FBG : 5.

6mmol/L – 7mmol/L

OGTT : 7.8mmol/L – 11.1mmol/L

DEFINITION

Diabetes mellitus refers to a group of diseases that affect how the body uses blood sugar (glucose). Glucose is
an important source of energy for the cells that make up the muscles and tissues. It's also the brain's main
source of fuel.

Chronic diabetes conditions include type 1 diabetes and type 2 diabetes. Potentially reversible diabetes
conditions include prediabetes and gestational diabetes. Prediabetes happens when blood sugar levels are
higher than normal. But the blood sugar levels aren't high enough to be called diabetes. And prediabetes can
lead to diabetes unless steps are taken to prevent it. Gestational diabetes happens during pregnancy. But it may
go away after the baby is born.

SYMPTOMS

Diabetes symptoms depend on how high your blood sugar is. Some people, especially if they have prediabetes
or type 2 diabetes, may not have symptoms. In type 1 diabetes, symptoms tend to come on quickly and be more
severe.

Some of the symptoms of type 1 diabetes and type 2 diabetes are:

• Feeling more thirsty than usual.

• Urinating often.

• Losing weight without trying.

• Presence of ketones in the urine. Ketones are a byproduct of the breakdown of muscle and fat that
happens when there's not enough available insulin.

• Feeling tired and weak.

• Feeling irritable or having other mood changes.

• Having blurry vision.

• Having slow-healing sores.

• Getting a lot of infections, such as gum, skin and vaginal infections.

Type 1 diabetes can start at any age. But it often starts during childhood or teen years. Type 2 diabetes, the
more common type, can develop at any age. Type 2 diabetes is more common in people older than 40.
CAUSES

To understand diabetes, it's important to understand how the body normally uses glucose.

How insulin works

• The pancreas releases insulin into the bloodstream.

• The insulin circulates, letting sugar enter the cells.

• Insulin lowers the amount of sugar in the bloodstream.

• As the blood sugar level drops, so does the secretion of insulin from the pancreas.
The role of glucose

Glucose — a sugar — is a source of energy for the cells that make up muscles and other tissues.

• Glucose comes from two major sources: food and the liver.

• Sugar is absorbed into the bloodstream, where it enters cells with the help of insulin.

• The liver stores and makes glucose.

• When glucose levels are low, such as when you haven't eaten in a while, the liver breaks down stored
glycogen into glucose. This keeps your glucose level within a typical range.

The exact cause of most types of diabetes is unknown. In all cases, sugar builds up in the bloodstream. This is
because the pancreas doesn't produce enough insulin. Both type 1 and type 2 diabetes may be caused by a
combination of genetic or environmental factors. It is unclear what those factors may be.

RISK FACTOR

Risk factors for diabetes depend on the type of diabetes. Family history may play a part in all types.
Environmental factors and geography can add to the risk of type 1 diabetes.

Sometimes family members of people with type 1 diabetes are tested for the presence of diabetes immune
system cells (autoantibodies). If you have these autoantibodies, you have an increased risk of developing type 1
diabetes. But not everyone who has these autoantibodies develops diabetes.

Race or ethnicity also may raise your risk of developing type 2 diabetes. Although it's unclear why, certain
people — including Black, Hispanic, American Indian and Asian American people — are at higher risk.

Prediabetes, type 2 diabetes and gestational diabetes are more common in people who are overweight or
obese.
COMPLICATION

Long-term complications of diabetes develop gradually. The longer you have diabetes — and the less controlled
your blood sugar — the higher the risk of complications. Eventually, diabetes complications may be disabling or
even life-threatening. In fact, prediabetes can lead to type 2 diabetes. Possible complications include:

• Heart and blood vessel (cardiovascular) disease. Diabetes majorly increases the risk of many heart
problems. These can include coronary artery disease with chest pain (angina), heart attack, stroke and
narrowing of arteries (atherosclerosis). If you have diabetes, you're more likely to have heart disease or
stroke.

• Nerve damage (neuropathy). Too much sugar can injure the walls of the tiny blood vessels (capillaries)
that nourish the nerves, especially in the legs. This can cause tingling, numbness, burning or pain that
usually begins at the tips of the toes or fingers and gradually spreads upward.

Damage to the nerves related to digestion can cause problems with nausea, vomiting, diarrhea or
constipation. For men, it may lead to erectile dysfunction.

• Kidney damage (nephropathy). The kidneys hold millions of tiny blood vessel clusters (glomeruli) that
filter waste from the blood. Diabetes can damage this delicate filtering system.

• Eye damage (retinopathy). Diabetes can damage the blood vessels of the eye (diabetic retinopathy).
This could lead to blindness.

• Foot damage. Nerve damage in the feet or poor blood flow to the feet increases the risk of many foot
complications.

• Skin and mouth conditions. Diabetes may leave you more prone to skin problems, including bacterial
and fungal infections.

• Hearing impairment. Hearing problems are more common in people with diabetes.

• Alzheimer's disease. Type 2 diabetes may increase the risk of dementia, such as Alzheimer's disease.

• Depression. Depression symptoms are common in people with type 1 and type 2 diabetes.
PREVENTION

Type 1 diabetes can't be prevented. But the healthy lifestyle choices that help treat prediabetes, type 2 diabetes
and gestational diabetes can also help prevent them:

• Eat healthy foods. Choose foods lower in fat and calories and higher in fiber. Focus on fruits, vegetables
and whole grains. Eat a variety to keep from feeling bored.

• Get more physical activity. Try to get about 30 minutes of moderate aerobic activity on most days of the
week. Or aim to get at least 150 minutes of moderate aerobic activity a week. For example, take a brisk
daily walk. If you can't fit in a long workout, break it up into smaller sessions throughout the day.

• Lose excess pounds. If you're overweight, losing even 7% of your body weight can lower the risk of
diabetes. For example, if you weigh 200 pounds (90.7 kilograms), losing 14 pounds (6.4 kilograms) can
lower the risk of diabetes.

But don't try to lose weight during pregnancy. Talk to your provider about how much weight is healthy
for you to gain during pregnancy.

To keep your weight in a healthy range, work on long-term changes to your eating and exercise habits.
Remember the benefits of losing weight, such as a healthier heart, more energy and higher self-esteem.

Sometimes drugs are an option. Oral diabetes drugs such as metformin (Glumetza, Fortamet, others) may lower
the risk of type 2 diabetes. But healthy lifestyle choices are important. If you have prediabetes, have your blood
sugar checked at least once a year to make sure you haven't developed type 2 diabetes.

DIAGNOSIS

Type 1 diabetes symptoms often start suddenly and are often the reason for checking blood sugar levels.
Because symptoms of other types of diabetes and prediabetes come on more gradually or may not be easy to
see, the American Diabetes Association (ADA) has developed screening guidelines. The ADA recommends that
the following people be screened for diabetes:

• Anyone with a body mass index higher than 25 (23 for Asian Americans), regardless of age, who
has additional risk factors. These factors include high blood pressure, non-typical cholesterol levels, an
inactive lifestyle, a history of polycystic ovary syndrome or heart disease, and having a close relative with
diabetes.

• Anyone older than age 35 is advised to get an initial blood sugar screening. If the results are normal,
they should be screened every three years after that.

• Women who have had gestational diabetes are advised to be screened for diabetes every three years.

• Anyone who has been diagnosed with prediabetes is advised to be tested every year.

• Anyone who has HIV is advised to be tested.

• Glycated hemoglobin (A1C) test. This blood test, which doesn't require not eating for a period of time
(fasting), shows your average blood sugar level for the past 2 to 3 months. It measures the percentage of
blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells.

The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level of
6.5% or higher on two separate tests means that you have diabetes. An A1C between 5.7% and 6.4%
means that you have prediabetes. Below 5.7% is considered normal.

• Random blood sugar test. A blood sample will be taken at a random time. No matter when you last ate, a
blood sugar level of 200 milligrams per deciliter (mg/dL) — 11.1 millimoles per liter (mmol/L) — or
higher suggests diabetes.

• Fasting blood sugar test. A blood sample will be taken after you haven't eaten anything the night before
(fast). A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level
from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or
higher on two separate tests, you have diabetes.

• Oral glucose tolerance test. For this test, you fast overnight. Then, the fasting blood sugar level is
measured. Then you drink a sugary liquid, and blood sugar levels are tested regularly for the next two
hours.

A blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal. A reading of more than 200 mg/dL (11.1
mmol/L) after two hours means you have diabetes. A reading between 140 and 199 mg/dL (7.8 mmol/L
and 11.0 mmol/L) means you have prediabetes.

If your provider thinks you may have type 1 diabetes, they may test your urine to look for the presence of
ketones. Ketones are a byproduct produced when muscle and fat are used for energy. Your provider will also
probably run a test to see if you have the destructive immune system cells associated with type 1 diabetes
called autoantibodies.

TREATMENT

Treatments for all types of diabetes

An important part of managing diabetes — as well as your overall health — is keeping a healthy weight through
a healthy diet and exercise plan:

• Healthy eating. There's no specific diabetes diet. You'll need to focus your diet on more fruits, vegetables,
lean proteins and whole grains. These are foods that are high in nutrition and fiber and low in fat and
calories. You'll also cut down on saturated fats, refined carbohydrates and sweets. In fact, it's the best
eating plan for the entire family. Sugary foods are OK once in a while. They must be counted as part of
your meal plan.
 Understanding what and how much to eat can be a challenge. A registered dietitian can help you create a
meal plan that fits your health goals, food preferences and lifestyle. This will likely include carbohydrate
counting, especially if you have type 1 diabetes or use insulin as part of your treatment.

• Physical activity. Everyone needs regular aerobic activity. This includes people who have diabetes.
Physical activity lowers your blood sugar level by moving sugar into your cells, where it's used for energy.
Physical activity also makes your body more sensitive to insulin. That means your body needs less insulin
to transport sugar to your cells.

Get your provider's OK to exercise. Then choose activities you enjoy, such as walking, swimming or
biking. What's most important is making physical activity part of your daily routine.

Aim for at least 30 minutes or more of moderate physical activity most days of the week, or at least 150
minutes of moderate physical activity a week. Bouts of activity can be a few minutes during the day. If you
haven't been active for a while, start slowly and build up slowly. Also avoid sitting for too long. Try to get
up and move if you've been sitting for more than 30 minutes.
Treatments for type 1 and type 2 diabetes

Treatment for type 1 diabetes involves insulin injections or the use of an insulin pump, frequent blood sugar
checks, and carbohydrate counting. For some people with type 1 diabetes, pancreas transplant or islet cell
transplant may be an option.

Treatment of type 2 diabetes mostly involves lifestyle changes, monitoring of your blood sugar, along with oral
diabetes drugs, insulin or both.

Monitoring your blood sugar

Depending on your treatment plan, you may check and record your blood sugar as many as four times a day or
more often if you're taking insulin. Careful monitoring is the only way to make sure that your blood sugar level
remains within your target range. People with type 2 diabetes who aren't taking insulin generally check their
blood sugar much less often.

People who receive insulin therapy also may choose to monitor their blood sugar levels with a continuous
glucose monitor. Although this technology hasn't yet completely replaced the glucose meter, it can lower the
number of fingersticks necessary to check blood sugar and provide important information about trends in
blood sugar levels.

Even with careful management, blood sugar levels can sometimes change unpredictably. With help from your
diabetes treatment team, you'll learn how your blood sugar level changes in response to food, physical activity,
medications, illness, alcohol and stress. For women, you'll learn how your blood sugar level changes in
response to changes in hormone levels.

Besides daily blood sugar monitoring, your provider will likely recommend regular A1C testing to measure
your average blood sugar level for the past 2 to 3 months.
Compared with repeated daily blood sugar tests, A1C testing shows better how well your diabetes treatment
plan is working overall. A higher A1C level may signal the need for a change in your oral drugs, insulin regimen
or meal plan.

Your target A1C goal may vary depending on your age and various other factors, such as other medical
conditions you may have or your ability to feel when your blood sugar is low. However, for most people with
diabetes, the American Diabetes Association recommends an A1C of below 7%. Ask your provider what your
A1C target is.

Insulin

People with type 1 diabetes need insulin therapy to survive. Many people with type 2 diabetes or gestational
diabetes also need insulin therapy.

Many types of insulin are available, including short-acting (regular insulin), rapid-acting insulin, long-acting
insulin and intermediate options. Depending on your needs, your provider may prescribe a mixture of insulin
types to use during the day and night.

Insulin can't be taken orally to lower blood sugar because stomach enzymes interfere with insulin's action.
Insulin is often injected using a fine needle and syringe or an insulin pen — a device that looks like a large ink
pen.

An insulin pump also may be an option. The pump is a device about the size of a small cellphone worn on the
outside of your body. A tube connects the reservoir of insulin to a tube (catheter) that's inserted under the skin
of your abdomen.

A continuous glucose monitor, on the left, is a device that measures blood sugar every few minutes using a
sensor inserted under the skin. An insulin pump, attached to the pocket, is a device that's worn outside of the
body with a tube that connects the reservoir of insulin to a catheter inserted under the skin of the abdomen.
Insulin pumps are programmed to deliver specific amounts of insulin continuously and with food.

A tubeless pump that works wirelessly is also now available. You program an insulin pump to dispense specific
amounts of insulin. It can be adjusted to give out more or less insulin depending on meals, activity level and
blood sugar level.

The Food and Drug Administration has approved four artificial pancreases for type 1 diabetes.

An artificial pancreas is also called closed-loop insulin delivery. The implanted device links a continuous
glucose monitor, which checks blood sugar levels every five minutes, to an insulin pump. The device
automatically delivers the correct amount of insulin when the monitor indicates it's needed.

There are more artificial pancreas (closed loop) systems currently in clinical trials.
Oral or other drugs

Sometimes your provider may prescribe other oral or injected drugs as well. Some diabetes drugs help your
pancreas to release more insulin. Others prevent the production and release of glucose from your liver, which
means you need less insulin to move sugar into your cells.

Still others block the action of stomach or intestinal enzymes that break down carbohydrates, slowing their
absorption, or make your tissues more sensitive to insulin. Metformin (Glumetza, Fortamet, others) is generally
the first drug prescribed for type 2 diabetes.

Another class of medication called SGLT2 inhibitors may be used. They work by preventing the kidneys from
reabsorbing filtered sugar into the blood. Instead, the sugar is eliminated in the urine.

Transplantation

In some people who have type 1 diabetes, a pancreas transplant may be an option. Islet transplants are being
studied as well. With a successful pancreas transplant, you would no longer need insulin therapy.

But transplants aren't always successful. And these procedures pose serious risks. You need a lifetime of
immune-suppressing drugs to prevent organ rejection. These drugs can have serious side effects. Because of
this, transplants are usually reserved for people whose diabetes can't be controlled or those who also need a
kidney transplant.

Bariatric surgery

Some people with type 2 diabetes who are obese and have a body mass index higher than 35 may be helped by
having bariatric surgery. People who've had gastric bypass have seen major improvements in their blood sugar
levels. But this procedure's long-term risks and benefits for type 2 diabetes aren't yet known.

Treatment for prediabetes

If you have prediabetes, healthy lifestyle choices can help bring your blood sugar level back to normal. Or it
could keep it from rising toward the levels seen in type 2 diabetes. Keeping a healthy weight through exercise
and healthy eating can help. Exercising at least 150 minutes a week and losing about 7% of your body weight
may prevent or delay type 2 diabetes.

Drugs — such as metformin, statins and high blood pressure medications — may be an option for some people
with prediabetes and other conditions such as heart disease.
SIGN OF TROUBLE IN ANY TYPE OF DIABETES

Many factors can affect your blood sugar. Problems may sometimes come up that need care right away.

High blood sugar (hyperglycemia)

Your blood sugar level can rise for many reasons, including eating too much, being sick or not taking enough
glucose-lowering medication. Check your blood sugar level as directed by your provider. And watch for
symptoms of high blood sugar, including:

• Urinating often

• Feeling thirstier than usual

• Blurred vision

• Tiredness (fatigue)

• Headache

• Irritability

If you have hyperglycemia, you'll need to adjust your meal plan, drugs or both.

Increased ketones in your urine (diabetic ketoacidosis)

If your cells are starved for energy, your body may begin to break down fat. This makes toxic acids known as
ketones, which can build up in the blood. Watch for the following symptoms:

• Nausea

• Vomiting

• Stomach (abdominal) pain

• A sweet, fruity smell on your breath

• Shortness of breath

• Dry mouth

• Weakness

• Confusion

• Coma

You can check your urine for excess ketones with a ketones test kit that you can get without a prescription. If
you have excess ketones in your urine, talk with your provider right away or seek emergency care. This
condition is more common in people with type 1 diabetes.
Hyperglycemic hyperosmolar nonketotic syndrome

Hyperosmolar syndrome is caused by very high blood sugar that turns blood thick and syrupy.

Symptoms of this life-threatening condition include:

• A blood sugar reading over 600 mg/dL (33.3 mmol/L)

• Dry mouth

• Extreme thirst

• Fever

• Drowsiness

• Confusion

• Vision loss

• Hallucinations

This condition is seen in people with type 2 diabetes. It often happens after an illness. Call your provider or
seek medical care right away if you have symptoms of this condition.

Low blood sugar (hypoglycemia)

If your blood sugar level drops below your target range, it's known as low blood sugar (hypoglycemia). If you're
taking drugs that lower your blood sugar, including insulin, your blood sugar level can drop for many reasons.
These include skipping a meal and getting more physical activity than normal. Low blood sugar also occurs if
you take too much insulin or too much of a glucose-lowering medication that causes the pancreas to hold
insulin.

Check your blood sugar level regularly and watch for symptoms of low blood sugar, including:

• Sweating

• Shakiness

• Weakness

• Hunger

• Dizziness

• Headache

• Blurred vision

• Heart palpitations

• Irritability
 • Slurred speech

• Drowsiness

• Confusion

• Fainting

• Seizures

Low blood sugar is best treated with carbohydrates that your body can absorb quickly, such as fruit juice or
glucose tablets.