Diabetes mellitus

13

Diabetes mellitus encompasses a range of conditions that affect how the body processes glucose (blood sugar). Glucose is essential for providing energy to the cells in muscles and tissues, and it also serves as the brain’s primary fuel source.

The underlying cause of diabetes depends on the specific type. However, all types of diabetes result in elevated blood sugar levels, which can lead to significant health issues if left unmanaged.

Types of Diabetes:

1. Chronic Types:
   • Type 1 Diabetes: A long-term condition where the body fails to produce insulin.
   • Type 2 Diabetes: The body either doesn’t use insulin effectively or doesn’t produce enough of it.
2. Reversible Types:
   • Prediabetes: Blood sugar levels are higher than normal but not high enough to be classified as diabetes. Without intervention, it can develop into type 2 diabetes.
   • Gestational Diabetes: Occurs during pregnancy and may resolve after the birth of the child, but it increases the risk of developing type 2 diabetes later on.

Each type of diabetes, if not controlled, can result in dangerously high levels of sugar in the blood, leading to a range of serious health complications.

Causes

The exact cause of most diabetes types remains unclear, but in all cases, there is a buildup of sugar in the bloodstream, often due to insufficient insulin production or insulin resistance.

Risk Factors

Risk Factors Vary by Diabetes Type:

• Type 1 Diabetes: Often influenced by genetic and environmental factors. In some cases, family members are tested for immune system cells that may indicate a higher risk.
• Type 2 Diabetes: More common in people over 40 and in certain ethnic groups, such as Black, Hispanic, American Indian, and Asian Americans. Overweight and obesity are key contributors to developing type 2 diabetes, prediabetes, and gestational diabetes.

How the Body Uses Glucose and Insulin

To understand diabetes better, it’s essential to know how glucose and insulin function in the body.

• Insulin: Produced by the pancreas, insulin allows sugar to enter cells, lowering the amount of sugar in your bloodstream. When blood sugar drops, insulin production slows down.
• Glucose: Primarily comes from food and is absorbed into the bloodstream with the help of insulin. The liver also stores and releases glucose when needed, ensuring stable sugar levels.

Common Symptoms of Diabetes

The symptoms of diabetes can vary depending on how elevated your blood sugar levels are. While some people, especially those with prediabetes, gestational diabetes, or type 2 diabetes, may not experience noticeable symptoms, type 1 diabetes tends to show more sudden and severe signs. Key symptoms of both type 1 and type 2 diabetes include:

• Feeling unusually thirsty
• Frequent urination
• Unexplained weight loss
• Presence of ketones in urine (byproducts when the body uses fat and muscle for energy due to lack of insulin)
• Fatigue or weakness
• Irritability or mood changes
• Blurred vision
• Slow-healing wounds
• Frequent infections, such as skin, gum, or vaginal infections

Type 1 vs. Type 2 Diabetes:

• Type 1 diabetes: Often starts in childhood or teenage years but can occur at any age.
• Type 2 diabetes: Commonly occurs in individuals over 40, but rising rates in children due to lifestyle factors are concerning.

Diagnosing Diabetes

Understanding diabetes diagnosis can help detect the condition early and prevent complications. Symptoms of type 1 diabetes often appear suddenly, making it easier to diagnose, while prediabetes and type 2 diabetes tend to develop more gradually. To ensure early detection, the American Diabetes Association (ADA) has outlined several screening guidelines.

Who Should Get Screened for Diabetes?

The ADA recommends the following groups be screened for diabetes:

1. People with a BMI over 25 (or over 23 for Asian Americans) who have additional risk factors like high blood pressure, abnormal cholesterol levels, a sedentary lifestyle, polycystic ovary syndrome (PCOS), heart disease, or a close family history of diabetes.
2. Individuals over 35 years old: An initial blood sugar screening is recommended, followed by testing every three years if results are normal.
3. Women with a history of gestational diabetes: Screening is advised every three years.
4. Individuals diagnosed with prediabetes: Annual testing is recommended.
5. People living with HIV: They are advised to get tested for diabetes regularly.

Tests for Diagnosing Diabetes and Prediabetes

1. A1C Test: This blood test provides an average of your blood sugar levels over the past two to three months. An A1C level of 6.5% or higher indicates diabetes, 5.7%-6.4% means prediabetes, and below 5.7% is normal.
2. Random Blood Sugar Test: A blood sample is taken randomly, and a reading of 200 mg/dL (11.1 mmol/L) or higher indicates diabetes.
3. Fasting Blood Sugar Test: After fasting overnight, a blood sample is taken. A reading below 100 mg/dL (5.6 mmol/L) is normal, 100-125 mg/dL (5.6-6.9 mmol/L) signals prediabetes, and 126 mg/dL (7 mmol/L) or higher on two occasions confirms diabetes.
4. Glucose Tolerance Test: After fasting overnight, your blood sugar is tested, then you drink a sugary solution, and levels are checked over the next two hours. A reading below 140 mg/dL (7.8 mmol/L) is normal, 140-199 mg/dL indicates prediabetes, and over 200 mg/dL means diabetes.

For type 1 diabetes, your doctor may check for ketones in your urine, which are produced when the body breaks down fat and muscle. A test for autoantibodies, which indicate an immune response leading to type 1 diabetes, may also be performed.

Women at high risk for gestational diabetes are usually screened during their first prenatal visit, while those at average risk are tested during the second trimester.

Treatment of Diabetes

Managing diabetes involves a combination of blood sugar monitoring, medications (like insulin or oral drugs), a healthy diet, regular physical activity, and maintaining a healthy weight.

General Treatment for All Types of Diabetes

1. Healthy Eating: A balanced diet is essential for controlling blood sugar levels. The focus should be on:
   • Fruits, vegetables, lean proteins, and whole grains: These foods are high in fiber and nutrients but low in fat and calories.
   • Limiting saturated fats, refined carbs, and sweets: Occasional sugary treats are okay, but they need to be accounted for in your meal plan.
   • Personalized meal plans: A registered dietitian can help create a plan tailored to your health goals and preferences. If you have type 1 diabetes or use insulin, carbohydrate counting will be part of your management strategy.
2. Physical Activity: Exercise plays a crucial role in lowering blood sugar by helping it move into your cells where it can be used for energy. It also enhances your body’s sensitivity to insulin, reducing the amount needed to manage blood sugar levels. Regular physical activity is essential for everyone, including people with diabetes.
   • Exercise tips: Aim for 30 minutes of moderate aerobic exercise most days, or a total of 150 minutes per week. Choose activities you enjoy, like walking, swimming, or cycling, and gradually increase the intensity if you’re just starting out.
   • Avoid prolonged sitting: Make a habit of getting up and moving around if you’ve been sitting for over 30 minutes.

Treatments for Type 1 and Type 2 Diabetes

Type 1 Diabetes Treatment

Type 1 diabetes primarily requires insulin therapy for survival. Key treatments include:

1. Insulin Therapy:
   • Insulin must be injected or delivered through an insulin pump because it cannot be taken orally.
   • Different types of insulin (short-acting, rapid-acting, long-acting, and intermediate) may be prescribed based on individual needs. A combination of insulin types is often used to control blood sugar throughout the day and night.
2. Blood Sugar Monitoring:
   • Frequent blood sugar checks (up to four or more times daily) are essential for maintaining target blood sugar levels.
   • Continuous glucose monitors (CGM) can reduce the need for fingersticks and provide detailed blood sugar trends.
3. Carbohydrate Counting:
   • This technique helps balance insulin doses with carbohydrate intake to maintain stable blood sugar levels.
4. Insulin Pumps and Advanced Systems:
   • Insulin pumps can deliver insulin continuously and adjust doses based on meals or activity.
   • Hybrid closed-loop systems combine CGM with an insulin pump to automatically adjust insulin delivery, although user input is still required for factors like carbohydrate intake.
5. Pancreas or Islet Cell Transplants:
   • These are options for people whose diabetes is difficult to control with insulin therapy. However, these procedures carry significant risks and are generally reserved for severe cases.

Type 2 Diabetes Treatment

Treatment for type 2 diabetes focuses on lifestyle changes, medication, and sometimes insulin therapy. Core components include:

1. Lifestyle Changes:
   • A healthy diet and regular exercise (at least 150 minutes per week) are key for managing blood sugar and maintaining a healthy weight.
   • Weight loss (around 7% of body weight) can help lower blood sugar and improve insulin sensitivity.
2. Blood Sugar Monitoring:
   • People with type 2 diabetes usually check their blood sugar less frequently than those with type 1 diabetes. However, if insulin is used, more frequent monitoring may be needed.
3. Medications:
   • Metformin is often the first-line treatment to reduce liver glucose production and improve insulin sensitivity.
   • Other oral drugs may stimulate insulin production, reduce glucose absorption in the intestines, or improve insulin sensitivity in tissues.
   • SGLT2 inhibitors prevent the kidneys from reabsorbing sugar, causing it to be eliminated in the urine.
4. Insulin Therapy:
   • Some individuals with type 2 diabetes may require insulin therapy, either in combination with oral drugs or alone.
5. Bariatric Surgery:
   • For people with a body mass index (BMI) over 35, bariatric surgery may improve blood sugar control and even lead to remission of type 2 diabetes.

Blood Sugar Monitoring and A1C Testing

For both types of diabetes, A1C testing every two to three months helps track long-term blood sugar control. The American Diabetes Association recommends a target A1C of below 7%, though individual targets may vary.

Other Treatment Options

1. Gestational Diabetes:
   • Managing blood sugar levels through diet, exercise, and sometimes insulin or oral drugs helps keep both mother and baby healthy. Blood sugar levels are also monitored during labor to prevent complications.
2. Prediabetes:
   • Healthy lifestyle changes, such as regular exercise and weight loss, can prevent the progression to type 2 diabetes.
   • Medications like metformin may be prescribed for those with prediabetes who are at high risk, particularly if they also have other conditions like heart disease.

Transplantation

Pancreas transplants or islet cell transplants are sometimes considered for people with type 1 diabetes who struggle with managing their condition. However, these procedures require lifetime immunosuppressive therapy and are usually reserved for people with severe complications.

Signs of Trouble in Any Type of Diabetes

Diabetes can present complications if blood sugar levels become too high or too low. Understanding the signs of trouble can help prevent serious issues.

High Blood Sugar (Hyperglycemia)

Hyperglycemia occurs when blood sugar levels rise above the target range. Common causes include overeating, missed medications, illness, or stress. Symptoms include:

• Frequent urination
• Increased thirst
• Blurred vision
• Fatigue
• Headache
• Irritability

If hyperglycemia occurs, it may be necessary to adjust medications, insulin, or meal plans.

Increased Ketones (Diabetic Ketoacidosis – DKA)

DKA occurs when the body breaks down fat for energy, producing ketones that build up in the blood. This is more common in people with type 1 diabetes. Symptoms include:

• Nausea and vomiting
• Abdominal pain
• Fruity-smelling breath
• Shortness of breath
• Dry mouth
• Weakness
• Confusion or coma in severe cases

You can check for ketones using over-the-counter test kits. If ketones are present, seek medical care immediately.

Hyperosmolar Syndrome

This condition occurs in people with type 2 diabetes, usually after illness, when blood sugar levels become extremely high (above 600 mg/dL or 33.3 mmol/L). Blood becomes thick and syrupy. Symptoms include:

• Dry mouth
• Extreme thirst
• Fever
• Drowsiness or confusion
• Vision loss
• Hallucinations

Hyperosmolar syndrome is life-threatening, and emergency medical care is needed immediately.

Low Blood Sugar (Hypoglycemia)

Hypoglycemia occurs when blood sugar drops below the target range, often due to missed meals, too much insulin, or excessive physical activity. Symptoms include:

• Sweating
• Shakiness
• Weakness
• Hunger
• Dizziness
• Headache
• Blurred vision
• Palpitations
• Irritability
• Slurred speech
• Confusion, fainting, or seizures in severe cases

Treatment involves consuming quick-acting carbohydrates like fruit juice or glucose tablets to raise blood sugar levels.

Lifestyle and Home Remedies for Diabetes Management

Diabetes is a serious condition, but proper lifestyle management can help reduce the risk of complications and improve overall health. Here are key lifestyle changes and home remedies that can assist in managing diabetes:

1. Commit to Managing Diabetes

• Education: Learn as much as you can about diabetes and build a relationship with a diabetes educator. Reach out to your diabetes care team for guidance when needed.
• Consistent Monitoring: Regularly check blood sugar levels as instructed by your healthcare provider to maintain control.

2. Healthy Eating and Weight Management

• Healthy Diet: Choose a diet rich in fruits, vegetables, lean proteins, whole grains, and legumes. Limit foods with saturated fat.
• Weight Loss: If you’re overweight, losing just 7% of your body weight can improve blood sugar control, especially for those with prediabetes or type 2 diabetes.

3. Regular Physical Activity

• Exercise Routine: Aim for at least 150 minutes of moderate aerobic activity (like brisk walking, biking, or dancing) each week. Include resistance training (weight lifting or bodyweight exercises) at least twice a week for better blood sugar control.
• Stay Active: Avoid prolonged sitting. Try to move for a few minutes every 30 minutes when awake.

4. Diabetes-Specific Recommendations

• Wear Medical Identification: Always wear a tag or bracelet identifying your condition and keep a glucagon kit nearby for emergencies.
• Yearly Checkups: Schedule regular physical exams and eye exams to monitor for diabetes-related complications like retinopathy or cataracts.
• Foot Care: Wash and dry your feet daily, moisturize (but not between the toes), and check for any sores or blisters. Contact a healthcare provider for any wounds that do not heal quickly.

5. Vaccinations

• Stay Up to Date: Diabetes weakens the immune system, so ensure you receive annual flu shots, COVID-19 vaccines, and pneumonia vaccines. The CDC recommends hepatitis B vaccination for adults with type 1 or type 2 diabetes.

6. Control Blood Pressure and Cholesterol

• Healthy Lifestyle: A combination of healthy eating, regular exercise, and possibly medication can help keep your blood pressure and cholesterol in check, reducing the risk of cardiovascular disease.

7. Dental Care

• Gum Health: Brush and floss twice a day and schedule regular dental exams. People with diabetes are at higher risk for gum infections, so talk to your dentist if your gums bleed or are swollen.

8. Quit Smoking

• Tobacco Use: Smoking increases the risk of diabetes complications, especially cardiovascular disease. Speak with your provider for resources to quit smoking or using tobacco.

9. Alcohol Moderation

• Drink Responsibly: Alcohol can affect blood sugar levels. If you choose to drink, do so in moderation (one drink per day for women, two for men) and always with food. Include the carbs from alcohol in your daily carbohydrate count and monitor blood sugar levels, especially before bed.

10. Stress Management

• Stress Control: Stress hormones can interfere with insulin, leading to higher blood sugar levels. Learn relaxation techniques, set realistic boundaries, and ensure you’re getting enough sleep to reduce stress.

Alternative Medicine

Some alternative therapies claim to help manage diabetes, but results are inconsistent. No alternative therapy is proven to cure diabetes or replace prescribed medications like insulin. If you’re considering an alternative therapy, always consult your healthcare provider to ensure it won’t interfere with your current treatment.

Complications of Diabetes

Diabetes, if unmanaged, can lead to several long-term complications, increasing in severity over time:

1. Heart Disease: Diabetes increases the risk of cardiovascular issues like coronary artery disease, heart attacks, and strokes.
2. Nerve Damage (Diabetic Neuropathy): High blood sugar damages the nerves, causing tingling, pain, or numbness, particularly in the legs. It may also affect digestion and lead to erectile dysfunction in men.
3. Kidney Damage (Diabetic Nephropathy): Diabetes can harm the kidneys’ filtering system, potentially leading to kidney failure.
4. Eye Damage (Diabetic Retinopathy): High blood sugar can damage the blood vessels in the eyes, risking blindness.
5. Foot Problems: Poor circulation and nerve damage raise the risk of foot infections, which could lead to serious complications.
6. Skin and Mouth Conditions: More prone to infections such as fungal and bacterial skin conditions.
7. Hearing Loss: Diabetes may contribute to hearing impairment.
8. Alzheimer’s Disease: Type 2 diabetes is linked to an increased risk of dementia, including Alzheimer’s.
9. Depression: Those with diabetes may experience symptoms of depression.

Gestational Diabetes Complications:

Gestational diabetes usually resolves after pregnancy but can cause problems if untreated:

• For the baby: Excess growth, low blood sugar, higher risk of type 2 diabetes, or even death.
• For the mother: Increased risk of preeclampsia, high blood pressure, and the likelihood of gestational diabetes in future pregnancies.

Preventing Diabetes

While we can’t prevent type 1 diabetes, lifestyle choices can help reduce the risk of prediabetes, type 2 diabetes, and gestational diabetes. Here’s how:

1. Healthy Diet: Focus on low-fat, high-fiber foods like fruits, vegetables, and whole grains.
2. Regular Physical Activity: Aim for 30 minutes of moderate exercise, such as brisk walking, most days of the week.
3. Weight Management: If overweight, losing even a small percentage (7%) of body weight can reduce the risk. However, avoid weight loss during pregnancy and follow your healthcare provider’s advice on healthy weight gain.

In some cases, medications like metformin may help lower the risk of type 2 diabetes, but lifestyle changes are the cornerstone of prevention.

Regular check-ups are essential if you have prediabetes, allowing you to monitor and prevent the progression to type 2 diabetes.

Key Takeaways:

• Managing diabetes requires a lifelong commitment to healthy eating, regular exercise, and monitoring.
• Stay proactive by seeking help from your diabetes care team and staying informed.
• Regular checkups, vaccinations, and attention to foot and dental health are critical to preventing complications.
• Stress management and quitting smoking are vital for long-term health in diabetes management.

Sources

• Centers for Disease Control and Prevention.
• Cunningham FG, et al. Diabetes mellitus. In: Williams Obstetrics. 25th ed. McGraw-Hill Education; 2018.
• American Diabetes Association. https://www.diabetes.org/diabetes/dka-ketoacidosis-ketones.
• Papadakis MA, et al., eds. Diabetes mellitus. In: Current Medical Diagnosis & Treatment 2022. 61st ed. McGraw Hill; 2022.
• Diabetes Canada Clinical Practice Guidelines Expert Committee. Complementary and alternative medicine for diabetes. Canadian Journal of Diabetes.
• Obesity and weight management for the prevention and treatment of type 2 diabetes, Diabetes technology,Glycemic targets,Prevention or delay of type 2 diabetes and associated comorbidities, Pharmacologic approaches to glycemic treatment, Facilitating behavior change and well-being to improve health outcomes, Classification and diagnosis of diabetes, Comprehensive medical evaluation and assessment of comorbidities: Standards of Medical Care in Diabetes .
• Ferri FF. Diabetes mellitus. In: Ferri’s Clinical Advisor 2022. Elsevier; 2022.
• Jameson JL, et al., eds. Diabetes mellitus: Diagnosis, classification and pathophysiology. In: Harrison’s Principles of Internal Medicine. 20th ed. McGraw-Hill Education; 2018.
• Mayo Clinic. Type 1 diabetes mellitus.