What is Diabetes?

Diabetes mellitus gets its name from two words: ‘diabetes’, a Greek word meaning ‘to pass through’, and ‘mellitus’, a Latin word which means ‘sweet’. The term ‘diabetes’ was first used around 250 to 300 BC by Apollonius of Memphis. Ancient Greek, Indian, and Egyptian societies discovered that the urine of people with this condition was sweet, hence the name. In 1889, Mering and Minkowski discovered that the pancreas plays a critical role in causing diabetes. Insulin, a hormone from the pancreas of cows, was purified in 1922 by Banting, Best, and Collip at the University of Toronto, bringing a breakthrough treatment for diabetes. Over time, lots of vital research has taken place and many strategies have been developed to manage this growing health problem globally. However, diabetes continues to be one of the most common chronic diseases worldwide and the seventh-leading cause of death in the US.

Diabetes mellitus (DM) is a metabolic disease that causes unusually high blood sugar levels. There are several types of DM, including type 1, type 2, maturity-onset diabetes of the young (MODY), gestational diabetes, neonatal diabetes, and secondary diabetes caused by hormonal disorders, steroid use, and so on. The primary types are Type 1 diabetes mellitus (T1DM) and Type 2 diabetes mellitus (T2DM), which usually result from problems with insulin secretion (T1DM) and/or how insulin works (T2DM). Type 1 typically appears in children or teenagers, while Type 2 usually affects middle-aged and older adults who have consistently high blood sugar levels due to poor lifestyle and dietary habits. The causes, symptoms, and treatments for T1DM and T2DM are significantly different, as their development involves different processes.

What Causes Diabetes?

In the part of the pancreas called the islets of Langerhans, there are two important types of cells – cells that produce insulin called beta cells, and cells that secrete a hormone called glucagon, known as alpha cells. These cells continually adjust the amount of hormones they release based on sugar levels around them. If insulin and glucagon aren’t balanced, sugar levels can become imbalanced. In diabetes mellitus (DM), the body either doesn’t have enough insulin or can’t use it effectively, leading to high blood sugar levels.

Type 1 Diabetes Mellitus (T1DM) happens when the body’s immune system destroys the insulin-producing cells in the pancreas. The result is a severe shortage of insulin, or sometimes none at all.

Type 2 Diabetes Mellitus (T2DM) develops more gradually. Here, an imbalance between insulin levels and how effectively the body uses insulin causes a lack of functional insulin. Conditions like obesity and aging often contribute to the development of this type of insulin resistance.

Genetic factors play a critical role in the risk of both types of diabetes. Various types of genetic variations increase the risk of T1DM, such as certain traits in major immune system genes.

T2DM involves a more complex interaction between genetics and lifestyle. Research suggests that T2DM is more likely to be inherited than T1DM. In fact, most people with T2DM have at least one parent with the disease. If one of a pair of identical twins has T2DM, the other twin has a 90% chance of developing it during their lifetime.

MODY, or Maturity Onset Diabetes of the Young, is a disorder characterized by diabetes diagnosed at a young age (usually under 25 years). Different from T1DM, it doesn’t involve antibodies from an immune response and is passed down through families. People with this disorder may have mutations in a number of different genes but why some patients develop the disease and others do not is still not clear.

Gestational diabetes is diabetes that develops during pregnancy. It’s unclear why it happens but some guess that certain immune system genes and high amounts of certain hormones may affect how insulin is produced and used by the body.

Several hormone-related conditions, such as acromegaly, Cushing syndrome, and others, can cause high blood sugar and diabetes due to an overproduction of certain hormones. Other conditions, like hemochromatosis, which results in too much iron in the body, can also cause diabetes by causing damage to the insulin-producing cells in the pancreas.

Risk Factors and Frequency for Diabetes

Diabetes affects 1 in 11 adults worldwide, with 90% having type 2 diabetes. Type 1 diabetes typically begins from birth and peaks at ages 4 to 6 and 10 to 14. Almost half of the children diagnosed with type 1 diabetes are under ten years old. In young individuals below 20 years old, it affects roughly 2.3 in 1000 people. Unlike many autoimmune diseases, type 1 diabetes affects both boys and girls equally. There is, however, a higher likelihood for older boys of European descent (over 13 years) to develop the condition.

The occurrence of type 1 diabetes has been increasing globally. In Europe, Australia, and the Middle East, the rates are growing by 2% to 5% each year. In the United States, the rates also rose by about 2% yearly in most age and ethnic groups, with more pronounced rates in Hispanic youths. The exact cause of this pattern is unknown.

Type 2 diabetes often appears later in life, but a rise in obesity among adolescents has led to increased cases among younger people. Around 9% of the total US population has type 2 diabetes, but in those over 65 years, the rate is about 25%. The International Diabetes Federation estimated that in 2015, 1 in 11 adults worldwide between the ages of 20 and 79 had diabetes. Experts predict a significant rise in diabetes, from 415 to 642 million people by 2040, due to changing income levels.

Type 2 diabetes varies among ethnic groups and is 2 to 6 times more common in Black, Native American, Pima Indian, and Hispanic Americans compared to White Americans. While ethnicity plays an important role in type 2 diabetes, environmental factors also contribute to developing the disease. For instance, Pima Indians in Mexico are less likely to get type 2 diabetes than those in the United States.

Signs and Symptoms of Diabetes

When diagnosing diabetes, doctors consider a patient’s medical history, including family history, autoimmune diseases, and evidence of insulin resistance. Often, diabetes doesn’t present any symptoms, but when it does, patients typically experience increased urination, excessive thirst, and weight loss. In patients with high blood sugar, the physical examination might reveal poor skin elasticity due to dehydration or a unique fruity odor on their breath (especially in patients with ketosis, a diabetes complication).

In cases of diabetic ketoacidosis, a severe complication of diabetes, doctors may observe signs like rapid, deep, labored breathing (Kussmaul respirations), fatigue, nausea, and vomiting. Diabetes can also affect the eyes; an examination might reveal signs of bleeding or fluid leakage in the area of the eye responsible for sharp, central vision (the macula). Advanced diabetic eye disease can lead to abnormal blood vessel growth, increased bleeding, fluid buildup in the macula, and, in severe cases, blindness.

Even though type 1 and type 2 diabetes can present similar symptoms, there are ways to distinguish between them. For instance, patients with type 2 diabetes are often overweight or obese and show signs of insulin resistance. They may have dark, velvety patches of skin (acanthosis nigricans) around the neck, armpits, or groin. Those who’ve had high blood sugar levels for an extended period may complain of blurred vision, frequent yeast infections, numbness, or nerve pain. During each visit, doctors should also ask about any recent changes in their feet and make sure to check the feet for sensitivity and signs of complications using simple tests like the monofilament test.

Testing for Diabetes

Type 1 diabetes (T1DM) is usually diagnosed based on specific symptoms and high blood sugar levels. These elevated blood sugar levels can be identified through tests like fasting glucose and hemoglobin A1C (HbA1c). If you have a fasting glucose level higher than 126 mg/dL, a random glucose level over 200 mg/dL, or a HbA1c level above 6.5%, you might have T1DM. Doctors might also check for antibodies to certain proteins in your body.

Fasting glucose levels and HbA1c tests are also handy for spotting type 2 diabetes (T2DM) early on. If your test results are borderline, a glucose tolerance test might help your doctor understand how your body responds to sugar. You might be in a state known as prediabetes, which often comes before T2DM, if your fasting blood glucose level is between 100 to 125 mg/dL or if you have a specific glucose level from 140 to 200 mg/dL after the glucose tolerance test.

The American Diabetes Association lays out a few ways to diagnose diabetes. These include having an HbA1c level of 6.5% or higher; a fasting plasma glucose level of 126 mg/dL (7.0 mmol/L) or higher (meaning no food for at least 8 hours); a plasma glucose level of 200 mg/dL or higher after a 75-g glucose tolerance test; or a random plasma glucose of 200 mg/dL or higher if you’re showing symptoms of high blood sugar. These symptoms include frequent urination, feeling very thirsty, feeling very hungry, or losing weight suddenly. It’s suggested that adults over 45 get screened, as well as those aged 40 to 70 who are overweight.

All pregnant women should be screened for gestational diabetes between 24 to 28 weeks of pregnancy using a glucose challenge test. If your blood glucose levels are over 140mg/dL, you then get a more extended glucose challenge test. You might have gestational diabetes if there’s at least one abnormal reading according to specific thresholds during the longer test.

There are several lab tests helpful in managing long-term diabetes. Home glucose testing can show if your blood sugar levels are too high or too low. The HbA1c test can show how high your blood sugar levels have been on average over around three months. Urine tests can catch early signs of kidney disease related to diabetes. It’s also wise to monitor blood fats, as diabetes increases your risk of heart disease. Some also recommend yearly checks of your thyroid hormone levels as there’s a higher incidence of underactive thyroid in people with diabetes.

Treatment Options for Diabetes

Managing diabetes can be challenging because it involves several different treatments to successfully control the disease. Key to this care is educating patients and getting them involved in their own healthcare. This approach leads to better results. For instance, teaching them to control their diet, exercise for more than two and a half hours a week, and check their blood sugar levels independently can all improve their health. Usually, people will need to continue their treatment for life to avoid complications. The goal for patients is to keep blood sugar levels between 90 and 130 mg/dL and HbA1c, a measure of long-term blood glucose control, under 7%. It’s also crucial to avoid pushing blood sugar levels extremely low to prevent dangerous or even deadly low blood sugar episodes.

Administering insulin daily, either through injections or an insulin pump, is at the heart of treating type 1 diabetes, because the body doesn’t produce enough insulin. With type 2 diabetes, a healthy diet and regular exercise can often help manage the disease, at least at first. There are also a variety of other treatments that can improve insulin sensitivity or stimulate the pancreas to produce more insulin. Metformin, a common first-line drug, helps to lower both fasting and post-meal blood sugar levels. Some people with type 2 diabetes may also need insulin, particularly those in advanced stages of the disease. For those who are significantly overweight, bariatric (weight loss) surgery could help regulate blood sugar levels.

Testing regularly for complications is crucial because people with diabetes are at risk for issues like eye and nerve damage. For instance, regular eye exams can identify diabetes-related eye disease, and neuropathy tests can identify nerve damage that could lead to amputation. It’s also recommended that patients inspect their feet daily for sores that could go unnoticed due to neuropathy. Various antidepressants and anticonvulsants can help control diabetic nerve pain. Additionally, checking urine for protein can highlight early kidney damage from diabetes.

The Food and Drug Administration has approved certain medications for treating diabetic nerve pain. Blood pressure should be checked regularly, aiming for less than 130/85 mmHg. Several types of medication can be used to reach this goal. Additionally, keeping cholesterol levels under control is important, with statins often used to lower bad cholesterol levels. And while the role of low-dose aspirin in preventing heart problems in people with diabetes isn’t entirely clear, it’s still recommended by some experts.

Not just Type 1 and Type 2 diabetes or MODY (Maturity Onset Diabetes of the Young), several diseases can potentially damage the pancreas and result in diabetes. These could include:

  • Cystic fibrosis
  • Hereditary hemochromatosis (a condition that leads to too much iron in the body)
  • Pancreatic cancer
  • Chronic pancreatitis (long-term inflammation of the pancreas)

There are also certain hormone-induced syndromes, which might affect insulin production and subsequently lead to diabetes. Some examples are:

  • Pheochromocytoma (a rare tumor of adrenal gland tissue)
  • Acromegaly (excessive growth hormone production)
  • Cushing syndrome (too much cortisol hormone)

Certain medications may lead to insulin resistance, which could potentially result in diabetes. These could include drugs like:

  • Phenytoin (a medication for seizures)
  • Glucocorticoids (steroid hormones)
  • Estrogen (a female hormone)

Additional conditions that might be confused with regular diabetes include:

  • Gestational diabetes (a high blood sugar condition that some women develop during pregnancy)
  • Thyroid disorders

What to expect with Diabetes

Diabetes was the seventh most common cause of death in the U.S. in 2015. How well a person manages their blood sugar levels significantly affects the outlook of someone with diabetes. Constantly high blood sugar levels greatly increase the risk of complications from diabetes. According to studies conducted by the Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study, individuals with both Type 1 and Type 2 diabetes had an increased risk of certain complications if they had chronically high blood sugar levels.

Patients who can manage to get their blood sugar levels back to normal when moving from pre-diabetes to full diabetes generally have a better outlook and may be able to slow down the progression of the disease.

Possible Complications When Diagnosed with Diabetes

Diabetes, regardless of the type, can cause complications that involve small blood vessels (microvascular), large blood vessels (macrovascular), and nerves (neuropathic). These complications, which include kidney disease, eye disease, nerve disease, and heart disease, can vary depending on how well and for how long the diabetes has been controlled. They can become increasingly severe if the person also has other health conditions, such as high cholesterol and high blood pressure.

One of the most serious effects of diabetes is its impact on heart disease. Roughly two out of three people with diabetes will die from a heart attack or stroke. In Type 2 diabetes, if blood glucose levels are consistently above 100 mg/dL, this significantly contributes to the chance of developing heart disease.

Diabetes can also cause blindness. It is one of the most common reasons for loss of sight in US adults aged 20 to 74. Each year, diabetic eye disease (diabetic retinopathy) results in 12,000 to 24,000 new cases of blindness. Laser surgery and control of blood glucose levels are the typical treatments for this.

Diabetes is a major cause of kidney disease as well. It is the main contributor to end-stage renal disease in the US, a condition which eventually requires the patient to start dialysis or have a kidney transplant. Diabetes is also the leading cause of amputations of legs or feet in the US, mainly due to problems with blood vessels and nerves caused by the disease.

Not controlling blood glucose levels well over time is the main risk factor for developing diabetic eye disease. It usually starts about 5 years after Type 1 diabetes begins. Most people with Type 2 diabetes already have some eye damage present at the time of diagnosis. Uncontrolled high blood pressure is an extra risk factor for a condition called macular edema in patients with diabetes. Macular edema can be treated by injecting antibodies into the eye.

Additionally, there is some evidence suggesting that Type 2 diabetes may also be linked to the development of bladder cancer in those taking a certain medication, pioglitazone. Women with diabetes during pregnancy (gestational diabetes) have a higher chance of needing a caesarean section and developing long-term high blood pressure. Their babies have a greater risk of being born large and having low blood sugar levels.

The most severe complication of Type 1 diabetes is a condition called diabetic ketoacidosis (DKA). This can occur when the person has missed or insufficient insulin injections or has an infection. In Type 2 diabetes, a similar but slightly different emergency condition that can occur is called hyperosmolar hyperglycemic syndrome (HHS). Both these conditions require urgent treatment with insulin, intravenous fluids and careful management of electrolyte levels, especially potassium, to prevent them from becoming life-threatening.

Preventing Diabetes

Healthcare providers should actively teach patients with diabetes about managing their illness. It’s a wrong assumption for patients to believe that making temporary lifestyle adjustments is enough. Instead, permanent changes to their lifestyle may be needed to properly manage their diabetes. One study found that personalized education was more beneficial than group-based education for patients whose diabetes was not well-managed. Often, healthcare providers other than doctors, like nurses or pharmacists, are well-trained in diabetes education and typically have more time to offer personalized advice.

Frequently asked questions

Diabetes is a metabolic disease that causes unusually high blood sugar levels.

Diabetes affects 1 in 11 adults worldwide.

Signs and symptoms of diabetes include: - Increased urination - Excessive thirst - Weight loss - Poor skin elasticity due to dehydration - Fruity odor on breath (especially in patients with ketosis) - Rapid, deep, labored breathing (Kussmaul respirations) in cases of diabetic ketoacidosis - Fatigue - Nausea and vomiting in cases of diabetic ketoacidosis - Signs of bleeding or fluid leakage in the area of the eye responsible for sharp, central vision (the macula) - Dark, velvety patches of skin (acanthosis nigricans) around the neck, armpits, or groin in patients with type 2 diabetes - Blurred vision - Frequent yeast infections - Numbness or nerve pain in patients with high blood sugar levels for an extended period - Changes in the feet, including sensitivity and signs of complications, which can be checked using tests like the monofilament test.

There are several ways to get diabetes, including genetic factors, immune system destruction of insulin-producing cells, insulin resistance, hormonal imbalances, certain hormone-related conditions, and environmental factors.

The conditions that a doctor needs to rule out when diagnosing Diabetes are: - Cystic fibrosis - Hereditary hemochromatosis - Pancreatic cancer - Chronic pancreatitis - Pheochromocytoma - Acromegaly - Cushing syndrome - Phenytoin - Glucocorticoids - Estrogen - Gestational diabetes - Thyroid disorders

The types of tests needed for diabetes include: - Fasting glucose test - Hemoglobin A1C (HbA1c) test - Glucose tolerance test - Antibody tests - Urine tests for kidney disease - Thyroid hormone level checks - Home glucose testing for monitoring blood sugar levels - Eye exams for diabetes-related eye disease - Neuropathy tests for nerve damage - Foot inspections for sores - Blood pressure checks - Cholesterol level checks - Protein tests for kidney damage

Diabetes is treated through a combination of different approaches. For type 1 diabetes, administering insulin daily through injections or an insulin pump is essential since the body doesn't produce enough insulin. Type 2 diabetes can often be managed initially with a healthy diet and regular exercise. Other treatments for type 2 diabetes include medications that improve insulin sensitivity or stimulate the pancreas to produce more insulin, such as metformin. Some individuals with type 2 diabetes may also require insulin, especially in advanced stages of the disease. Bariatric surgery may be an option for significantly overweight individuals to regulate blood sugar levels. Regular testing for complications, such as eye and nerve damage, is crucial, and medications can be used to control diabetic nerve pain. Monitoring blood pressure and cholesterol levels is also important, with various medications available to reach target levels.

When treating diabetes, there can be several side effects and complications. These include: - Heart disease: Diabetes significantly increases the risk of heart attack or stroke, especially if blood glucose levels are consistently above 100 mg/dL. - Blindness: Diabetic eye disease (diabetic retinopathy) can lead to loss of sight, with 12,000 to 24,000 new cases of blindness each year in the US. Treatment typically involves laser surgery and controlling blood glucose levels. - Kidney disease: Diabetes is a major cause of kidney disease and end-stage renal disease, which may require dialysis or a kidney transplant. - Amputations: Diabetes can lead to problems with blood vessels and nerves, resulting in amputations of legs or feet. - Diabetic eye disease: Uncontrolled blood glucose levels over time can lead to diabetic eye disease, which usually starts about 5 years after Type 1 diabetes begins. Most people with Type 2 diabetes already have some eye damage at the time of diagnosis. - Bladder cancer: There is some evidence suggesting a link between Type 2 diabetes and the development of bladder cancer in those taking the medication pioglitazone. - Pregnancy complications: Women with gestational diabetes have a higher chance of needing a caesarean section, developing long-term high blood pressure, and having babies at risk of being born large with low blood sugar levels. - Diabetic ketoacidosis (DKA): This is a severe complication of Type 1 diabetes that can occur when there is a lack of insulin or an infection. It requires urgent treatment with insulin, intravenous fluids, and careful management of electrolyte levels. - Hyperosmolar hyperglycemic syndrome (HHS): This emergency condition can occur in Type 2 diabetes and requires similar urgent treatment as DKA.

The prognosis for diabetes depends on how well a person manages their blood sugar levels. Constantly high blood sugar levels greatly increase the risk of complications from diabetes. Patients who can manage to get their blood sugar levels back to normal when moving from pre-diabetes to full diabetes generally have a better outlook and may be able to slow down the progression of the disease.

An endocrinologist.

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