SECTIO

N
Hormonal Disorders
SUBJEC
T
Diabetes Mellitus (DM)
Diabetes Mellitus
Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally
high because the body does not produce enough insulin to meet its needs.
Urination and thirst are increased, and people lose weight when they are not
trying to.
Diabetes damages the nerves and causes problems with sensation.
Diabetes damages blood vessels and increases the risk of heart attack, stroke, and
kidney failure.
Doctors diagnose diabetes by measuring blood sugar levels.
eople with diabetes need to follow a low!sugar, low!fat diet, e"ercise, and
usually take drugs.
#nsulin, a hormone released from the pancreas, controls the amount of sugar in the blood.
$hen people eat or drink, food is broken down into materials, including the simple sugar
glucose, that the body needs to function. %ugar is absorbed into the bloodstream and
stimulates the pancreas to produce insulin. #nsulin allows sugar to move from the blood
into the cells. &nce inside the cells, it is converted to energy, which is either used
immediately or stored as fat or glycogen until it is needed.
'he levels of sugar in the blood vary normally throughout the day. 'hey rise after a meal
and return to normal within about ( hours after eating. &nce the levels of sugar in the
blood return to normal, insulin production decreases. 'he variation in blood sugar levels
is usually within a narrow range, about )* to ++* milligrams per deciliter (mg,d-) of
blood. #f people eat a large amount of carbohydrates, the levels may increase more.
eople older than ./ years tend to have slightly higher levels, especially after eating.
#f the body does not produce enough insulin to move the sugar into the cells, the resulting
high levels of sugar in the blood and the inade0uate amount of sugar in the cells together
produce the symptoms and complications of diabetes.
Doctors often use the full name diabetes mellitus, rather than diabetes alone, to
distinguish this disorder from diabetes insipidus, a relatively rare disorder that does not
affect blood sugar levels (see ituitary 1land Disorders2 3entral Diabetes #nsipidus).
Types
Prediabetes: rediabetes is a condition in which blood sugar levels are too high to be
considered normal but not high enough to be labeled diabetes. eople have prediabetes if
their fasting blood sugar level is between +*+ mg,d- and +(. mg,d- or if their blood
sugar level ( hours after a glucose tolerance test is between +4* mg,d- and (** mg,d-.
#dentifying people with prediabetes is important because the condition carries a higher
risk for future diabetes as well as heart disease. Decreasing body weight by / to +* 5
through diet and e"ercise can significantly reduce the risk of developing future diabetes.
Type 1: #n type + diabetes (formerly called insulin!dependent diabetes or 6uvenile!onset
diabetes), more than 7*5 of the insulin!producing cells of the pancreas are permanently
destroyed. 'he pancreas, therefore, produces little or no insulin. &nly about +*5 of all
people with diabetes have type + disease. Most people who have type + diabetes develop
the disease before age 8*.
%cientists believe that an environmental factor9possibly a viral infection or a nutritional
factor in childhood or early adulthood9causes the immune system to destroy the insulin!
producing cells of the pancreas. : genetic predisposition may make some people more
susceptible to the environmental factor.
Type 2: #n type ( diabetes (formerly called non!insulin!dependent diabetes or adult!onset
diabetes), the pancreas continues to produce insulin, sometimes even at higher!than!
normal levels. However, the body develops resistance to the effects of insulin, so there is
not enough insulin to meet the body;s needs.
'ype ( diabetes was once rare in children and adolescents but has recently become more
common. However, it usually begins in people older than 8* and becomes progressively
more common with age. :bout +/5 of people older than )* have type ( diabetes. eople
of certain racial and ethnic backgrounds are at increased risk of developing type (
diabetes2 blacks, <ative :mericans, and Hispanics who live in the United %tates have a
twofold to threefold increased risk. 'ype ( diabetes also tends to run in families.
&besity is the chief risk factor for developing type ( diabetes, and =* to 7*5 of people
with this disorder are overweight or obese. >ecause obesity causes insulin resistance,
obese people need very large amounts of insulin to maintain normal blood sugar levels.
3ertain disorders and drugs can affect the way the body uses insulin and can lead to type
( diabetes. High levels of corticosteroids (from 3ushing;s disease or from taking
corticosteroid drugs) and pregnancy (gestational diabetes9see regnancy at High ?isk2
1estational Diabetes) are the most common causes of altered insulin use. Diabetes also
may occur in people with e"cess production of growth hormone (acromegaly) and in
people with certain hormone!secreting tumors. %evere or recurring pancreatitis and other
disorders that directly damage the pancreas can lead to diabetes.
Symptoms
'he two types of diabetes have very similar symptoms. 'he first symptoms are related to
the direct effects of high blood sugar levels. $hen the blood sugar level rises above +.*
to +=* mg,d-, sugar spills into the urine. $hen the level of sugar in the urine rises even
higher, the kidneys e"crete additional water to dilute the large amount of sugar. >ecause
the kidneys produce e"cessive urine, people with diabetes urinate large volumes
fre0uently (polyuria). 'he e"cessive urination creates abnormal thirst (polydipsia).
>ecause e"cessive calories are lost in the urine, people lose weight. 'o compensate,
people often feel e"cessively hungry. &ther symptoms include blurred vision,
drowsiness, nausea, and decreased endurance during e"ercise.
Type 1: #n people with type + diabetes, the symptoms often begin abruptly and
dramatically. : condition called diabetic ketoacidosis may 0uickly develop. $ithout
insulin, most cells cannot use the sugar that is in the blood. 3ells still need energy to
survive, and they switch to a back!up mechanism to obtain energy. @at cells begin to
break down, producing compounds called ketones. Aetones provide some energy to cells
but also make the blood too acidic (ketoacidosis). 'he initial symptoms of diabetic
ketoacidosis include e"cessive thirst and urination, weight loss, nausea, vomiting,
fatigue, and9particularly in children9abdominal pain. >reathing tends to become deep
and rapid as the body attempts to correct the blood;s acidity (see :cid!>ase >alance2
:cidosis). 'he breath smells like nail polish remover, the smell of the ketones escaping
into the breath. $ithout treatment, diabetic ketoacidosis can progress to coma and death,
sometimes within a few hours.
Type 2: eople with type ( diabetes may not have any symptoms for years or decades
before they are diagnosed. %ymptoms may be subtle. #ncreased urination and thirst are
mild at first and gradually worsen over weeks or months. Bventually, people feel
e"tremely fatigued, are likely to develop blurred vision, and may become dehydrated.
%ometimes during the early stages of diabetes, the blood sugar level is abnormally low, a
condition called hypoglycemia (see Hypoglycemia).
>ecause people with type ( diabetes produce some insulin, ketoacidosis does not usually
develop. However, the blood sugar levels can become e"tremely high (often e"ceeding
+,*** mg,d-). %uch high levels often happen as the result of some superimposed stress,
such as an infection or drug use. $hen the blood sugar levels get very high, people may
develop severe dehydration, which may lead to mental confusion, drowsiness, and
seiCures, a condition called nonketotic hyperglycemic-hyperosmolar coma.
Complications
eople with diabetes may e"perience many serious, long!term complications. %ome of
these complications begin within months of the onset of diabetes, although most tend to
develop after a few years. Most of the complications are progressive. 'he more strictly
people with diabetes are able to control the levels of sugar in the blood, the less likely it
is that these complications will develop or become worse.
Most complications are the result of problems with blood vessels. High sugar levels over
a long time cause narrowing of both the small and large blood vessels. 'he narrowing
reduces blood flow to many parts of the body, leading to problems. 'here are several
causes of blood vessel narrowing. 3omple" sugar!based substances build up in the walls
of small blood vessels, causing them to thicken and leak. oor control of blood sugar
levels also tends to cause the levels of fatty substances in the blood to rise, resulting in
atherosclerosis (see :therosclerosis) and decreased blood flow in the larger blood
vessels. :therosclerosis is between ( and . times more common in people with diabetes
than in people who do not have diabetes and tends to occur at younger ages.
&ver time, elevated levels of sugar in the blood and poor circulation can harm the heart,
brain, legs, eyes, kidneys, nerves, and skin, resulting in angina, heart failure, strokes, leg
cramps on walking (claudication), poor vision, kidney failure, damage to nerves
(neuropathy), and skin breakdown. Heart attacks and strokes are more common among
people with diabetes.
oor circulation to the skin can lead to ulcers and infections and causes wounds to heal
slowly. eople with diabetes are particularly likely to have ulcers and infections of the
feet and legs. 'oo often, these wounds heal slowly or not at all, and amputation of the
foot or part of the leg may be needed.
People with diabetes often develop bacterial and fungal infections, typically of the skin.
When the levels of sugar in the blood are high, white blood cells cannot effectively fight
infections. Any infection that develops tends to be more severe.
Did o! "no#$$$
eople who can strictly
control their blood sugar levels
may be able to minimiCe or delay
diabetes complications.
Damage to the blood vessels of the eye can cause loss of vision (diabetic retinopathy9
see ?etinal Disorders2 Diabetic ?etinopathy). -aser surgery can seal the leaking blood
vessels of the eye and prevent permanent damage to the retina. 'herefore, people with
diabetes should have yearly eye e"aminations to check for damage.
'he kidneys can malfunction, resulting in kidney failure that may re0uire dialysis or
kidney transplantation. Doctors usually check the urine of people with diabetes for
abnormally high levels of protein (albumin), which is an early sign of kidney damage. :t
the earliest sign of kidney complications, people are often given angiotensin!converting
enCyme (:3B) inhibitors, drugs that slow the progression of kidney damage.
Damage to nerves can manifest in several ways. If a single nerve malfunctions, an arm
or leg may suddenly become weak. If the nerves to the hands, legs, and feet become
damaged (diabetic polyneuropathy, sensation may become abnormal, and tingling or
burning pain and weakness in the arms and legs may develop (see Peripheral !erve
Disorders" #auses. Damage to the nerves of the skin makes repeated in$uries more
likely because people cannot sense changes in pressure or temperature.
%ong-Term Complications o& Diabetes
Tiss!e or
Organ
'&&ected
(hat )appens Complications
>lood
vessels
@atty material (atherosclerotic
pla0ue) builds up and blocks
large or medium!siCed arteries
in the heart, brain, legs, and
penis.
'he walls of small blood
vessels are damaged so that the
vessels do not transfer o"ygen
oor circulation causes wounds
to heal poorly and can lead to
heart disorders, strokes, gangrene
of the feet and hands, erectile
dysfunction (impotence), and
infections.
to tissues normally, and the
vessels may leak.
Byes 'he small blood vessels of the
retina are damaged.
Decreased vision and, ultimately,
blindness occur.
Aidney >lood vessels in the kidney
thicken.
rotein leaks into urine.
>lood is not filtered normally.
'he kidneys malfunction, and
ultimately, kidney failure occurs.
<erves <erves are damaged because
glucose is not metaboliCed
normally and because the blood
supply is inade0uate.
-egs suddenly or gradually
weaken.
eople have reduced sensation,
tingling, and pain in their hands
and feet.
:utonomic
nervous
system
'he nerves that control blood
pressure and digestive processes
are damaged.
%wings in blood pressure occur.
%wallowing becomes difficult.
Digestive function is altered, and
sometimes bouts of diarrhea
occur.
Brectile dysfunction develops.
%kin >lood flow to the skin is
reduced, and sensation is
decreased, resulting in repeated
in6ury.
%ores and deep infections
(diabetic ulcers) develop.
Healing is poor.
>lood $hite blood cell function is
impaired.
eople become more susceptible
to infections, especially of the
urinary tract and skin.
3onnective
tissue
1lucose is not metaboliCed
normally, causing tissues to
thicken or contract.
3arpal tunnel syndrome and
Dupuytren;s contracture develop.
The *oot in Diabetes
Diabetes causes many changes in the
body. 'he following changes in the
feet are common and difficult to
treat.
Damage to the nerves
(neuropathy) affects sensation to
the feet, so that pain is not felt.
#rritation and other forms of
in6ury may go unnoticed. :n
in6ury may wear through the skin
before any pain is felt.
3hanges in sensation alter the
way people with diabetes carry
weight on their feet, concentrating
weight in certain areas so that
calluses form. 3alluses (and dry
skin) increase the risk of skin
breakdown.
Diabetes can cause poor
circulation in the feet, making
ulcers more likely to form when
the skin is damaged and making
the ulcers slower to heal.
>ecause diabetes can affect the
body;s ability to fight infections, a
foot ulcer, once it forms, easily
becomes infected. >ecause of
neuropathy, people may not feel
discomfort from the infection until it
becomes serious and difficult to treat,
leading to gangrene. eople with
diabetes are more than 8* times more
likely to re0uire amputation of a foot
or leg than are people without
diabetes.
@oot care is critical (see 3aring for
the @eet ). 'he feet should be
http2,,www.merck.com,mmhe,sec+8,ch+./,ch+./a.html