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Diabetes Mellitus

Diabetes mellitus is a metabolic disorder characterized by hyperglycemia resulting from lack

of insulin, lack of insulin effect, or both. Three general classifications are recognized:

 type 1—absolute insulin insufficiency

 type 2—insulin resistance with varying degrees of insulin secretory defects
 gestational diabetes—manifested during pregnancy.

Pathophysiology

 Type 1 and type 2 diabetes mellitus are two separate and distinct pathophysiological
entities. In persons genetically susceptible to type 1 diabetes, a triggering event,
possibly a viral infection, causes production of autoantibodies which kill the beta
cells of the pancreas. This leads to a decline in and an ultimate lack of insulin
secretion. Insulin deficiency, when more than 90% of the beta cells have been
destroyed, leads to hyperglycemia, enhanced lipolysis, and protein catabolism.
 Type 2 diabetes mellitus is a chronic disease caused by one or more of the following
factors: impaired insulin production, inappropriate hepatic glucose production, or
peripheral insulin receptor insensitivity.
 Gestational diabetes mellitus is glucose intolerance during pregnancy in a woman
not previously diagnosed with diabetes. This may occur if placental hormones
counteract insulin, causing insulin resistance.

Signs and symptoms

 Polyuria and polydipsia

 Nausea; anorexia (common) or polyphagia (occasional)
 Weight loss (usually 10% to 30%; persons with type 1 diabetes often have almost no
body fat at diagnosis)
 Headaches, fatigue, lethargy, reduced energy levels, impaired school or work
performance
 Muscle cramps, irritability, emotional lability
 Vision changes such as blurring
 Numbness and tingling
 Abdominal discomfort and pain; diarrhea or constipation
 Recurrent vaginal candidiasis

Normal glucose levels: 60 -120 mg/dl

Three types of cells require insulin to transport glucose:

 Myocardial cells
 Skeletal muscle cells
 Adipose tissue cells

Brain cells do not require insulin for glucose transport.

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What causes diabetes?

Insufficient production of insulin (either absolutely or relative to the body's needs),

production of defective insulin (which is uncommon), or the inability of cells to use insulin
properly and efficiently leads to hyperglycemia and diabetes. This latter condition affects
mostly the cells of muscle and fat tissues, and results in a condition known as "insulin
resistance." This is the primary problem in type 2 diabetes. The absolute lack of insulin,
usually secondary to a destructive process affecting the insulin producing beta cells in the
pancreas, is the main disorder in type 1 diabetes. In type 2 diabetes, there also is a steady
decline of beta cells that adds to the process of elevated blood sugars. Essentially, if
someone is resistant to insulin, the body can, to some degree, increase production of insulin
and overcome the level of resistance. After time, if production decreases and insulin cannot
be released as vigorously, hyperglycemia develops.

Glucose is a simple sugar found in food. Glucose is an essential nutrient that provides
energy for the proper functioning of the body cells. Carbohydrates are broken down in the
small intestine and the glucose in digested food is then absorbed by the intestinal cells into
the bloodstream, and is carried by the bloodstream to all the cells in the body where it is
utilized. However, glucose cannot enter the cells alone and needs insulin to aid in its
transport into the cells. Without insulin, the cells become starved of glucose energy despite
the presence of abundant glucose in the bloodstream. In certain types of diabetes, the cells'
inability to utilize glucose gives rise to the ironic situation of "starvation in the midst of
plenty". The abundant, unutilized glucose is wastefully excreted in the urine.

Insulin is a hormone that is produced by specialized cells (beta cells) of the pancreas. (The
pancreas is a deep-seated organ in the abdomen located behind the stomach.) In addition
to helping glucose enter the cells, insulin is also important in tightly regulating the level of
glucose in the blood. After a meal, the blood glucose level rises. In response to the increased
glucose level, the pancreas normally releases more insulin into the bloodstream to help
glucose enter the cells and lower blood glucose levels after a meal. When the blood glucose
levels are lowered, the insulin release from the pancreas is turned down. It is important to
note that even in the fasting state there is a low steady release of insulin than fluctuates a
bit and helps to maintain a steady blood sugar level during fasting. In normal individuals,
such a regulatory system helps to keep blood glucose levels in a tightly controlled range. As
outlined above, in patients with diabetes, the insulin is either absent, relatively insufficient
for the body's needs, or not used properly by the body. All of these factors cause elevated
levels of blood glucose (hyperglycemia).
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Long-Term Complications of Diabetes

Blood vessels

Fatty material (atherosclerotic plaque) builds up and blocks large or medium-sized arteries
in the heart, brain, legs, and penis.

The walls of small blood vessels are damaged so that the vessels do not transfer oxygen to
tissues normally, and the vessels may leak.

Poor circulation causes wounds to heal poorly and can lead to heart disorders, strokes,
gangrene of the feet and hands, erectile dysfunction (impotence), and infections.

Eyes

The small blood vessels of the retina are damaged.

Decreased vision and, ultimately, blindness occur.

Kidney

Blood vessels in the kidney thicken.

Protein leaks into urine.

Blood is not filtered normally.

The kidneys malfunction, and ultimately, kidney failure occurs.

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Nerves

Nerves are damaged because glucose is not metabolized normally and because the blood
supply is inadequate.

Legs suddenly or gradually weaken.

People have reduced sensation, tingling, and pain in their hands and feet.

Autonomic nervous system

The nerves that control blood pressure and digestive processes are damaged.

Swings in blood pressure occur.

Swallowing becomes difficult.

Digestive function is altered, and sometimes bouts of diarrhea occur.

Erectile dysfunction develops.

Skin

Blood flow to the skin is reduced, and sensation is decreased, resulting in repeated injury.

Sores and deep infections (diabetic ulcers) develop.

Healing is poor.

Blood

White blood cell function is impaired.

People become more susceptible to infections, especially of the urinary tract and skin.

Connective tissue

Glucose is not metabolized normally, causing tissues to thicken or contract.

Carpal tunnel syndrome and Dupuytren's contracture develop.

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Type 1 Diabetes

In response to high levels of glucose in the blood, the insulin-producing cells in the pancreas secrete
the hormone insulin. Type I diabetes occurs when these cells are destroyed by the body’s own
immune system.

What are the symptoms of hypoglycemia?

Symptoms of hypoglycemia include the following:

 Shakiness
 Dizziness
 Sweating
 Hunger
 Headache
 Pale skin color
 Sudden moodiness or behavior changes, such as crying for no apparent reason
 Clumsy or jerky movements
 Seizure
 Difficulty paying attention, or confusion
 Tingling sensations around the mouth