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

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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.