What is Diabetes Mellitus?

Diabetes mellitus is a kind of metabolic disease that is brought about by either the insufficient production of insulin or the inability of the body to respond to the insulin formed within the system.

 

In response to this, the body also produces symptoms of polyuria or frequent urination, polyphagia or increased hunger and polydipsia or increased thirst. Read on and get to know what is diabetes mellitus and the underlying processes that produce such conditions.

So what is diabetes mellitus exactly?

For us to know what is diabetes mellitus and to fully understand the condition, we must discuss the different types of diabetes mellitus.
The disease can be classified into three different categories: the type 1, type 2 and the gestational diabetes.

What is diabetes mellitus type 1?

Diabetes mellitus type 1 is caused by the loss of beta cells found in the islets of Langerhans in the pancreas.
Beta cells primarily produce insulin and hence, their loss will lead to huge insulin deficiencies in the body.
In most cases, the loss of the beta cells is caused by an autoimmune attack mediated by the body’s own T-cells.

Type 1 diabetes mellitus makes up 10% of all the diabetes mellitus cases in Europe and in North America.
Up until today, there have been no preventive measures found for disease. Most of the patients who acquire this type of diabetes are found in the younger populations. Because of this, Type 1 diabetes mellitus is also now known as the juvenile diabetes.

What is diabetes mellitus type 2?

Another type of diabetes mellitus is the type 2 diabetes. Type 2 diabetes is generally characterized by the body’s resistance to insulin. This is primarily attributed to the loss of certain insulin receptors in the tissues that are supposed to mediate the entrance of insulin into the body’s cells.

This particular kind of diabetes is the most common kind that afflicts most of the reported cases of the disease. Type 2 diabetes usually leads to hyperglycemia which can be tre
ated by a series of medications that can either improve the body’s insulin sensitivity or improve the liver’s production of insulin in the system.

The last major category of diabetes mellitus is the gestational diabetes. This type of diabetes commonly occurs in pregnant women and may disappear or even progress right after delivery. Gestational diabetes generally manifests the same kind of complication found in type 2 diabetes.

Just like in type 2 diabetes, the body also exhibits a resistance to insulin and can sometimes produce insufficient amounts of the substance as well. This kind of diabetes is fully treatable but may require very close monitoring.

Diabetes Mellitus: What is gestational diabetes?

 

 What is Diabetes Mellitus?
 

Gestational diabetes can have damaging effects to both the mother and the unborn baby.
Mothers who have untreated gestational diabetes may give birth to babies with macrosomia or high birth weight, congenital heart and nervous system anomalies, respiratory disease syndrome and even malformations of the skeletal muscles.

In most cases, pregnant women who have gestational diabetes are induced during labor or they are recommended to go through a caesarean section to prevent further complications during delivery.
Knowing such things about the disease is very important since it can give you a better understanding of what is diabetes mellitus and the proper steps that are needed to be taken for treatment.

Now I know, his got Neurofibromatosis

 

Aside from the ‘silent hill’ attraction, one of my earliest memories along ADD St (the main street at ADD Compound) was when I came to meet a man on my way home from school. He has remarkable bumps all over his body and is scattered throughout his face which now appears disfigured.

 

Many would think he may have a contagious illness, which will compel you to cover nose or curb on the edgiest way to simply avoid him, I on the other hand never did. Besides, compound guards and personnel are very strict about permitting anyone to enter the gates; you can rest your confidence that they do their jobs well by ensuring protection and security among its inhabitants, which took me to the conclusion that the man is not at all contagious.

 

My focal concern was on the bumps itself. I’ve never seen such before. My innocence about the condition was only cracked open when I read an article in the Philippine Star about a woman who suffers from the same disease only different in classification and symptoms which they call NEUROFIBROMATOSIS. The latter suffers from NF2 Neurofibromatosis having the symptoms of deafness, paralysis and brain tumors while the former is categorized under NF1 or Neurofibromatosis Type 1.

 

Neurofibromatosis is characterized by the growth of tumors around the nerve tissues which can be harmless or may cause serious damage if nerves or tissues are compressed. Tumors excessively proliferate to areas with rich nerve supply such as the skin, and main parts of the Central Nervous System (CNS). These also interferes melanocyte function which result to disordered skin pigmentation. This very rare disease is usually genetically-inherited or cause can be traced through family history. In very extreme cases can occur through gene-mutation. Both men and women is equally affected (autosomal dominant) and in order to have the disease only one copy of the disordered gene is needed. Therefore, if one of the parents has neurofibromatosis at least 50% is the chance for their child to acquire the condition as well.

 

Inflicted Individuals commonly have bumps under the skin, colored spots, skeletal problems, pressure on the spinal nerve roots, and other neurological problems.
I made superficial research about the different classification of Neurofibromatosis to gain wider understanding of the pathology and symptoms like and unlike.

Neurofibromatosis Type 1

-This is characterized by the growth of neurofibromas (which are noncancerous (benign) tumors that are usually located on or just under the skin.) However, when tumors strike nerves along the spine can become cancerous and now dubbed as malignant peripheral nerve sheath tumors. Malignancy happens usually on adolescence or adulthood period. Beginning early childhood, café-au-lait spots, a dark flat spots, Lisch nodule (a benign tumor developing in the colored part of the eye but don’t interfere vision operation), gliomas(tumor growing along the nerve path from eye to the brain and is responsible for vision reduction.) may occur.

-Additional signs and symptoms of neurofibromatosis type 1 include high blood pressure (hypertension), short stature, an unusually large head (macrocephaly), and skeletal abnormalities such as an abnormal curvature of the spine (scoliosis). Although most people with neurofibromatosis type 1 have normal intelligence, learning disabilities and attention deficit hyperactivity disorder (ADHD) occur frequently in affected individuals.

Neurofibromatosis Type 2

-This type of neurofibromatosis,unfortunately, can turn someone out a bed-ridden like the woman I was referring above post. Schwannomas or acoustic neuromas, tumors that develop along the nerve that carries information from the inner to the brain, are mostly associated with NF2. The usual symptoms are hearing loss, ringing of ears or tinnitus, motion and balance problem. When an affected person reach the early thirties or any period depending on severity, complication becomes aggravating, changes in vision or sensation, numbness or weakness in the arms or legs, and fluid buildup in the brain. Some people with neurofibromatosis type 2 also develop clouding of the lens (cataracts) in one or both eyes, often beginning in childhood.

Diabetes Mellitus – 12 Important Facts You Need to Know

Diabetes is a group of diseases caused by a relative or absolute deficiency of insulin in the body. Insulin is the hormone responsible for the proper uptake and utilization of glucose by the different body cells, the body cells need glucose to produce energy for them to use. The deficiency of this hormone thus causes accumulation of glucose in the blood leading to the development of the disease.

1. Diabetes mellitus is world wide epidemic with about 177 million people living with diabetes mellitus worldwide. This is expected to rise to 300 million by the year 2025.
80% of diabetes mellitus cases live in the developing countries while the remaining 20% live in developed countries.

There are however about 40% of undiagnosed cases. The projected rate of increase in developed countries by 2025 is 42% and 170% in developing countries {WHO1999}

2. Diabetes has no cure, it can only be controlled to keep the blood levels within the normal range and as long as this is maintained there will be less occurrence of complications.

3. It affects people of different sexes, different race, and different background.

4. It can be prevented.

5. It can cause serious hardship and suffering especially if not properly controlled.

6. There are different classes of diabetes;
a.type 1 diabetes mellitus
b.type 2 diabetes mellitus
c.gestational diabetes mellitus
d.impaired glucose tolerance {pre- diabetes}
e.secondary diabetes

7. It is the leading cause of blindness in adults.

8. It is the second most common cause of limb amputation after trauma.

9. It is the fourth most common cause of death in developed countries.

10. The occurrence of stroke and heart attack is four times more common amongst diabetics than in the normal population.

11. Diabetic management includes:
a- health education for diabetics to achieve healthy lifestyles.
b- nutritional consultations to achieve the adoption of healthy diet by the diabetic
c- close medical care and follow up by your physician
d- maintenance of blood sugar levels within normal range, fasting blood sugar

Diabetic (Diabetes mellitus)

Diabetic, Diabetes or Diabetes mellitus is a diseases in which your body cannot regulate the level of sugar in your blood. Basically, the sugar you take in form of food is broken down in glucose. This glucose is then transferred in the blood to be circulated in the body. Glucose is the fuel of the cells so cell takes their fuel from your blood. In your body there is an organ known as pancreas, this organ maintain the glucose level in your blood by injecting sufficient amount of Insulin so that cells can use glucose properly for their fueling.

If pancreas becomes ineffective than sugar level become high and you know that over fuelling or lubricating will result in engine failure. But before engine fails completely there are symptoms that engine will going to be failed and this stage is known as Pre-Diabetes.

• Pre-Diabetes: What is Pre-Diabetes

As I write above that before complete failure engine shows some symptoms so same as in your body if your pancreas are on route for failure and not producing sufficient amount of insulin as required, your sugar level will increase from normal but not much high and this is the sign that you are going to be a diabetic (diabetes) patient sooner or later this is also called “impaired glucose tolerance” or “impaired fasting glucose”. You should seriously concentrate on losing weight and changing your life style.

There are two types of diabetes, which are

1. Type 1 diabetes
2. Type 2 diabetes

1. Type 1 diabetes

Type 1 diabetes is the complete failure of pancreas, in this your pancreas are unable to produce insulin to regulate sugar level in blood. The only cause which is understood is the genetic disorder and other causes are still not known. This can be most probably hit you after age of 30, but it can also hit you at any age. After getting in Type 1 diabetes you must use insulin by injecting in your skin to maintain sugar level in the blood.

2. Type 2 diabetes

Type 2 diabetes is not a complete failure but can be called as complete disorder of sugar level in your glucose regulation system means no synchronization between the components of this system. In this your pancreas produces insulin, but your cell does not react to it and in result your sugar level become too high which lead to complications. This diabetic (diabetes) disease usually hit you over 35 year of age but can also hit in any age depending on your lifestyle, having junk food regularly, no exercise, genetics and increased age.

There is another special type of diabetic (diabetes) which is only related with pregnant woman and baby which is know as Gestational Diabetes:

• Gestational Diabetes:

Gestational Diabetes

Gestational Diabetes is just like Type 2 diabetes. In this your body’s glucose regulatory system becomes unsynchronized and your sugar level shoots up. This disease affects around 4~5 percent of all pregnant women, if not controlled serious complication will occurs which affects both you and your baby. This usually appears on the second trimester and disappears after the birth of the baby. Your doctor will guide you with medication, diet plan and some exercises. Gestational Diabetes will increase your chance of getting in Type 2 diabetes in life and also risk of getting in Gestational Diabetes in your next pregnancy.

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Diabetes mellitus (contents)

General information

• What is diabetes mellitus?
• Clinical presentation of diabetes
• Types of diabetes
• What is pre-diabetic state?
• Maturity onset dibetes of young adults
• Epidemiology of diabetes
• Nutrition of diabetes
• Ayurveda remedy for diabetes mellitus
• Bitter gourd remedy for diabetes mellitus
  

Type 1 Diabetes mellitus

• Type 1 diabetes mellitus
• Clinical features of type 1 dm
• Investigations for type1 dm
• Overview of management of type 1 dm
• Medication for type 1 dm
• Follow up plan for type 1dm

Type 2 Diabetes mellitus

• Type 2 diabetes mellitus
• Clinical features of type 2 dm
• Investigations for type2 dm
• Overview of management of type 2 dm
• Medication for type 2 dm
• Follow up plan for type 2 dm

Diabetes and pregnancy

• Diabetes and pregnancy
• Fetal abnormalities/problems (morbidity) with diabetes during pregnancy
• Maternal problems (morbidity) associated with diabetes during pregnancy
• Perinatal morbidities and birth injuries associated with pregnancies complicated with diabetes
• Investigations of diabetes during pregnancy
• Diagnosing diabetes during pregnancy
• Peripartal management of patients and fetuses with diabetes
• Pregnancy management of women with gestational diabetes (GDM)
• Pregnancy management of women with preexisting diabetes
• Insulin therapy for pregnant mothers with diabetes
• Medical Care for pregnancies complicated with diabetes
• Timing and route of delivery for pregnancies with diabetes.
• Screening for diabetes during pregnancy
• Follow up of diabetes mothers following delivery
• Medicolegal Pitfalls and diabetes in pregnancies

Investigations

• Laboratory tests for Screening and Diagnosis of diabetes mellitus
• Glucose tolerance test
• Glycosylated Hemoglobin (HbA1C)

Management

• Overview of management
• Nutritional advices
• Life style modifications
• Oral antidiabetic drugs
• Insulin

Oral antidiabetic drugs

• Oral glucose lowering agents
• Sulphonylureas
• Biguanides
• Thiazolidinediones
• Arcabose
• Meglitinides

Insulin

• PHYSIOLOGY OF INSULIN
• TYPES OF INSULIN
• Insulin injection technique
• Insulin resistance
• C-peptide

Diabetic emergencies

• Diabetic ketoacidosis
• Hyperglycemic hyperosmolar state

Complications of diabetes

• Complications of diabetes mellitus
• Diabetic Nephropathy
• Diabetic neuropathy
• Diabetic Retinopathy
• DIABETIC FOOT
• Management of diabetic foot diseases
• erectile dysfunction

Diabetes insipidus

• Diabetes insipidus
  

Erectile dysfunction and diabetes

• Male Erectile Failure and Diabetes
• Management of erectile dysfunction in diabetic patients

Diabetes and other conditions

• Hypertention and diabetes
• Surgery and diabetes
• Psychological aspects of diabetes

New developments

SearchMotron.com

What is diabetes mellitus?

Diabetes mellitus is a metabolic disorder. patients with diabetes mellitus have a high blood sugar (glucose) due to the lack of insulin or due to increased resistance to insulin. Diabetes mellitus is the new world pandemic. Now diabetes is considered as a part of metabolic syndrome.

There are four types of diabetes;

1. Type 1 diabetes mellitus ( due to lack of insulin)
2. Type 2 diabetes mellitus (due to increased resistence to insulin)
3. Type 3 diabetes mellitus ( secondary to other illness)
4. Type 4 diabetes mellitus (diabets mellitus during pregnancy)

Universal blue circle symbol for diabetes

clinical features, management and different aspects of diabetes mellitus depend on the type of diabetes mellitus.

What are the types of diabetes mellitus?

DEFINITION

Diabetes is a metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion or insulin action or both.

TYPES OF DIABETES

There are four types of diabetes.

1. Type 1 diabetes.
2. Type 2 diabetes.
3. Diabetes secondary to other diseases
4. Diabetes during pregnancy.

Type 1 diabetes

This is due to the lack of insulin. Insulin deficiency is due to the beta cell destruction by an autoimmune process. There are two types of type 1 diabetes according to the presence of immunological markers.

Type 1A diabetes is a condition resulting from autoimmune destruction of beta cells in which immunological markers can be detected whereas in Type 2B immunological markers cannot be detected.
Type 1 diabetes is common among younger people especially children. But it can affect any age group.
Latent Autoimmune Diabetes of Adults (LADA) is a variant of type 1 diabetes but it is difficult to distinguish from type 2 diabetes mellitus.

Type 2 diabetes

This is the commonest form of diabetes and it carries a significant risk of morbidities and mortalities. 90-95% of patients with diabetes belong to this category. This condition is due to the resistance to insulin. But sometime it can be due to the lack of insulin or both. Majority of patients are middle or older age group.

Diabetes secondary to other diseases

1-2% of diabetes patients belong to this group. This condition can be cured if the underlying cause is identified. This can be due to liver disorders, pancreatic disorders, other endocrinopathies or drug induced.

Diabetes during pregnancy (gestational diabetes mellitus).

This is a special category and it occurs during pregnancy and disappears after the delivery. But it is a real burden for the patient and doctors as it can be difficult to control. Obesity, family history of diabetes and past history of gestational diabetes are some risk factors.

Clinical presentation of diabetes mellitus

There are four ways of presentations;

1. asymptomatic( incidental finding)
2. presentation with acute symptoms
3. subacute presentation
4. presentation with complications

Asymptomatic presentation

This is the commonest presentation and it is an incidental finding during routine examination or medical examination for insurance/ license/ employment

There is no evidence of ill health

Elevated blood sugar level could be a finding at those routine examinations. There can be glucose in the urine as well, even though it is a clue of hyperglycemia, not diagnostic

Further investigations should be done

Acute presentation

Usually these patients present with classic triad of symptoms;

1. polyuria
2. polydipsia
3. weight loss

They have a brief history (2-6 weeks)

Usually patients with type 2 diabetes present like this

Subacute presentation

These patients have symptoms over a period of months or years. Common symptoms are polyuria, polydipsia, and weight loss.

They can also present with non-specific symptoms such as:

1. lack of energy
2. visual blurring
3. pruritus vulvae
4. balanitis

This is the usual presentation of type 2 diabetes mellitus.

Presentation with complications

Types of complications are;

1. microvascular
2. macrovascular
3. others

Microvascular complications;

1. nephropathy
2. neuropathy
3. retinopathy

Macrovascular complications;

1. Ischemic heart disease
2. stroke
3. peripheral vascular disease

Others;

1. staphylococcal skin infections (furuncles, carbuncles, abscesses)
2. wound infections

3. fungal infections

What is pre-diabetes?

Introduction

Pre-diabetes is a condition that comes before type 2 diabetes. Blood glucose (sugar) levels are higher than normal but aren’t high enough to be called diabetes. Pre-diabetes is a silent disease, meaning you can have it but not know it. By reducing the calorie intake, being physically active and loosing weight can delay the type 2 diabetes mellitus.

Prevention of type 2 diabetes mellitus

People with risk factors should be identified and they should be educated on how to reduce those risk factors.

Cut down calorie intake
Stop smoking
Exercise about 30 minutes per day
Loosing weight

People who are at risks;

You’re at risk for diabetes if you

1. are overweight
2. are physically inactive
3. have a parent, brother, or sister with diabetes
4. are African American, Native American, Asian American, Pacific Islander, or Hispanic American
5. have had a baby weighing more than 9 pounds or have had gestational diabetes
6. have high blood pressure (over 140/90 mmHg)
7. have low HDL cholesterol (35 mg/dl or lower)
8. or high triglycerides (250 mg/dl or higher)

Investigations

It does not have any symptoms therefore people with risk factors should undergo investigations.

1. fasting blood glucose

Pre-diabetes is diagnosed when fasting glucose levels are between 100 and 125 mg/dl. A fasting plasma glucose of 126 mg/dl or higher means diabetes.

2. oral glucose tolerance test

Pre-diabetes is diagnosed when blood glucose is between 140 and 199 mg/dl 2 hours after drinking glucose drink. These glucose levels are above normal but not high enough to be called diabetes. A 2-hour blood glucose of 200 mg/dl or higher means diabetes.


Treatment

There are no drugs to be effective in this condition. Only measures that patient should take is reduction of risk factors and undergoing regular assessments.

Maturity onset Diabetes of the Young (MODY)

Introduction

Diabetes is a metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion or insulin action or both. Several types of diabetes mellitus were described. Maturity onset diabetes of the young is a special type. The different MODY genotypes are associated with different clinical phenotypes. MODY should be considered in young people presenting with a typical family history (diabetes affecting a parent and 50% expression of the disease in the family) plus a form of early-onset diabetes which appears easy to control.

Maturity onset diabetes of the young (MODY) is a subtype of DM. It is characterized by autosomal dominant inheritance, early onset of hyperglycemia, and impairment in insulin secretion. Several monogenic forms of DM have been identified.

1. MODY 1

2. MODY 2

3. MODY 3

4. MODY 4

5. MODY 5

6. MODY 6

The glucokinase gene is intimately involved in the glucose-sensing mechanism within the pancreatic beta-cell. The hepatic nuclear factor (HNF) genes and the insulin promoter factor-1 (IPF-1) gene control nuclear transcription in the beta-cell where they regulate its development and function. Abnormal nuclear transcription genes may cause pancreatic agenesis or more subtle progressive pancreatic damage

MODY 1

This is caused by mutations in the hepatocyte nuclear transcription factors (HNF) 4a.

Chromosomal location	20q
Proportion of all MODY cases	5%
Onset	Teens to thirties
Progression	Progressive hyperglycemia
Microvascular complications	Frequent
Other features	None

MODY 2

MODY 2 is the result of mutations in the glucokinase gene that lead to mild-to-moderate hyperglycemia. Glucokinase catalyzes the formation of glucose-6-phosphate from glucose.

Chromosomal location	7q
Proportion of all MODY cases	15%
Onset	Present from birth
Progression	Little deterioration with age
Microvascular complications	Rare
Other features	Reduced birthweight

MODY 3

This is caused by mutations in the hepatocyte nuclear transcription factors (HNF) 1a.

Chromosomal location	12q
Proportion of all MODY cases	12q
Onset	teens/twenties
Progression	Progressive hyperglycemia
Microvascular complications	frequent
Other features	sensitive to sulphonylurea

MODY 4

This is a rare variant caused by mutations in the insulin promoter factor (IPF) 1, which is a transcription factor that regulates pancreatic development and insulin gene transcription.

Chromosomal location	13q
Proportion of all MODY cases	<1%
Onset	teens to thirties
Progression	Progression unclear
Microvascular complications	few data
Other features	Pancreatic agenesis in homozygotes

MODY 5

This is caused by mutations in the hepatocyte nuclear transcription factors (HNF) 1b.

Chromosomal location	17q
Proportion of all MODY cases	2%
Onset	Teens/twenties
Progression	Progression unclear
Microvascular complications	Frequent
Other features	Renal cysts, Proteinuria, Renal failure

MODY 6

This is due to the mutation in the neurogenic differention factor1 (NeuroD1)

Chromosomal location	2q
Proportion of all MODY cases	<7%
Onset
Progression
Microvascular complications
Other features

Type 1 diabetes mellitus

Introduction

Diabetes mellitus is a multisystem. Consequences are in the form of biochemical and anatomical. Disturbances in the metabolism of carbohydrates, protein and fat are the biochemical consequences whereas macrovascular and microvascular complications are the anatomical derangements. Absence or deficiency of insulin is the cause which result all the consequences of the type 1 DM. This is a disease of young individuals, not always.

How does it happen (Pathophysiology)?

Type 1 DM is a catabolic disorder in which circulating insulin is very low or absent. This is due to the failure of pancreatic beta cells to respond to all insulin-secretory stimuli. Therefore patients require exogenous insulin to reverse this catabolic condition, prevent ketosis, and normalize lipid and protein metabolism.

This is an autoimmune disease. There are histological evidence of immunological involvement such as lymphocytic infiltration and destruction of insulin-secreting cells of the islets of Langerhans, causing insulin deficiency. Approximately 85% of patients have circulating islet cell antibodies, and the majority also has detectable anti-insulin antibodies before receiving insulin therapy. Most islet cell antibodies are directed against glutamic acid decarboxylase (GAD) within pancreatic B cells.

There is another school of thought and it says that pancreatic beta cell destruction is due to an infectious or environmental agent. It triggers the immune system in a genetically susceptible individual to develop an autoimmune response against altered pancreatic beta cell antigens or molecules in beta cells that resemble a viral protein. Environmental agents that have been hypothesized to induce an attack on beta cell function include viruses (eg, mumps, rubella, Coxsackie B4), toxic chemicals, and exposure to cow's milk in infancy, and cytotoxins.

Recent evidence suggests a role for vitamin D in the pathogenesis and prevention of diabetes mellitus as well.

Epidemiology

This is the commonest metabolic disorder of childhood. Scandinavia has the highest prevalence rates for type 1 DM (ie, approximately 20% of the total number of people with DM), while China and Japan have the lowest prevalence rates, with less than 1% of all people with diabetes. Some of these differences may relate to definitional issues and the completeness of reporting.

Type 1 DM is more common in men than in women.

Type 1 DM usually starts in children aged 4 years or older, with the peak incidence of onset at 11-13 years of age, coinciding with early adolescence and puberty.

Type 1 DM is more common among non-Hispanic whites, followed by African Americans and Hispanic Americans. It is comparatively uncommon among Asians

Type 1 DM is associated with a high morbidity and premature mortality due to complications.

Epidemiology of Diabetes

Type 1 diabetes

The acute onset of type 1 diabetes and the fact that almost all cases rapidly reach medical attention means that registers of new cases can be relatively easily established. Provided ascertainment can be verified, these data can be combined with population denominator data to give age-specific and sex-specific rates.

1. Geographical variation

There is a marked geographical variation in the incidence of type 1 diabetes.In Finland, the age-standardized incidence in children aged 14 years and under is 36.8/100,000/year. A high rate is also observed in Sardinia (36.5/100,000/year) that is notably discordant with the incidence in Italy as a whole. These two countries have incidences 350-fold greater than those in Zunyi, China and Caracas, Venezuela, where the incidence is 0.1/100,000/year. In general, countries in Europe and North America have either high or intermediate incidences. The incidence in Africa is generally intermediate, and that in
Asia is low. Variation in incidence by age and sex – in the UK, wellestablished registers with high ascertainment (98.6%) (e.g. in Scotland) show an incidence of 15.3/100,000/year in children aged 0–4 years, rising to 24.4/100,000/year at 5–9 years and 31.9/100,000/year at 10–14 years. Overall, the incidence is slightly higher in boys than in girls (ratio 1.08:1). The peak incidence in boys is at 12–13 years,whereas in girls the peak occurs at 9–12 years.

2. Temporal variation

In the Scottish register, a steady increase in the incidence of type 1 diabetes of about 2% per annum was described during the period 1984–1993. This increase is seen in other studies worldwide in both low incidence and high-incidence areas. The overall pooled increase in 37 countries was 3.0% per year; the increase was relatively greater in populations with the lowest incidence. The incidence of type 1 diabetes also varies with season, being highest in autumn and winter.

3. Aetiological factors

genetic susceptibility is necessary but not sufficient as a cause of type 1 diabetes. The nature of the environmental factors that impact on this genetic predisposition are unclear. Studies have concentrated on the ecological correlation between incidence and geographical variation in environmental factors. These have includedsocial factors such as population density, household overcrowding and population mixing. These studies are ecological because the data on the risk of outcome (diabetes) is not collected from the same individuals as that on exposure (social factors). Inferences about causality from such data are weaker than evidence from studies based on the association between individual exposure and risk. However, prospective cohort studies are difficult to conduct in type 1 diabetes because of the relatively low incidence – many individuals would have to be recruited and assessed and only a few would progress to disease.The case-control approach is efficient, but is subject to recall bias because exposure is assessed by proxy from parents after the diagnosis has been made. Case-control studies havedemonstrated associations with early social mixing, viral infections, toxins and dietary factors such as exclusive breastfeeding and delayed introduction of cows’ milk.

Type 2 diabetes

1. geographical variation

The slow onset of type 2 diabetes, and its presentation without the acute metabolic disturbance seen in type 1 diabetes, means that the true time of onset is difficult to determine. Thus, the distinction between abnormality and normality is more blurred, there is a long pre-detection period, and as many as one-half of cases in the population at any one time are undiagnosed. Data on the prevalence of clinically detected type 2 diabetes provide information that is useful for health service planning, but cannot provide any insight into the true prevalence unless the prevalence of undetected diabetes is also known. Because the ratio of detected to undetected cases may vary over time and between places, epidemiological research aimed at defining the true prevalence of type 2 diabetes has had to rely on special studies in which the presence and absence of disease is defined by the oral glucose tolerance test (OGTT). However, the distinction between normality and abnormality is unclear, and debate continues about how it should be defined. The WHO currently recommends use of the 75-g OGTT, with diabetes defined by fasting glucose 7.0 mmol/litre or more and/or 2-hour post-challenge glucose 11.1 mmol/litre or more. Geographical variation – Figure 2 shows the agestandardized and sex-standardized prevalence of type 2 diabetes and impaired glucose tolerance as defined by the 75-g OGTT in various countries. As in type 1 diabetes, there is marked geographical variation, but the pattern is different. The prevalence is lowest in rural areas of developing countries, is generally intermediate in developed countries, and is highest in certain ethnic groups who have adopted Western lifestyle patterns. The populations with the highest prevalences (Pima Indians in Arizona and Nauruans in Micronesia) have a high prevalence of obesity. It is hypothesized that genetic susceptibility to obesity in these populations would be disadvantageous in times of food abundance, but would be advantageous when food is scarce, giving rise to maintenance of the gene by natural selection. This ‘thrifty genotype’ hypothesis is supported by evidence of gene–environment interaction – individuals who migrate from low prevalence areas (e.g. Japan) to the West are at increased risk of type 2 diabetes.

In the UK, the prevalence of known diabetes is about 2% and the age-standardized prevalence of undiagnosed diabetes is 2% in the over-40s. The true incidence of the disease is difficult to determine because this requires repeated glucose tolerance testing. However, such studies have been undertaken and the incidence found to be about 6/1000 personyears of follow-up. The incidence in individuals known to have impaired glucose tolerance is about eight times greater than in those with normal glucose tolerance; the absolute cumulative incidence is 10% over 5 years in Caucasians, but may be higher in high-risk populations. The risk of future progression to diabetes is also greater in those with other hyperglycaemic states, including gestational diabetes mellitus.

2. Temporal variation

data from studies such as the National Health and Nutrition Examination Survey (NHANES III) demonstrate that the prevalence of type 2 diabetes in the USA increased by 33%, from 4.9% in 1990 to 6.5% in 1998. This increase mirrors the increasing prevalence of obesity. Repeated surveys in developing countries show even more marked increases, particularly in areas where populations are rapidly adopting Western lifestyles . The increase in the prevalence of obesity in childhood has led to the appearance of type 2 diabetes in children and young adults, particularly those in highly susceptible ethnic groups.

3. Aetiological factors

Prospective population-based cohort studies suggest that the main pathophysiological defects leading to type 2 diabetes are insulin resistance and a relative insulin secretory defect. The main aetiological risk factors for type 2 diabetes are age, obesity, family history, physical inactivity and dietary factors such as a high proportion of energy consumed as saturated fat and low intake of fruit and vegetables. The observation of an association between low birth weight and risk of diabetes in later life has led to the development of an alternative to the thrifty genotype hypothesis. In this ‘thrifty phenotype’ hypothesis, the risk of diabetes and other adult disorders is programmed by fetal nutrition and the pattern of early growth. The causal nature of these associations is strengthened by data from studies in which the incidence of diabetes is reduced by interventions aimed at reducing weight, increasing activity and improving diet.

Clinical features of type 1diabetes mellitus

In clinical practice, history, examination and investigations are important to diagnose the disease. History and examinations are the fundamental things and they give evidence of the condition.

History

Polyuria (increased frequency of urination), polydipsia (thirst), and polyphagia (Increased appetite) are the cardinal features of type 1 diabetes. Patients can have other features like lassitude, nausea and blurred vision as well. These symptoms are due to the hyperglycemic state. Usually the onset is sudden. Disease maybe diagnosed following an infection. Usually patients are lean and present with features of ketoacidosis. History may reveal following features;

1. Polyuria: this is due to osmotic diuresis secondary to hyperglycemia.
2. Thirst is due to the hyperosmolar state and dehydration.
3. Polyphagia with weight loss: The weight loss with a normal or increased appetite is due to depletion of water and a catabolic state with reduced glycogen, proteins, and triglycerides.
4. Fatigue and weakness: This may be due to muscle wasting from the catabolic state of insulin deficiency, hypovolemia, and hypokalemia.
5. Muscle cramps: This is due to electrolyte imbalance.
6. Nocturnal enuresis: Severe enuresis secondary to polyuria can be an indication of onset of diabetes in young children.
7. Blurred vision: This also is due to the effect of the hyperosmolar state on the lens and vitreous humor. Glucose and its metabolites cause dilation of the lens, altering its normal focal length.
8. Gastrointestinal symptoms: Nausea, abdominal discomfort or pain, and change in bowel movements may accompany acute DKA. Acute fatty liver may lead to distention of the hepatic capsule, causing right upper quadrant pain. Persistent abdominal pain may indicate another serious abdominal cause of DKA, eg, pancreatitis. Chronic gastrointestinal symptoms in the later stage of diabetes are due to visceral autonomic neuropathy.
9. Patients may maintain their normal weight or exhibit wasting, depending on the interval between the onset of the disease and initiation of treatment.
10. Peripheral neuropathy: It presents as numbness and tingling in both hands and feet, in a glove and stocking pattern. It is bilateral, symmetric, and ascending neuropathy, which results from many factors, including the accumulation of sorbitol in peripheral sensory nerves due to sustained hyperglycemia.
11. Symptoms at the time of the first clinical presentation usually can be traced back several days to several weeks; however, beta cell destruction may have started months, or even years, before the onset of clinical symptoms.

Examination findings

Usually physical examination is normal. If the patient present with diabetes ketoacidosis, signs of Kussmaul respiration, dehydration, hypotension will be there.
In established cases, patients should be examined every 3 months for macrovascular and microvascular complications. They should have funduscopic examination for retinopathy and monofilament testing for peripheral neuropathy.

Investigations for type1 diabetes mellitus

Investigations are important to diagnose the diabetes and to identify the type of the diabetes as well. Types of investigations are;

1. hematological
2. genetic studies


Hematological investigations (Blood tests)

• Blood glucose: This is the mainstay of test to diagnose. Results are interpreted according to the
• Serum electrolytes: to identify the renal involvement.
• Urinalysis for glucose, ketones, and protein: these are important to detect renal involvement and diabetes ketoacidosis.
• White blood cell count and blood and urine cultures to rule out infections.
• Glycosylated hemoglobin (Hb)/Hb A1c ; this is a good test to recognize the glycemic control
• Oral glucose tolerance test with insulin levels: Although this test usually is considered unnecessary to make the diagnosis in type 1 DM, with the dramatic increase of type 2 diabetes in the young population, assessment of insulin secretion may become more important.
• To determine whether the individual has type 1 rather than type 2 DM, an insulin and/or C-peptide level below 5 µU/mL, or 0.6 ng/mL, suggests type 1. C-peptide is formed during conversion of proinsulin to insulin. A high positive titre of glutamic acid decarboxylase antibodies also suggests type 1 DM. An exception is the individual with type 2 DM who presents with a very high glucose, eg, above 300 mg/dL, who temporarily has a low insulin and/or C-peptide level but who will recover insulin production once normal glucose is restored.
• Islet cell antibodies
• Thyroxine (T4) and thyroid antibodies

Genetic studies

• HLA typing may be considered.

Overview of management of type 1 diabetes mellitus

Treatment of this disease requires a multidisciplinary approach by physician, nurse, and dietitian.

Medical Care

Type 1 DM patients require insulin therapy to control initial hyperglycemia and maintain serum electrolytes and hydration. At times, the first incidence of ketoacidosis is followed by a symptom-free period where patients do not need treatment. This "honeymoon period" follows the initial treatment, in which the disease remits and the patient requires little or no insulin. This remission is due to a partial return of endogenous insulin, which may last for several weeks or months (and sometimes 1-2 y). Ultimately, however, the disease recurs, and patients require insulin therapy.

Multiple subcutaneous insulin injections are administered to control hyperglycemia after meals and to maintain normal plasma glucose levels throughout the day. This may increase the risks of hypoglycemia. Therefore, patients should be well educated about their disease and about self-monitoring of plasma glucose levels.


Surgical Care

Pancreatic transplantation is a possibility in some referral centers and is performed most commonly with simultaneous kidney transplantation for end-stage renal disease.

Consultations

These patients should be referred to an endocrinologist for multidisciplinary management.
These patients should have a complete retinal examination by an ophthalmologist at least once a year.The patients with significant proteinuria or a reduced creatinine clearance should be referred to a nephrologist.

Diet

One of the first steps in managing type 1 DM is diet control. Diet recommendations should be made in view of the patient's eating habits and lifestyle.Diet management includes education about the timing, size, frequency, or composition of meals to avoid hypoglycemia or postprandial hyperglycemia. All patients on insulin should receive a comprehensive diet plan that includes a daily caloric intake prescription; recommendations for amounts of dietary carbohydrate, fat, and protein; and how to divide calories between meals and snacks. A professional dietitian should be involved to create the individual diet plan.

Activity

Exercise is an important aspect of diabetes management. Patients should be encouraged to exercise regularly. Educate the patients about the effects of exercise on the blood glucose level. If patients are planning to participate in rigorous exercise for more than 30 minutes, they may develop hypoglycemia. To prevent hypoglycemia, they either can decrease the insulin by 10-20% or can have an extra snack. These patients must maintain their hydration status during exercise