DIABETES MELLITUS (DM)

Diabetes mellitus is a disorder of the endocrine gland and it is a major or common condition that is characterized by elevated blood sugar (hyperglycemia). Diabetes mellitus result from deficiency of insulin or resistance of the body to available insulin in metabolism of carbohydrate which is characterized by elevated blood sugar (hyperglycemia).

For instance, when an individual eat carbohydrate (Rice, Bread, etc.), the body breaks it down into glucose (sugar). The glucose remains in the bloodstream and needs “a key” to get it to where it is used inside the body’s cells. The key is called insulin. Insulin is a hormone produced by the pancreas that regulates the level of blood glucose. The pancreas releases insulin which allows glucose to enter into the body’s cells. If the individual’s pancreas doesn’t make enough or any insulin or if the pancreas makes insulin but the body’s cells don’t respond to it and can’t use it as it used to, Diabetes can be diagnosed.

Types of Diabetes Mellitus

The types of Diabetes Mellitus include:

  1. Type 1 Diabetes Mellitus: Also known as Insulin dependent diabetes mellitus (IDDM). The individual depends on synthetic insulin because the pancreas is not able to secrete insulin needed for glucose regulation. This type is common in people younger than 25 years of age. It can also be called the Juvenile Diabetes Mellitus.  
  2. Type 2 Diabetes Mellitus: Also known as non-insulin dependent diabetes mellitus (NIDDM). In this type, the pancreas doesn’t make enough insulin or the body’s cells does not respond normally to insulin. This is the most common type of diabetes. It is common in people that are over 40 years of age.
  3. Gestational Diabetes Mellitus: this occurs during pregnancy. During pregnancy, the rate of secretion of placenta hormones (e.g., progesterone) increases which create anti-insulin effects, making the available insulin less effective bringing about hyperglycemia. It subsides after childbirth.
  4. Prediabetes: This is the type before Type 2 diabetes mellitus. The blood glucose is higher than normal but not high enough to be officially diagnosed with Type 2 diabetes mellitus.
  5. Diabetes Mellitus associated with other conditions or pathological processes: This type of diabetes could be related to pancreatic diseases, hormonal abnormality, and use of drugs such as excess management of hypoglycemic (low blood glucose level) conditions.

Risk Factors of Diabetes Mellitus

There are certain factors that increase one’s chance of developing a type of Diabetes Mellitus.

Risk factors for Type 1 Diabetes Mellitus

  1. Family history of Type 1 Diabetes mellitus
  2. Exposure to illnesses caused by virus
  3. Presence of autoantibodies that mistakenly attack the individual’s own body tissues
  4. Injury to the pancreas
  5. Physical stress from surgery or illnesses

Risk Factors for Type 2 and Gestational Diabetes Mellitus

  1. Family history of Type 2 Diabetes mellitus
  2. Obesity
  3. Age 40 or older
  4. Having preexisting disease conditions like hypertension, heart disease or stroke, liver disease, etc.
  5. Being physically inactive
  6. Race: being African-American, Native American, Asian-American, Hispanic or Pacific Islander.

Symptoms of Diabetes Mellitus

They include:

  1. Polyphagia: excessive hunger
  2. Polydipsia: excessive thirst
  3. Polyuria: excessive urination
  4. Glucosuria: Glucose in urine
  5. Dehydration
  6. Weight loss
  7. Slow-healing cuts or sores
  8. Fatigue
  9. Weakness
  10. Acetone breath
  11. Poor skin tugor
  12. Visual disturbances
  13. Decreased peripheral pulse
  14. Recurrent skin, vulva and urinary tract infection

Diagnostic Evaluation of Diabetes Mellitus

Diabetes mellitus can be diagnosed when blood glucose is analyzed on at least two (2) occasions.

  1. Fasting Plasma (Blood) Glucose: This test is done early in the morning after an eight hour fast. Fasting blood glucose level of 126mg/dL or above is diagnostic of diabetes mellitus. Fasting blood sugar level of 99mg/dL or lower is normal and 100 to 125mg/dL is shows prediabetes.
  2. Random Blood Glucose Level: This test is done anytime of the day without the need to fast. The normal level for random blood glucose is less than 140mg/dL, Prediabetes is between 140 and 199mg/dL and Diabetes is diagnosed at 200mg/dL or higher.
  3. Post Prandial Blood Glucose: The individual is conditioned to orally take high dose of glucose. In a normal individual, the glucose level will reduce after sometime while in a diabetic person, the glucose level remains elevated. Normal range is below 140mg/dL. A level between 140 and 199mg/dL indicates prediabetes. Any value above 200mg/dL is diagnostic.
  4. Glycosylated Hemoglobin Test (A1c Test): This test measures the amount of glucose in hemoglobin, and the protein in red blood cells. The test shows the average blood sugar level over the past two to three months.
  5. Glucose Tolerance Test: This reveals elevated glucose both in the blood and urine after ingestion of carbohydrate substances. Here, blood glucose levels are checked at hours one, two or three. The blood glucose level is first measured after an overnight fast, then the individual takes a sugary drink before the next check. The normal level is less than 140mg/dL, Prediabetes is between 140 and 199mg/dL and Diabetes is diagnosed at 200mg/dL or higher.
  6. Arterial blood gas studies: Which will reveal mild lactic acidosis.
  7. Renal Function Test: This test will reveal azotemia (elevated blood urea).
  8. Urinalysis: This test will reveal glucose in urine.

Management of Diabetes Mellitus

To best manage diabetes, it requires careful monitoring and healthy lifestyle adjustment to maintain blood sugar level to normal and to prevent complications and emergencies.

Components of Diabetes Mellitus Management includes:

N: Nutritional management

A: Activity/Exercise

A: Appropriate monitoring

P: Pharmacological management (drugs)

P: Patient and family education

  1. Nutritional Management: For all types of diabetes, refined and simple sugar should be restricted. Plan what to eat and follow a healthy meal plan. Follow a Mediterranean diet (vegetables, whole grains, beans, fruits, healthy fats, low sugar) or DASH diet (foods rich in fruits, vegetables, whole grains and low-fat dairy foods). Also, weight reduction is necessary especially for individuals with type 2 diabetes.
  2. Activity/Exercise: Exercise at least 30 minutes per day. The exercise programme must be consistent. Exercise lowers blood glucose level as well as maintaining lower cholesterol level. It also improves insulin sensitivity. It helps to reduce weight, increase strength and promote circulation.
  3. Appropriate Monitoring: Self-monitoring can be facilitated by the use of glucose monitoring devices designed to provide timely measurement of glucose level e.g., the use of glucometer and urinalysis will reveal glucose level. Appropriate monitoring helps to reduce complications and manage diabetes effectively.
  4. Pharmacological Management (Drugs): This involves insulin replacement in Type 1 and the use of oral hypoglycemic agents in Type 2. Insulin could also be used in some Type 2 diabetes.

Insulin Replacement: There are three types of synthetic insulin which is based on their onset, the peak, and the duration, for the treatment of diabetes.

  1. Rapid/Short Acting Insulin: A typical example is the regular insulin also known as “Humulin”. Its onset of action in the body is 15-30 minutes, peak at 1to 2 hours and last for 8-12 hours. The regular insulin is the only form of insulin that is clear and therefore administered through IV (Intravenously) or subcutaneous route.
  2. Intermediate Acting Insulin: A typical example of this form of insulin is NPH (Neural Prostamine Hagedon). When administered subcutaneously, the insulin is gradually released giving it the intermediate acting. It has an onset of one to one and half hours, peak at 4-12 hours and last for 20-24 hours.
  3. Long-Acting Insulin: a typical example is ultra-Lente. It is a crystalline insulin with an onset of 2-6 hours, peak of 7-10 hours, and duration of 24-36 hours.

Oral Hypoglycemic Agents: These are used for individuals with Type 2 diabetes mellitus for whom diet alone cannot control the high blood glucose level. The major action of the agent is to increase insulin production. Examples include:

  1. Sulfonylureas: e.g., Chlorpropamide, Acetohexamide, Glipizide, etc. These drugs reduce blood glucose by causing the pancreas to release more insulin.
  2. Biguanides: a major example is Metformin (Glucophage). This drug keeps the liver from releasing too much stored glucose.
  3. Alpha-Glycosidase Inhibitors: e.g., Acarbose. This drug slows the digestion of some carbohydrate thereby reducing blood glucose level.
  4. Glinides (Meglitinides): e.g., Repaglinide, Nateglinide. These drugs lower blood sugar by allowing the pancreas to release more insulin.
  5. Thiazolidinediones: e.g., Pioglitazone and Rosiglitazone. These drugs make muscle cells more sensitive to insulin thereby decreasing blood glucose level. Patient and Family Education: The following must be emphasized when educating the patient and his/her family: Ensure home monitoring of blood glucose; Ensure daily exercise; Properly bathe, dry and lubricate feet. Inspect feet daily for redness, blisters and wear well fitted shoes; Diet should be low in fat and high in fiber; Ensure proper care of minor wounds; Lower stress level and; Ensure compliance to medications.

Prevention of Diabetes Mellitus

Type 1 diabetes can not be prevented because it is an autoimmune disease (the body attacks itself) and can also be caused by genetic factors. Prevention of Type 2 and Gestational diabetes include:

  1. Eat a healthy diet e.g., Mediterranean or Dash diet
  2. Ensure adequate physical exercise at least 30 minutes per day
  3. If overweight or obese, lose weight
  4. Reduce stress level. Adopt healthy strategies to manage stress e.g., deep breathing exercises, Yoga, etc.
  5. Reduce alcohol intake
  6. Quit smoking
  7. Ensure to have enough rest and adequate sleep for at least 8 hours per day
  8. Ensure strict compliance to medications for managing preexisting conditions e.g., Hypertension
  9. Ensure proper hydration
  10. Monitor blood glucose level closely

Complications of Diabetes Mellitus

  1. Gangrene: death of tissue caused by lack of blood flow or infection in the extremities or skin.
  2. Retinopathy (visual problems)
  3. Infection
  4. Diabetic ketoacidosis: acute and life-threatening condition that result from abnormal carbohydrate, fat, and protein metabolism due to lack of effective insulin.
  5. Hypoglycemia or insulin reactions
  6. Cardiovascular issues including hypertension, atherosclerosis, coronary artery disease, etc.
  7. Nerve damage (Neuropathy)
  8. Kidney damage (Nephropathy)
  9. Complications of gestational diabetes in the mother include preeclampsia (high blood pressure, excess protein in urine, and feet swelling).
  10. Complications of gestational diabetes in the baby/newborn include fetal macrosomia (higher than normal birth weight) and low blood sugar (hypoglycemia).

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