ABSTRACT:
Diabetes mellitus, commonly known as Diabetes, comprises a group of prevalent endocrine disorders characterized by sustained elevated levels of blood sugar. Diabetes arises from either inadequate insulin production by the pancreas or reduced responsiveness of the body's cells to the effects of this hormone. The indications encompass thirst, polyuria, weight loss, and blurred vision. If it is left untreated, the ailment can lead to various health complications, including disorders of the cardiovascular system, eyes, kidneys, and nerves.
INTRODUCTION:
The primary categories of Diabetes are type 1 and type 2, though there are other variants. Type 1 is typically managed through insulin replacement therapy (insulin injections), while type 2 can be controlled with anti-diabetic medications (like metformin and semaglutide) as well as lifestyle adjustments. Gestational Diabetes, occurring during pregnancy in some women, usually resolves shortly after childbirth. More than half a billion people are living with Diabetes worldwide, affecting men, women, and children of all ages in every country, and that number is projected to more than double to 1.3 billion people in the next 30 years.
SYMPTOMS:
Retinopathy, nephropathy, and neuropathy stand as potential diabetes complications.
Untreated Diabetes traditionally exhibits symptoms such as polyuria, thirst, and weight loss. Several other symptoms may also emerge, including fatigue, impaired vision, and genital itchiness. Type 1 diabetes emerges after a preclinical phase, while type 2 has a more gradual onset, with patients possibly remaining asymptomatic for numerous years.
Diabetic ketoacidosis represents a medical emergency, primarily seen in type 1 diabetes but also possible in longstanding type 2 or cases involving significant β-cell dysfunction. Excessive ketone body production gives rise to symptoms such as nausea, vomiting, abdominal pain, and reduced consciousness levels. Hypoglycaemia is a recognized complication of insulin treatment in Diabetes. Acute occurrences can encompass mild symptoms like sweating, trembling, and palpitations, progressing to more severe outcomes including impaired cognition, confusion, seizures, coma, and, rarely, death.
LONG TERM COMPLICATIONS:
Diabetes's major long-term complications damage blood vessels and double the risk of cardiovascular disease, with approximately 75% of diabetes-related deaths attributed to coronary artery disease. Microvascular ailments affect the eyes, kidneys, and nerves. Damage to the retina, known as diabetic retinopathy, is the leading cause of working-age blindness, including cataracts and glaucoma.
CAUSES:
WHO classifies Diabetes into six categories: type 1 diabetes, type 2 diabetes, hybrid forms of diabetes, hyperglycemia first detected during pregnancy, "other specific types," and "unclassified diabetes." Diabetes is more diverse than initially believed, and individuals might have a blend of different forms.
TYPE 1:
Type 1 diabetes comprises 5 to 10% of diabetes cases and is the predominant type diagnosed in individuals under 20 years old. Nevertheless, the term "juvenile-onset diabetes" is obsolete, as the disease can begin in adulthood. This condition involves the loss of insulin-producing beta cells in the pancreatic islets, causing a profound scarcity of insulin. It can be categorized as immune-mediated or idiopathic, lacking a known cause. Most cases are immune-mediated, where an autoimmune attack driven by T cells destroys beta cells, causing insulin deficiency. Due to severely low insulin levels and impaired counter-response to hypoglycemia, patients frequently experience erratic and unpredictable blood sugar levels.
TYPE 2:
Insulin resistance, sometimes coupled with reduced insulin secretion, characterizes type 2 diabetes. Type 2 diabetes constitutes the vast majority, accounting for 95% of diabetes cases. Many individuals with type 2 diabetes show signs of prediabetes (impaired fasting glucose and/or impaired glucose tolerance) before meeting the criteria for full-blown type 2 diabetes. Progression from prediabetes to overt type 2 diabetes can be managed by lifestyle adjustments or medications that enhance insulin sensitivity or reduce the liver's glucose output.
The primary contributors to type 2 diabetes are lifestyle factors and genetics. Several lifestyle elements play crucial roles in type 2 diabetes development, including obesity (defined by a body mass index over 30), sedentary behavior, unhealthy diets, stress, and urban living. Excess body fat contributes to 30% of cases in individuals of Chinese and Japanese descent, 60–80% in those of European and African descent, and 100% in Pima Indians and Pacific Islanders. Even non-obese individuals may have a high waist-to-hip ratio. Dietary components, such as sugary drinks, heighten risk, while the types of fats consumed matter, with saturated and trans fats increasing risk, and polyunsaturated and monounsaturated fats reducing it. Overconsumption of white rice is linked to elevated diabetes risk, especially in Chinese and Japanese populations. Inadequate physical activity also raises diabetes risk in some individuals. Additionally, adverse childhood experiences, like abuse and neglect, increase the likelihood of type 2 diabetes by 32%, with neglect exerting the strongest influence.
GESTATIONAL DIABETES:
Gestational diabetes shares similarities with type 2 diabetes, involving a combination of insufficient insulin secretion and responsiveness. It occurs in around 2-10% of pregnancies and may ameliorate or vanish after childbirth. Testing is recommended for all pregnant women around weeks 24-28 of gestation. Diagnosis usually occurs in the second or third trimester, coinciding with elevated levels of insulin-antagonist hormones. Nevertheless, around 5-10% of women initially diagnosed with gestational Diabetes subsequently show another form of Diabetes, most often type 2. The condition can be effectively managed through medical supervision during pregnancy, involving dietary adjustments, blood glucose monitoring, and potentially insulin administration.
OTHER TYPES:
Maturity onset diabetes of the young (MODY) is a rare form of Diabetes inherited in an autosomal dominant manner. It is caused by specific single-gene mutations that lead to defects in insulin production. Unlike the three main types of Diabetes, MODY is far less prevalent, constituting only 1-2% of all cases. The term "Maturity onset diabetes of the young" originates from initial theories about its nature. Since it arises from a faulty gene, its onset age and severity can vary depending on the specific gene mutation involved. There are at least 13 subtypes of MODY identified. People with MODY can often manage their condition without requiring insulin treatment.
Another variant of Diabetes that individuals might develop is referred to as double Diabetes. This occurs when a person with type 1 diabetes becomes insulin resistant, a hallmark of type 2 diabetes, or has a familial predisposition to type 2 diabetes. The concept of double Diabetes was first identified in 1990 / 1991.
LIST OF CONDITIONS THAT CAN ELEVATE THE RISK OF DIABETES:
- Genetic defects affecting β-cell function
- Maturity onset diabetes of the young
- Mutations in mitochondrial DNA
- Genetic defects in insulin processing or insulin action
- Aberrations in proinsulin conversion
- Mutations in the insulin gene
- Mutations in insulin receptors
EXOCRINE PANCREATIC DISORDER: (referred to as Type 3c diabetes)
- Chronic pancreatitis
- Pancreatectomy
- Pancreatic neoplasms
- Cystic fibrosis
- Hemochromatosis
- Fibrocalculous pancreatopathy
- Endocrine disorders
- Excess growth hormone (acromegaly)
- Cushing syndrome
- Hyperthyroidism
- Hypothyroidism
- Pheochromocytoma
- Glucagonoma
INFECTIONS:
- Cytomegalovirus infection
- Coxsackievirus B
MEDICATIONS:
- Glucocorticoids
- Thyroid hormone
- β-adrenergic agonists
- Statins
CAUSES OF INSULIN PRODUCTION:
Insulin is the primary hormone responsible for regulating glucose uptake from the bloodstream into most cells, including the liver and adipose tissue. Thus, any deficiency in insulin or the insensitivity of its receptors plays a central role in all types of Diabetes mellitus. The body acquires glucose from three primary sources: the absorption of food in the intestines, the breakdown of liver-stored glycogen, and the creation of glucose from non-carbohydrate substances in the body. Insulin governs glucose levels by inhibiting glycogen breakdown and gluconeogenesis, encouraging glucose transport into fat and muscle cells, and promoting glucose storage as glycogen. The outcome is consistently high blood glucose levels, impaired protein synthesis, and various metabolic abnormalities, including metabolic acidosis in cases of complete insulin deficiency.
Persistent high blood glucose concentrations prompt the kidneys to surpass their reabsorption threshold, causing glucose to be expelled in urine. This elevates urine osmotic pressure and hampers kidney water reabsorption, resulting in greater urine production and increased fluid loss. The body replenishes lost blood volume osmotically by drawing water from cells and other compartments, leading to dehydration and heightened thirst. Moreover, insufficient intracellular glucose triggers appetite, causing excessive food consumption.
DIAGNOSIS:
Diabetes mellitus is diagnosed using a blood test to measure glucose levels, and diagnosis involves meeting any of the criteria below:
- Fasting plasma glucose level ≥ 7.0 mmol/L (126 mg/dL). This involves taking blood after an overnight fast, typically in the morning before breakfast.
- Plasma glucose ≥ 11.1 mmol/L (200 mg/dL) two hours after consuming a 75-gram oral glucose load during a glucose tolerance test (OGTT).
- Presence of high blood sugar symptoms and plasma glucose ≥ 11.1 mmol/L (200 mg/dL) whether fasting or not.
- Glycated hemoglobin (HbA1C) ≥ 48 mmol/mol (≥ 6.5 DCCT %).
According to WHO’s diabetes diagnostic criteria,[74][75] the values are as follows:
- Normal: 2-hour glucose < 7.8 mmol/L, fasting glucose < 6.1 mmol/L, HbA1c < 42 mmol/mol
- Impaired fasting glycaemia: 2-hour glucose < 7.8 mmol/L, fasting glucose 6.1–7.0 mmol/L, HbA1c 42–46 mmol/mol
- Impaired glucose tolerance: 2-hour glucose ≥ 7.8 mmol/L, fasting glucose < 7.0 mmol/L, HbA1c 42–46 mmol/mol
- Diabetes mellitus: 2-hour glucose ≥ 11.1 mmol/L, fasting glucose ≥ 7.0 mmol/L, HbA1c ≥ 48 mmol/mol
A positive result without clear high blood sugar requires confirmation on a different day using the same methods. Fasting glucose measurement is preferred due to its ease compared to the two-hour glucose tolerance test, which offers no added advantage. According to the current definition, two fasting glucose measurements at or above 7.0 mmol/L (126 mg/dL) confirm diabetes mellitus.
Per WHO, fasting glucose levels between 6.1 and 6.9 mmol/L (110 to 125 mg/dL) indicate impaired fasting glucose. Plasma glucose at or above 7.8 mmol/L (140 mg/dL), but below 11.1 mmol/L (200 mg/dL) two hours after a glucose load suggests impaired glucose tolerance. The latter condition significantly increases the risk of developing Diabetes and cardiovascular disease.[78] The American Diabetes Association (ADA) uses a slightly different range for impaired fasting glucose, 5.6 to 6.9 mmol/L (100 to 125 mg/dL).
Glycated hemoglobin is a more effective marker than fasting glucose for predicting cardiovascular risks and all-cause mortality. For individuals with type 1 diabetes experiencing severe complications such as end-stage kidney disease necessitating kidney transplantation, a pancreas transplant is occasionally considered.
DIABETES LEADS TO BLOOD PRESSURE:
Cardiovascular disease is a severe complication linked to Diabetes, and numerous international guidelines propose blood pressure targets lower than 140/90 mmHg for individuals with Diabetes. Nevertheless, the exact recommended lower targets are supported by limited evidence. A systematic review in 2016 revealed potential harm in aiming for targets below 140 mmHg. Subsequently, a 2019 systematic review noted that reducing blood pressure to between 130 – 140 mmHg showed no added benefits and posed an increased risk of adverse events.
The 2015 recommendations of the American Diabetes Association state that individuals with Diabetes and albuminuria should be prescribed inhibitors of the renin-angiotensin system to minimize the chances of progressing to end-stage renal disease, cardiovascular events, and mortality. Some evidence suggests that angiotensin-converting enzyme inhibitors (ACEIs) are more effective than other renin-angiotensin system inhibitors like angiotensin receptor blockers (ARBs) or aliskiren in preventing cardiovascular disease. However, a more recent review found similar effects of ACEIs and ARBs on major cardiovascular and renal outcomes. There is no evidence supporting additional benefits from combining ACEIs and ARBs.
LIFESTYLE:
Individuals diagnosed with Diabetes can gain valuable insights into managing their condition through education about the disease, treatment options, dietary adjustments, and physical activity. The aim is to maintain blood glucose levels within acceptable ranges in the short and long term. Furthermore, due to the heightened risks of cardiovascular issues, it’s advisable to make lifestyle changes to regulate blood pressure.
Promoting weight loss can impede the progression from prediabetes to type 2 diabetes, mitigate cardiovascular disease risks, and even lead to partial remission in diabetic individuals. While there's no universal dietary approach for everyone with Diabetes, recommended options like the Mediterranean, low-carbohydrate, or DASH diets are often suggested. Although no single diet is definitively superior, the American Diabetes Association (ADA) indicates that decreasing overall carbohydrate intake has shown the most evidence in enhancing glycemic control. In cases where type 2 diabetics struggle to meet glycemic targets or prioritize reducing anti-glycemic medications, opting for low or very-low carbohydrate diets is a viable strategy. For overweight individuals with type 2 diabetes, any weight loss-inducing diet is effective.
In a 2020 Cochrane systematic review, various non-nutritive sweeteners were compared to sugar, placebo, and a nutritive low-calorie sweetener (tagatose). However, the results regarding their impact on HbA1c, body weight, and adverse events remained inconclusive. The studies included in the review were largely of low certainty and didn’t provide information on health-related quality of life, diabetes-related complications, all-cause mortality, or socioeconomic effects.
STATISTICS ABOUT DIABETES:
Overall numbers
- Prevalence: In 2019, 37.3 million Americans, or 11.3% of the population, had Diabetes.
- Nearly 1.9 million Americans have type 1 diabetes, including about 244,000 children and adolescents.
- Diagnosed and undiagnosed: Of the 37.3 million adults with Diabetes, 28.7 million were diagnosed, and 8.5 million were undiagnosed.
- Prevalence in seniors: The percentage of Americans age 65 and older remains high, at 29.2%, or 15.9 million seniors (diagnosed and undiagnosed).
- New cases million Americans are diagnosed with Diabetes every year.
- Prediabetes: In 2019, 96 million Americans age 18 and older had prediabetes.
DIABETES IN YOUTH:
- About 283,000 Americans under age 20 are estimated to have been diagnosed with Diabetes, approximately 0.35% of that population.
- In 2014–2015, the annual incidence of diagnosed Diabetes in youth was estimated at 18,200 with type 1 diabetes, 5,800 with type 2 diabetes.
MEDICATION:
The majority of Diabetes medications function by reducing blood sugar levels through various mechanisms. Consensus exists that maintaining strict glucose control in individuals with Diabetes – thereby keeping blood glucose within normal ranges – results in fewer complications like kidney or eye problems. However, there is an ongoing debate about the appropriateness and cost-effectiveness of this approach for older individuals who might face a higher risk of hypoglycemia. Numerous categories of anti-diabetic medications are available. Type 1 diabetes necessitates insulin treatment, ideally utilizing a “basal bolus” regimen, mirroring natural insulin release: long-acting insulin for basal needs and short-acting insulin for meals. Generally, type 2 diabetes is managed with oral medications (e.g. metformin), although some may eventually require injectable treatments like insulin or GLP-1 agonists.
CONCLUSION:
Diabetes, a prevalent global disease, often catches people unaware of its origin, impact, and the experiences of those affected. While it may not personally affect you, demonstrating respect and compassion for individuals with Diabetes is crucial. This not only benefits them but also enhances their understanding of the condition. Diabetes, characterized by elevated blood sugar levels, can harm vital organs and lead to various health issues. A severe, life-threatening condition requires consistent monitoring and effective management through medication and a healthy lifestyle. Embracing a wholesome way of life, regular check-ups, and appropriate medication can lead to a healthier, longer life.
REFERENCES:
https://my.clevelandclinic.org
https://www.healthdata.org/news-events/newsroom/news-releases/global-diabetes
https://diabetes.org/about-diabetes/statistics/about-diabetes