes mellitus should be considered in obese patients, patients with a
first-degree relative with type 2 diabetes mellitus, members of high-risk ethnic groups (ie, black,
Hispanic, Native American, Asian American, Pacific Islander), women with a previous delivery of a
large infant (>9 lb) or with a history of gestational diabetes mellitus, patients with hypertension, or
patients with high triglycerides (>250 mg/dL) or low HDL-C (<35 mg/dL). While the United States
Public Health Service and the American College of Physicians do not recommend routine screening for
diabetes, targeted screening may be useful. For example, in one study of patients admitted to the
hospital with acute coronary syndrome, none of whom were known to have diabetes, admission and
fasting plasma glucose testing identified diabetes in 27%.12
Because polycystic ovary disease is an insulin-resistant state, screening these women may be
warranted.
Whether at-risk persons should be screened for prediabetes is unclear at present. The therapy would
generally be lifestyle changes to facilitate weight loss and improve cardiovascular fitness, and in
virtually all cases, this would be the recommendation for such patients without a measured glucose
value.
Physical
Early in the course of diabetes mellitus, the physical examination findings are likely to be unrevealing.
However, ultimately, end-organ damage may be observed. Potential findings are listed in the image below.
Superimposition of caloric excess (typically, high intake and low expenditure) on a susceptible
genotype appears to cause type 2 diabetes mellitus. A large, population-based, prospective study has
shown that an energy-dense diet may be a risk factor for the development of diabetes that
is independent of baseline obesity.13
Diabetes mellitus may be caused by other conditions. Secondary diabetes may occur in patients taking
glucocorticoids or when patients have conditions that antagonize the actions of insulin (eg, Cushing
syndrome, acromegaly, pheochromocytoma).
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INTRODUCTION
THE IMPACT OF DIABETES
CAUSES
DIAGNOSIS
TREATMENT
COMPLICATIONS
PREGNANCY AND DIABETES
WHERE TO GET MORE INFORMATION
REFERENCES
GRAPHICS
FIGURES
Pancreas anatomy
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A1C and blood glucose
INTRODUCTION
Type 2 diabetes mellitus occurs when the pancreas (an organ in the abdomen) produces
insufficient amounts of the hormone insulin and/or the body's tissues become resistant to
normal or even high levels of insulin (figure 1). This causes high blood glucose (sugar)
levels, which can lead to a number of complications if untreated.
Type 2 diabetes is a chronic medical condition that requires regular monitoring and
treatment. Treatment, which includes lifestyle adjustments, self-care measures, and
sometimes medications, can control blood sugar levels in the near-normal range and
minimize the risk of diabetes-related complications.
In the United States, Canada, and Europe, type 2 diabetes accounts for about 90 percent of
all cases of diabetes. More than 6 percent of all people between the ages of 20 and 74 years
and more than 12 percent of people over age 40 have type 2 diabetes; these numbers
continue to increase.
Topics that discuss other aspects of type 2 diabetes are also available. (See "Patient
information: Diabetes mellitus type 2: Treatment" and "Patient information: Diabetes
mellitus type 2: Insulin treatment" and "Patient information: Type 2 diabetes mellitus and
diet" and "Patient information: Self-blood glucose monitoring in diabetes mellitus" and
"Patient information: Hypoglycemia (low blood sugar) in diabetes mellitus" and "Patient
information: Diabetes mellitus type 2: Alcohol, exercise, and medical care" and "Patient
information: Preventing complications in diabetes mellitus".)
Being diagnosed with type 2 diabetes can be a frightening and overwhelming experience for
some people, and it is common to have questions about why it developed, what it means for
long-term health, and how it will affect everyday life. For most people, the first few months
after being diagnosed are filled with emotional highs and lows. People with newly-diagnosed
diabetes, as well as their families, can use this time to learn as much as possible so that
diabetes-related care (eg, blood sugar testing, medical appointments, daily medications)
becomes a "normal" part of the daily routine.
In addition, people who are newly diagnosed should talk to their healthcare provider about
resources that are available for medical as well as psychological support. This may include
group classes, meetings with a nutritionist, social worker, or nurse educator, and other
educational resources such as books, web sites, or magazines. Several of these resources
are listed below (see 'Where to get more information' below.
Despite the risks associated with type 2 diabetes, most people can lead active lives and
continue to enjoy the foods and activities that they previously enjoyed. Diabetes does not
mean an end to special occasion foods like birthday cake, and with a little advanced
planning, most people with diabetes can enjoy exercise in almost any form.
CAUSES
Type 2 diabetes is probably caused by a complex interaction of environmental factors and
predisposing genetic factors.
Genetic causes — Many people with type 2 diabetes have a family member with type 2
diabetes or conditions commonly associated with diabetes, such as high cholesterol levels,
high blood pressure, or obesity.
The lifetime risk that a first-degree relative (sister, brother, son, daughter) will develop
diabetes is five to ten times higher than that of a person with no family history of diabetes.
The likelihood of developing type 2 diabetes is greater in certain ethnic groups; for example,
people of Hispanic, African, and Asian descent are at greater risk of developing type 2
diabetes compared to people who are white.
Other causes — Other, less common causes of diabetes include endocrine conditions that
indirectly change the production and action of insulin and lead to diabetes. These include
Cushing's syndrome, acromegaly, pheochromocytoma, hyperthyroidism and polycystic
ovarian syndrome (PCOS). (See "Patient information: Cushing's syndrome" and "Patient
information: Acromegaly" and "Patient information: Hyperthyroidism" and "Patient
information: Polycystic ovary syndrome (PCOS)".)
DIAGNOSIS
The diagnosis of diabetes is based upon a person's symptoms and the results of laboratory
tests.
Symptoms — Before being diagnosed with diabetes, some people have symptoms of high
blood sugar, including frequent urination, excessive thirst, and blurred vision. Sometimes,
diabetes is discovered when a person seeks medical help for another problem (such as
erectile dysfunction or pain and numbness in the feet). However, most people with type 2
diabetes have no symptoms at all, and the diagnosis is often delayed for five or more years.
Because family history is a factor in the development of type 2 diabetes, people with family
members with diabetes or conditions commonly associated with diabetes, such as
hypertension, high blood lipid levels, and obesity, should mention this to their healthcare
provider. There are usually few signs of diabetes on a physical examination early in the
course of the disease.
Laboratory tests — Several blood tests are used to measure blood glucose levels, the
primary test for diagnosing diabetes. Additional tests can determine the type of diabetes
and its severity.
Random blood sugar test — For a random blood sugar test, blood can be drawn at
any time throughout the day, regardless of when the person last ate. A random blood sugar
level of 200 mg/dL (11.1 mmol/L) or higher in persons who have symptoms of high blood
sugar (see 'Symptoms' above) suggests a diagnosis of diabetes.
Fasting blood sugar test — Fasting blood sugar testing involves measuring blood
sugar after not eating or drinking for 8 to 12 hours (usually overnight). A normal fasting
blood sugar level is less than 100 mg/dL (5.55 mmol/L). A fasting blood sugar of 126 mg/dL
(7.0 mmol/L) or higher indicates diabetes. The test is done by taking a small sample of
blood from a vein or fingertip. It must be repeated on another day to confirm that it
remains abnormally high (see 'Criteria for diagnosis' below.
Hemoglobin A1C test (A1C) — The A1C blood test measures the average blood sugar
level during the past two to three months. It is used to monitor blood sugar control in
people with known diabetes. Normal values for A1C are 4 to 6 percent (table 1). The test is
done by taking a small sample of blood from a vein or fingertip.
One expert group has recommended using a hemoglobin A1C test to diagnose diabetes.
Unlike other tests, the A1C test can be done at any time of day (before or after eating).
Oral glucose tolerance test — Oral glucose tolerance testing (OGTT) can be used to
diagnose diabetes and pre-diabetes. However, the OGTT is not routinely recommended
because it is inconvenient compared to a fasting blood sugar test.
The standard OGTT includes a fasting blood sugar test. The person then drinks a 75 gram
liquid glucose solution (which tastes very sweet, and is usually cola or orange-flavored).
Two hours later, a second blood sugar level is measured. In some cases, a blood sugar level
is measured at 30 minutes and one hour after drinking the glucose solution.
Criteria for diagnosis — The following criteria are used to define a person's blood sugar
levels as normal, suggestive of pre-diabetes (defined as an abnormal blood sugar level
which is not high enough to be considered diabetic, but with an increased risk of diabetes in
the future), or as diagnostic for diabetes.
Impaired fasting glucose is defined as a fasting blood sugar level between 100 and
125 mg/dL (5.6 to 6.9 mmol/L).
Impaired glucose tolerance is defined as a blood sugar level of 140 to 199 mg/dL,
measured two hours after a 75 gram oral glucose tolerance test.
At least 50 percent of people with impaired glucose tolerance eventually develop type 2
diabetes, and they have an increased risk of heart disease even if diabetes does not
develop. Impaired glucose tolerance is very common; about 11 percent of all people
between the ages of 20 and 74 years have impaired glucose tolerance.
The blood tests must be repeated on another day to confirm that they remain abnormally
high.
However, there are situations where it is less clear if a person has type 1 or 2 diabetes. In
this situation, additional blood testing may be needed. When the type of diabetes is in
doubt, the clinician will usually treat the patient with insulin, as if they have type 1, since it
is critical to avoid a potentially dangerous condition known as diabetic ketoacidosis (DKA).
People with type 2 diabetes do not usually develop DKA. (See "Patient information: Diabetes
mellitus type 1: Overview".)
TREATMENT
A full discussion of the treatment for type 2 diabetes is available separately. (See "Patient
information: Diabetes mellitus type 2: Treatment" and "Patient information: Diabetes
mellitus type 2: Insulin treatment".)
COMPLICATIONS
Complications of type 2 diabetes may be related to the disease itself or to the treatments
necessary to manage diabetes. (See "Patient information: Preventing complications in
diabetes mellitus".)
PREGNANCY AND DIABETES
Women with type 2 diabetes are usually able to become pregnant and have a healthy baby.
However, it is important to tightly control blood sugar levels before and during pregnancy to
minimize the risk of complications. A full discussion of this topic is available separately. (See
"Patient information: Care during pregnancy for women with type 1 or 2 diabetes mellitus".)
Your healthcare provider is the best source of information for questions and concerns
related to your medical problem. Because no two people are exactly alike and
recommendations can vary from one person to another, it is important to seek guidance
from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site
(www.uptodate.com/patients). Additional topics as well as selected discussions written for
healthcare professionals are also available for those who would like more detailed
information.
A number of web sites have information about medical problems and treatments, although
it can be difficult to know which sites are reputable. Information provided by the National
Institutes of Health, national medical societies and some other well-established
organizations are often reliable sources of information, although the frequency with which
they are updated is variable.
(www.nlm.nih.gov/medlineplus/healthtopics.html)
(www.niddk.nih.gov)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
(www.endo-society.org)
[1-7]
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or
treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical
questions or conditions. The use of this website is governed by the UpToDate Terms of Use (click here) ©2010 UpToDate,
Inc.
References Top
1. Knowler, WC, Barrett-Connor, E, Fowler, SE, et al. Reduction in the incidence of type
2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346:393.
2. Effect of intensive blood-glucose control with metformin on complications in
overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study
(UKPDS) Group. Lancet 1998; 352:854.
3. Kjos, SL, Peters, RK, Xiang, A, et al. Predicting future diabetes in Latino women with
gestational diabetes: Utility of early postpartum glucose tolerance testing. Diabetes
1995; 44:586.
4. Selvin, E, Coresh, J, Golden, SH, et al. Glycemic control, atherosclerosis, and risk
factors for cardiovascular disease in individuals with diabetes: the atherosclerosis risk in
communities study. Diabetes Care 2005; 28:1965.
INTRODUCTION
THE IMPACT OF DIABETES
CAUSES
DIAGNOSIS
TREATMENT
COMPLICATIONS
PREGNANCY AND DIABETES
WHERE TO GET MORE INFORMATION
REFERENCES
GRAPHICS
FIGURES
Pancreas anatomy
TABLES
A1C and blood glucose
INTRODUCTION
Type 2 diabetes mellitus occurs when the pancreas (an organ in the abdomen) produces
insufficient amounts of the hormone insulin and/or the body's tissues become resistant to
normal or even high levels of insulin (figure 1). This causes high blood glucose (sugar)
levels, which can lead to a number of complications if untreated.
Type 2 diabetes is a chronic medical condition that requires regular monitoring and
treatment. Treatment, which includes lifestyle adjustments, self-care measures, and
sometimes medications, can control blood sugar levels in the near-normal range and
minimize the risk of diabetes-related complications.
In the United States, Canada, and Europe, type 2 diabetes accounts for about 90 percent of
all cases of diabetes. More than 6 percent of all people between the ages of 20 and 74 years
and more than 12 percent of people over age 40 have type 2 diabetes; these numbers
continue to increase.
Topics that discuss other aspects of type 2 diabetes are also available. (See "Patient
information: Diabetes mellitus type 2: Treatment" and "Patient information: Diabetes
mellitus type 2: Insulin treatment" and "Patient information: Type 2 diabetes mellitus and
diet" and "Patient information: Self-blood glucose monitoring in diabetes mellitus" and
"Patient information: Hypoglycemia (low blood sugar) in diabetes mellitus" and "Patient
information: Diabetes mellitus type 2: Alcohol, exercise, and medical care" and "Patient
information: Preventing complications in diabetes mellitus".)
Being diagnosed with type 2 diabetes can be a frightening and overwhelming experience for
some people, and it is common to have questions about why it developed, what it means for
long-term health, and how it will affect everyday life. For most people, the first few months
after being diagnosed are filled with emotional highs and lows. People with newly-diagnosed
diabetes, as well as their families, can use this time to learn as much as possible so that
diabetes-related care (eg, blood sugar testing, medical appointments, daily medications)
becomes a "normal" part of the daily routine.
In addition, people who are newly diagnosed should talk to their healthcare provider about
resources that are available for medical as well as psychological support. This may include
group classes, meetings with a nutritionist, social worker, or nurse educator, and other
educational resources such as books, web sites, or magazines. Several of these resources
are listed below (see 'Where to get more information' below.
Despite the risks associated with type 2 diabetes, most people can lead active lives and
continue to enjoy the foods and activities that they previously enjoyed. Diabetes does not
mean an end to special occasion foods like birthday cake, and with a little advanced
planning, most people with diabetes can enjoy exercise in almost any form.
CAUSES
Genetic causes — Many people with type 2 diabetes have a family member with type 2
diabetes or conditions commonly associated with diabetes, such as high cholesterol levels,
high blood pressure, or obesity.
The lifetime risk that a first-degree relative (sister, brother, son, daughter) will develop
diabetes is five to ten times higher than that of a person with no family history of diabetes.
The likelihood of developing type 2 diabetes is greater in certain ethnic groups; for example,
people of Hispanic, African, and Asian descent are at greater risk of developing type 2
diabetes compared to people who are white.
Other causes — Other, less common causes of diabetes include endocrine conditions that
indirectly change the production and action of insulin and lead to diabetes. These include
Cushing's syndrome, acromegaly, pheochromocytoma, hyperthyroidism and polycystic
ovarian syndrome (PCOS). (See "Patient information: Cushing's syndrome" and "Patient
information: Acromegaly" and "Patient information: Hyperthyroidism" and "Patient
information: Polycystic ovary syndrome (PCOS)".)
DIAGNOSIS
The diagnosis of diabetes is based upon a person's symptoms and the results of laboratory
tests.
Symptoms — Before being diagnosed with diabetes, some people have symptoms of high
blood sugar, including frequent urination, excessive thirst, and blurred vision. Sometimes,
diabetes is discovered when a person seeks medical help for another problem (such as
erectile dysfunction or pain and numbness in the feet). However, most people with type 2
diabetes have no symptoms at all, and the diagnosis is often delayed for five or more years.
Because family history is a factor in the development of type 2 diabetes, people with family
members with diabetes or conditions commonly associated with diabetes, such as
hypertension, high blood lipid levels, and obesity, should mention this to their healthcare
provider. There are usually few signs of diabetes on a physical examination early in the
course of the disease.
Laboratory tests — Several blood tests are used to measure blood glucose levels, the
primary test for diagnosing diabetes. Additional tests can determine the type of diabetes
and its severity.
Random blood sugar test — For a random blood sugar test, blood can be drawn at
any time throughout the day, regardless of when the person last ate. A random blood sugar
level of 200 mg/dL (11.1 mmol/L) or higher in persons who have symptoms of high blood
sugar (see 'Symptoms' above) suggests a diagnosis of diabetes.
Fasting blood sugar test — Fasting blood sugar testing involves measuring blood
sugar after not eating or drinking for 8 to 12 hours (usually overnight). A normal fasting
blood sugar level is less than 100 mg/dL (5.55 mmol/L). A fasting blood sugar of 126 mg/dL
(7.0 mmol/L) or higher indicates diabetes. The test is done by taking a small sample of
blood from a vein or fingertip. It must be repeated on another day to confirm that it
remains abnormally high (see 'Criteria for diagnosis' below.
Hemoglobin A1C test (A1C) — The A1C blood test measures the average blood sugar
level during the past two to three months. It is used to monitor blood sugar control in
people with known diabetes. Normal values for A1C are 4 to 6 percent (table 1). The test is
done by taking a small sample of blood from a vein or fingertip.
One expert group has recommended using a hemoglobin A1C test to diagnose diabetes.
Unlike other tests, the A1C test can be done at any time of day (before or after eating).
Oral glucose tolerance test — Oral glucose tolerance testing (OGTT) can be used to
diagnose diabetes and pre-diabetes. However, the OGTT is not routinely recommended
because it is inconvenient compared to a fasting blood sugar test.
The standard OGTT includes a fasting blood sugar test. The person then drinks a 75 gram
liquid glucose solution (which tastes very sweet, and is usually cola or orange-flavored).
Two hours later, a second blood sugar level is measured. In some cases, a blood sugar level
is measured at 30 minutes and one hour after drinking the glucose solution.
Criteria for diagnosis — The following criteria are used to define a person's blood sugar
levels as normal, suggestive of pre-diabetes (defined as an abnormal blood sugar level
which is not high enough to be considered diabetic, but with an increased risk of diabetes in
the future), or as diagnostic for diabetes.
Impaired fasting glucose is defined as a fasting blood sugar level between 100 and
125 mg/dL (5.6 to 6.9 mmol/L).
Impaired glucose tolerance is defined as a blood sugar level of 140 to 199 mg/dL,
measured two hours after a 75 gram oral glucose tolerance test.
At least 50 percent of people with impaired glucose tolerance eventually develop type 2
diabetes, and they have an increased risk of heart disease even if diabetes does not
develop. Impaired glucose tolerance is very common; about 11 percent of all people
between the ages of 20 and 74 years have impaired glucose tolerance.
The blood tests must be repeated on another day to confirm that they remain abnormally
high.
However, there are situations where it is less clear if a person has type 1 or 2 diabetes. In
this situation, additional blood testing may be needed. When the type of diabetes is in
doubt, the clinician will usually treat the patient with insulin, as if they have type 1, since it
is critical to avoid a potentially dangerous condition known as diabetic ketoacidosis (DKA).
People with type 2 diabetes do not usually develop DKA. (See "Patient information: Diabetes
mellitus type 1: Overview".)
TREATMENT
A full discussion of the treatment for type 2 diabetes is available separately. (See "Patient
information: Diabetes mellitus type 2: Treatment" and "Patient information: Diabetes
mellitus type 2: Insulin treatment".)
COMPLICATIONS
Complications of type 2 diabetes may be related to the disease itself or to the treatments
necessary to manage diabetes. (See "Patient information: Preventing complications in
diabetes mellitus".)
Women with type 2 diabetes are usually able to become pregnant and have a healthy baby.
However, it is important to tightly control blood sugar levels before and during pregnancy to
minimize the risk of complications. A full discussion of this topic is available separately. (See
"Patient information: Care during pregnancy for women with type 1 or 2 diabetes mellitus".)
Your healthcare provider is the best source of information for questions and concerns
related to your medical problem. Because no two people are exactly alike and
recommendations can vary from one person to another, it is important to seek guidance
from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site
(www.uptodate.com/patients). Additional topics as well as selected discussions written for
healthcare professionals are also available for those who would like more detailed
information.
A number of web sites have information about medical problems and treatments, although
it can be difficult to know which sites are reputable. Information provided by the National
Institutes of Health, national medical societies and some other well-established
organizations are often reliable sources of information, although the frequency with which
they are updated is variable.
National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
(www.niddk.nih.gov)
(800)-DIABETES (800-342-2383)
(www.diabetes.org)
(www.endo-society.org)
[1-7]
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or
treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical
questions or conditions. The use of this website is governed by the UpToDate Terms of Use (click here) ©2010 UpToDate,
Inc.
References Top
1. Knowler, WC, Barrett-Connor, E, Fowler, SE, et al. Reduction in the incidence of type
2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346:393.
2. Effect of intensive blood-glucose control with metformin on complications in
overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study
(UKPDS) Group. Lancet 1998; 352:854.
3. Kjos, SL, Peters, RK, Xiang, A, et al. Predicting future diabetes in Latino women with
gestational diabetes: Utility of early postpartum glucose tolerance testing. Diabetes
1995; 44:586.
4. Selvin, E, Coresh, J, Golden, SH, et al. Glycemic control, atherosclerosis, and risk
factors for cardiovascular disease in individuals with diabetes: the atherosclerosis risk in
communities study. Diabetes Care 2005; 28:1965.
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Viewer Comments: Diabetes Treatment - Effective Treatments
Cigarette smoking is the leading cause if avoidable death in the United States, and
accounts for almost 500,000 deaths a year. Smoking plays a role in one out of every five
deaths in the United States per year. Smoking is indeed bad.
Where the health of diabetic smokers is concerned, the statistics are even worse. There is an increased
risk of premature death and the development of heart disease in patients who have diabetes and continue
to smoke. There is also evidence that links cigarette smoking with microvascular disease (kidney and eye
damage) in diabetes. Additionally, there is data that shows that smoking may actually play a role in the
development of type 2 diabetes. Smoking is bad.
symptoms, gestational diabetes, diabetes and vision, type 1 diabetes, risk factors, diagnosis, prevention
Diabetes Overview
Diabetes mellitus (DM) is a set of related diseases in which the body cannot regulate the amount of sugar
(specifically, glucose) in the blood.
Glucose in the blood gives you energy to perform daily activities, walk briskly, run for a bus, ride your
bike, take an aerobic exercise class, and perform your day-to-day chores.
From the foods you eat, glucose in the blood is produced by the liver (an organ on the right side
of the abdomen near your stomach).
In a healthy person, the blood glucose level is regulated by several hormones, including insulin.
Insulin is produced by the pancreas, a small organ between the stomach and liver. The pancreas
secretes other important enzymes that help to digest food.
Insulin allows glucose to move from the blood into liver, muscle, and fat cells, where it is used for
fuel.
People with diabetes either do not produce enough insulin (type 1 diabetes) or cannot use
insulin properly (type 2 diabetes), or both (which occurs with several forms of diabetes).
In diabetes, glucose in the blood cannot move into cells, so it stays in the blood. This not only
harms the cells that need the glucose for fuel, but also harms certain organs and tissues exposed to
the high glucose levels.
Type 1 diabetes: The body stops producing insulin or produces too little insulin to regulate blood glucose
level.
Type 1 diabetes comprises about 10% of total cases of diabetes in the United States.
Type 1 diabetes can occur in an older individual due to destruction of pancreas by alcohol,
disease, or removal by surgery. It also results from progressive failure of the pancreatic beta cells,
which produce insulin.
People with type 1 diabetes require daily insulin treatment to sustain life.
Type 2 diabetes: The pancreas secretes insulin, but the body is partially or completely unable to use the
insulin. This is sometimes referred to as insulin resistance. The body tries to overcome this resistance by
secreting more and more insulin. People with insulin resistance develop type 2 diabetes when they do not
continue to secrete enough insulin to cope with the higher demands.
Type 2 diabetes is typically recognized in adulthood, usually after age 45 years. It used to be
called adult-onset diabetes mellitus, or non-insulin-dependent diabetes mellitus. These names are no
longer used because type 2 diabetes does occur in younger people, and some people with type 2
diabetes need to use insulin.
Type 2 diabetes is usually controlled with diet, weight loss, exercise, and oral medications. More
than half of all people with type 2 diabetes require insulin to control their blood sugar levels at some
point in the course of their illness.
Gestational diabetes is a form of diabetes that occurs during the second half of pregnancy.
Although gestational diabetes typically goes away after delivery of the baby. Women who have
gestational diabetes are more likely than other women to develop type 2 diabetes later in life.
Women with gestational diabetes are more likely to have large babies.
Pre-diabetes is a common condition related to diabetes. In people with pre-diabetes, the blood sugar
level is higher than normal but not high enough to be considered diabetic.
Pre-diabetes increases your risk of developing type 2 diabetes and of heart disease or stroke.
Pre-diabetes can typically be reversed without insulin or medication by losing a modest amount
of weight and increasing your physical activity. This weight loss can prevent, or at least delay, the
onset of type 2 diabetes.
An international expert committee of the American Diabetes Association redefined the criteria for
pre-diabetes, lowering the blood sugar level cut-off point for pre-diabetes. Approximately 20% more
adults are now believed to have this condition and may develop diabetes within 10 years if they do not
exercise or maintain a healthy weight.
About 17 million Americans (6.2% of adults in North America) are believed to have diabetes. About one
third of diabetic adults do not know they have diabetes.
About 1 million new cases occur each year, and diabetes is the direct or indirect cause of at
least 200,000 deaths each year.
The incidence of diabetes is increasing rapidly. This increase is due to many factors, but the
most significant are the increasing incidence of obesity and the prevalence of sedentary lifestyles.
Complications of diabetes
Both forms of diabetes ultimately lead to high blood sugar levels, a condition called hyperglycemia. Over
a long period of time, hyperglycemia damages the retina of the eye, the kidneys, the nerves, and the
blood vessels.
Damage to the retina from diabetes (diabetic retinopathy) is a leading cause of blindness.
Damage to the kidneys from diabetes (diabetic nephropathy) is a leading cause of kidney failure.
Damage to the nerves from diabetes (diabetic neuropathy) is a leading cause of foot wounds
and ulcers, which frequently lead to foot and leg amputations.
Damage to the nerves in the autonomic nervous system can lead to paralysis of the stomach
(gastroparesis), chronic diarrhea, and an inability to control heart rate and blood pressure during
postural changes.
Diabetes accelerates atherosclerosis, (the formation of fatty plaques inside the arteries), which
can lead to blockages or a clot (thrombus). Such changes can then lead to heart attack, stroke, and
decreased circulation in the arms and legs (peripheral vascular disease).
Diabetes predisposes people to high blood pressure and high cholesterol and triglyceride levels.
These conditions independently and together with hyperglycemia increase the risk of heart disease,
kidney disease, and other blood vessel complications.
In the short run, diabetes can contribute to a number of acute (short-lived) medical problems.
Many infections are associated with diabetes, and infections are frequently more dangerous in
someone with diabetes because the body's normal ability to fight infections is impaired. To compound
the problem, infections may worsen glucose control, which further delays recovery from infection.
Hypoglycemia, or low blood sugar, occurs from time to time in most people with diabetes. It
results from taking too much diabetes medication or insulin (sometimes called an insulin reaction),
missing a meal, doing more exercise than usual, drinking too much alcohol, or taking certain
medications for other conditions. It is very important to recognize hypoglycemia and be prepared to
treat it at all times. Headache, feeling dizzy, poor concentration, tremors of hands, and sweating are
common symptoms of hypoglycemia. You can faint or have a seizure if blood sugar level gets too low.
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From WebMD
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Diabetes
Diabetic Eye Disease »
Diabetic Eye Disease Overview
Diabetes mellitus is one of the leading causes of irreversible blindness worldwide, and, in the United States, it is the most
common cause of blindness in people younger than 65 years of age.
In addition to being a leading cause of blindness, diabetic eye disease encompasses a wide range of problems that can
affect the eyes.
Diabetes mellitus may cause a reversible, temporary blurring of the vision, or it can cause a severe, permanent
loss of vision.
Some people may not even realize they have had diabetes mellitus for several years until they begin to
experience problems with their eyes or vision. Severe diabetic eye disease most commonly develops in
people who have had diabetes mellitus for many years and who have had little or poor cont...
Read the Diabetic Eye Disease article »
Type 2 diabetes mellitus is a group of disorders characterized by hyperglycemia and associated with microvascular (ie,
retinal, renal, possibly neuropathic), macrovascular (ie, coronary, peripheral vascular), and neuropathic (ie, autonomic,
peripheral) complications.
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