Diabetes Mellitus

WHAT IS DIABETES MELLITUS?

It is a chronically state that begins when the pancreases stops completely or partly the
insulin production, or the produced insulin is not efficient in the organism. In that case
the cells don’t get the food necessary for their life.

WHAT IS INSULIN?
Insulin is a hormone produced by the pancreases – the key which opens the doors on
cells and enables them to take over the food (glucose which organism uses as an energy
source) form the blood. Glucose in the blood without insulin increases instead of going
into cells. That’s why it is important to inject insulin into the organism.

THERE ARE: Type 1, Type 2, Gestational diabetes

TYPE 1 DIABETES

• Sometimes called insulin dependent type of diabetes in which it is necessary to

inject insulin into the organism.
• This type of illness develops when the immunological system stops recognizing
that part of pancreases which produces and extracts insulin as a part of the body.
Immunological system destroys that part of the pancreases without destroying the
other parts. As a result, it creates less insulin and it slowly decreases till it finally
ends. In that case insulin must be taken into with an injection.
• It is more frequently with children and teenagers, but it can appear with adults,
too.
• It appears with frequency of about 10% from total number of patients.

SYMPTOMS
Origin of type 1, diabetes is usually sudden and dramatic and it can include
following symptoms:
 • Frequent urination
• Extraordinary thirst and
dryness of the mouth
• Outstanding
tiresomeness/lack of energy
• Permanent hunger
• Sudden weight loss
• Disturbance of eyesight
• The common infections
• Scorching and numbness in
the feet

WHO IS UNDER THE RISK OF DEVELOPMENT OF DIABETES?

Risk factor for the type 1 of diabetes is not defined enough, but the combination of
inheritance and the environment (virus infections, stress) can be predispositions for the
illness development. Etiology is unclear, probably it is about self immunity.

IS THERE A CURE?

There isn’t a cure but there is a successful treatment. A good regulation of diabetes
includes the maintenance of glucoses level that are closer to the normal values. It can be
achieved with the following:

• Healthy, balanced nutrition

• Regular physical activity
• Self-control of the sugar in the blood
• Taking pills and/or insulin if needed avoiding of stressful way of living

INSULIN
 Inzulin is extracted by the pancreases cells in the small amount during the whole day
and night. It helps that the glucose gets into the cell and feeds it. It is a protein which is
assembled from the amino acids; if it would be necessary to take insulin through the
mouth it would disintegrate in the stomach, so it would not enter into the blood.
Therefore it must be given with injections into the subcutaneous tissue or into the blood.
Insulin is given by syringes, special injections which are pen shaped.
Two Canadians Banting and Best, in 1921 managed to isolate insulin from the pig’s
pancreases, and for that won the Nobel Prize because their discovery would mean a
turning point in the medical treatment of diabetes.
The first patient was a 12-years-old boy Leonard, and with that discovery they saved
his life. Until that all people with diabetes have died soon or a couple of months after the
first signs of the illness.
There are couples of basic kinds of insulin that differ towards the speed of absorb into
the subcutaneous tissue after the injection, towards the time in which their effect is the
strongest and towards the length activities.

There are:

• short effectively or “clear” insulin – effects after 15 to 30 minutes

• medium long effective or “blurred” insulin – effects after 1,5 to 2 hours
• long effectively insulin – effects after 3 to 6 hours

There are two ways of insulin usage:

1. the conventional therapy - twice a day in the morning and in the evening
2. the intensive therapy - the goal is to imitate the extraction of the insulin which is
for the healthy person where in the time and after a meal there is a larger
extraction of the insulin.

Observation of the sick peron with diabetes

 good border bad
Self-control GUK on an
4,4 – 6,1 6,2 - 7,8 > 7,8
empty stomach after the
5,5 – 8,0 8,1 – 10,0 > 10
meal
HbA1c (%) < 6,5 6,5 – 7,5 > 7,5
The total cholesterol
< 5,2 5,2 - 6,2 > 6,5
(mmol/l)
Triglicerin on an empty
< 1,7 1,7 – 2,2 > 2,2
stomach (mmol/l)
BMI (kg/m )
male < 25 25 – 27 > 27
female < 24 24 – 26 > 26
Blood pressure Individually, the lowest acceptable values

HYPERGLICHEMIA - because of irregular eating habits and consuming large

amounts of food especially carbohydrates:
- because of lack of body activities
- during acute illness (virus infections, higher temperature, acute stress condition)
- because of consuming inadequate amount of drug (tablets or insulin )
- because of irregular self control and control and also because of inadequate care for the
self health

SIGNS THAT INDICATE

HYPERGLICHEMIA:

• Dry mouth and thirst

• Continuous urination
• Blur sight
• Itches on skin and mucous
membranes
• Red face
• The smell of acetone in breath
• Lower heart beats
• Deeper breathing

• Conscience disorder to coma

HOW CAN AND MUST I HELP?

Measure up the level of glucose in blood and in urine also the level of keton (acetone) in
urine. If the hyperglycemia is mild, without keton but with high amount (concentration)
of glucose in urine:
- drink larger amount of liquid (1-2 L- tea, mineral water or pure water)
- in the next meal reduce level of carbohydrate
- increase body activities (running, house gymnastics)
If the hyperglycemia is more serious, and there is keton and glucose in urine:
- drink large amount of liquid (2-3 L)
- higher the dosage of drug taken ( larger numbers of tablets or add 4 to 6 units of fast
acting insulin )
- take two tablets of sodium bicarbonate with 1 L of tea, if the ketons do not disappear
from urine.
- measured the level of glucose in blood every hour, glucose and ketons after every
urination monitor the changes and write them down (take notes).
- if the symptoms do not disappear and the glucose in blood does not decrease, inform the
doctor .

In case of acute illness (infections and higher body temperature):

Despite lower food needs the level of glucose in blood increases so the prescribed
treatment needs to be continued or even increased. If the patient already takes the
maximum amount of tablets it is required to include the insulin treatment while infection
(is active ).
The insulin won’t be necessary when the acute illness is cured. If the patient is already
on insulin treatment the dose needs to be increased according to glucose level in blood.
There for the level of glucose needs to be measured every hour.

HYPOGLICHEMIA - Low level of glucose in blood

• because of large amount of insulin during a long period of time between insulin
injection and meal or fast resumption of insulin, because of irregular injection ( in
muscular tissue or in blood vein ).
• low amounts of food ( because of ) caused by inadequate meal or skipped meal or
digestion problems. Continuous bowel movement and diarrhea.
• increased body activity caused by activity not planned and insufficient diet with
inadequate treatment.
• because of disturbed kidney activity and large glucose loss because of constant
urination or higher drug concentration in the body,
• because of large amounts of alcohol.

THE SIGNS THAT INDICATE

HYPOGLICHEMI:

• swatting
• faster heart beat
• shivering
• hunger
• pail face
• headache
• conscience disorder to coma
• fear
• dizziness
 • inappropriate behavior
• jawing

• concentration and sight disorder

Treatment and management

Diabetes mellitus is currently a chronic disease, without a cure, and medical emphasis
must necessarily be on managing/avoiding possible short-term as well as long-term
diabetes-related problems. There is an exceptionally important role for patient education,
dietetic support, sensible exercise, self glucose monitoring, with the goal of keeping both
short-term blood glucose levels, and long term levels as well, within acceptable bounds.
Careful control is needed to reduce the risk of long term complications. This is
theoretically achievable with combinations of diet, exercise and weight loss (type 2),
various oral diabetic drugs (type 2 only), and insulin use (type 1 and increasingly for type
2 not responding to oral medications). In addition, given the associated higher risks of
cardiovascular disease, lifestyle modifications should be undertaken to control blood
pressure and cholesterol by exercising more, smoking cessation, consuming an
appropriate diet, wearing diabetic socks, and if necessary, taking any of several drugs to
reduce pressure. Many Type 1 treatments include the combination use of regular or NPH
insulin, and/or synthetic insulin analogs such as Humalog, Novolog or Apidra; the
combination of Lantus/Levemir and Humalog, Novolog or Apidra. Another Type 1
treatment option is the use of the insulin pump with some of the most popular pump
brands being: Cozmo, Animas, Medtronic Minimed, and Omnipod.

Cures for type 1 diabetes

There is no practical cure now for type 1 diabetes. The fact that type 1 diabetes is due to
the failure of one of the cell types of a single organ with a relatively simple function (i.e.
the failure of the islets of Langerhans) has led to the study of several possible schemes to
cure this form diabetes mostly by replacing the pancreas or just the beta cells.
Only those type 1 diabetics who have received either a pancreas or a kidney-pancreas
transplant (when they have developed diabetic nephropathy) and become insulin-
independent may now be considered "cured" from their diabetes. A simultaneous
pancreas-kidney transplant is a promising solution, showing similar or improved survival
rates over a kidney transplant alone. Still, they generally remain on long-term
immunosuppressive drugs and there is a possibility that the immune system will mount a
host versus graft response against the transplanted organ.

Transplants of exogenous beta cells have been performed experimentally in both mice
and humans, but this measure is not yet practical in regular clinical practice. Thus far,
like any such transplant, it has provoked an immune reaction and long-term
immunosuppressive drugs will be needed to protect the transplanted tissue.[37] An
alternative technique has been proposed to place transplanted beta cells in a semi-
permeable container, isolating and protecting them from the immune system. Stem cell
research has also been suggested as a potential avenue for a cure since it may permit
regrowth of Islet cells which are genetically part of the treated individual, thus perhaps
eliminating the need for immuno-suppressants.[35] A 2007 trial of 15 newly diagnosed
patients with type 1 diabetes treated with stem cells raised from their own bone marrow
after immune suppression showed that the majority did not require any insulin treatment
for prolonged periods of time.[38]

Microscopic or nanotechnological approaches are under investigation as well, in one

proposed case with implanted stores of insulin metered out by a rapid response valve
sensitive to blood glucose levels. At least two approaches have been demonstrated in
vitro. These are, in some sense, closed-loop insulin pumps.

Cures for type 2 diabetes

Type 2 diabetes can be cured by one type of gastric bypass surgery in 80-100% of
severely obese patients. The effect is not due to weight loss because it usually occurs
within days of surgery, which is before significant weight loss occurs. The pattern of
secretion of gastrointestinal hormones is changed by the bypass and removal of the
duodenum and proximal jejunum, which together form the upper (proximal) part of the
small intestine.[39] One hypothesis is that the proximal small intestine is dysfunctional in
type 2 diabetes; its removal eliminates the source of an unknown hormone that
contributes to insulin resistance.This surgery has been widely performed on morbidly
obese patients and has the benefit of reducing the death rate from all causes by up to
40%. A small number of normal to moderately obese patients with type 2 diabetes have
successfully undergone similar operations.

Prognosis
Patient education, understanding, and participation is vital since the complications of
diabetes are far less common and less severe in people who have well-controlled blood
sugar levels.[44][45] Wider health issues accelerate the deleterious effects of diabetes. These
include smoking, elevated cholesterol levels, obesity, high blood pressure, and lack of
regular exercise. According to a study, women with high blood pressure have a threefold
risk of developing diabetes.

Anecdotal evidence suggests that some of those with type 2 diabetes who exercise
regularly, lose weight, and eat healthy diets may be able to keep some of the disease or
some of the effects of the disease in 'remission.' Certainly these tips can help prevent
people predisposed to type 2 diabetes and those at pre-diabetic stages from actually
developing the disorder as it helps restore insulin sensitivity. However patients should
talk to their doctors about this for real expectations before undertaking it (esp. to avoid
hypoglycemia or other complications); few people actually seem to go into total
'remission,' but some may find they need less of their insulin medications since the body
tends to have lower insulin requirements during and shortly following exercise.
Regardless of whether it works that way or not for an individual, there are certainly other
benefits to this healthy lifestyle for both diabetics and nondiabetics.

The way diabetes is managed changes with age. Insulin production decreases due to age-
related impairment of pancreatic beta cells. Additionally, insulin resistance increases due
to the loss of lean tissue and the accumulation of fat, particularly intra-abdominal fat, and
the decreased tissue sensitivity to insulin. Glucose tolerance progressively declines with
age, leading to a high prevalence of type 2 diabetes and postchallenge hyperglycemia in
the older population.[46] Age-related glucose intolerance in humans is often accompanied
by insulin resistance, but circulating insulin levels are similar to those of younger people.
[47]
Treatment goals for older patients with diabetes vary with the individual, and take into
account health status, as well as life expectancy, level of dependence, and willingness to
adhere to a treatment regimen.[48]

Acute complications

Diabetic ketoacidosis (DKA) is an acute and dangerous complication that is always a

medical emergency. Lack of insulin causes the liver to turn fat into ketone bodies, a fuel
mainly used by the brain. Elevated levels of ketone bodies in the blood decrease the
blood's pH, leading to most of the symptoms of DKA. On presentation at hospital, the
patient in DKA is typically dehydrated and is breathing rapidly and deeply. Abdominal
pain is common and may be severe. The level of consciousness is typically normal until
late in the process, when lethargy may progress to coma. Ketoacidosis can become severe
enough to cause hypotension, shock, and death. Analysis of the urine reveals significant
levels of ketone bodies present (which spill over from the blood when the kidneys filter
blood). Prompt proper treatment usually results in full recovery, though death can result
from inadequate or delayed treatment, or from complications. Ketoacidosis is much more
common in type 1 diabetes than type 2.

Nonketotic hyperosmolar coma

The hyperosmolar nonketotic state (HNS) is an acute complication with many symptoms
in common with DKA, but an entirely different cause and different treatment. In a person
with very high blood glucose levels (usually considered to be above 300 mg/dl (16
mmol/l)), water is drawn out of cells into the blood by osmosis and the kidneys dump
glucose into the urine. This results in loss of water and an increase in blood osmolality. If
fluid is not replaced (by mouth or intravenously), the osmotic effect of high glucose
levels combined with the loss of water will eventually lead to dehydration. The body's
cells become progressively dehydrated as water is taken from them and excreted.
Electrolyte imbalances are also common and dangerous. As with DKA, urgent medical
treatment is necessary, especially volume replacement. Lethargy may ultimately progress
to a coma, which is more common in type 2 diabetes than type 1.

Hypoglycemia

Hypoglycemia, or abnormally low blood glucose, is a complication of several diabetes

treatments. It may develop if the glucose intake does not cover the treatment. The patient
may become agitated, sweaty, and have many symptoms of sympathetic activation of the
autonomic nervous system resulting in feelings similar to dread and immobilized panic.
Consciousness can be altered or even lost in extreme cases, leading to coma, seizures, or
even brain damage and death. In patients with diabetes, this may be caused by several
factors, such as too much or incorrectly timed insulin, too much or incorrectly timed
exercise (exercise decreases insulin requirements) or not enough food (specifically
glucose-producing carbohydrates), but this is an over-simplification.

It is more accurate to note that iatrogenic hypoglycemia is typically the result of the
interplay of absolute (or relative) insulin excess and compromised glucose
counterregulation in type 1 and advanced type 2 diabetes. Decrements in insulin,
increments in glucagon, and, absent the latter, increments in epinephrine stand high in the
hierarchy of redundant glucose counterregulatory factors that normally prevent or rapidly
correct hypoglycemia. In insulin-deficient diabetes (exogenous) insulin levels do not
decrease as glucose levels fall, and the combination of deficient glucagon and
epinephrine responses causes defective glucose counterregulation.

Furthermore, reduced sympathoadrenal responses can cause hypoglycemia unawareness.

The concept of hypoglycemia-associated autonomic failure (HAAF) in diabetes posits
that recent incidents of hypoglycemia causes both defective glucose counterregulation
and hypoglycemia unawareness. By shifting glycemic thresholds for the sympathoadrenal
(including epinephrine) and the resulting neurogenic responses to lower plasma glucose
concentrations, antecedent hypoglycemia leads to a vicious cycle of recurrent
hypoglycemia and further impairment of glucose counterregulation. In many cases (but
not all), short-term avoidance of hypoglycemia reverses hypoglycemia unawareness in
most affected patients, although this is easier in theory than it is in practice.

In most cases, hypoglycemia is treated with sugary drinks or food. In severe cases, an
injection of glucagon (a hormone with the opposite effects of insulin) or an intravenous
infusion of dextrose is used for treatment, but usually only if the person is unconscious.
In hospitals, intravenous dextrose is often used.

Chronic complications
Vascular disease

Chronic elevation of blood glucose level leads to damage of blood vessels (angiopathy).
The endothelial cells lining the blood vessels take in more glucose than normal, since
they don't depend on insulin. They then form more surface glycoproteins than normal,
and cause the basement membrane to grow thicker and weaker. In diabetes, the resulting
problems are grouped under "microvascular disease" (due to damage to small blood
vessels) and "macrovascular disease" (due to damage to the arteries).

The damage to small blood vessels leads to a microangiopathy, which can cause one or
more of the following:

• Diabetic retinopathy, growth of friable and poor-quality new blood vessels in the
retina as well as macular edema (swelling of the macula), which can lead to
severe vision loss or blindness. Retinal damage (from microangiopathy) makes it
the most common cause of blindness among non-elderly adults in the US.
• Diabetic neuropathy, abnormal and decreased sensation, usually in a 'glove and
stocking' distribution starting with the feet but potentially in other nerves, later
often fingers and hands. When combined with damaged blood vessels this can
lead to diabetic foot (see below). Other forms of diabetic neuropathy may present
as mononeuritis or autonomic neuropathy. Diabetic amyotrophy is muscle
weakness due to neuropathy.
• Diabetic nephropathy, damage to the kidney which can lead to chronic renal
failure, eventually requiring dialysis. Diabetes mellitus is the most common cause
of adult kidney failure worldwide in the developed world.

Macrovascular disease leads to cardiovascular disease, to which accelerated

atherosclerosis is a contributor:

• Coronary artery disease, leading to angina or myocardial infarction ("heart

attack")
• Stroke (mainly the ischemic type)
• Peripheral vascular disease, which contributes to intermittent claudication
(exertion-related leg and foot pain) as well as diabetic foot.
• Diabetic myonecrosis ('muscle wasting')

Diabetic foot, often due to a combination of neuropathy and arterial disease, may cause
skin ulcer and infection and, in serious cases, necrosis and gangrene. It is why diabetics
are prone to leg and foot infections and why it takes longer for them to heal from leg and
foot wounds. It is the most common cause of adult amputation, usually of toes and or
feet, in the developed world.

Carotid artery stenosis does not occur more often in diabetes, and there appears to be a
lower prevalence of abdominal aortic aneurysm. However, diabetes does cause higher
morbidity, mortality and operative risks with these conditions.[49]