diabetes mellitus (dm)
diabetes mellitus (dm) is a chronic disease characterized by a state of chronic hyperglycemia resulting from a diversity of etiologies, environmental and genetic. The underlying cause of diabetes is the defective production or action of insulin. Diabetes is seen now a heterogeneous group of diseases.
Biabetes mellitus include:
- Insulin dependent DM (IDDM Type 1): is characterized by the lack of insulin production.
- Non insulin dependent diabetes mellitus (NIDM Type 2) : it is caused by the body`s ineffective use of insulin. It often results from excess body weight and lack of exercise.
- Malnutrition related diabetes mellitus (MRDM).
- Other types ( secondary to pancreatic dysfunctions, hormonal disorders, drug induced, .. etc)
- Gestational diabetes mellitus (GDM) is first recognized during pregnancy
- Impaired glucose tolerance.
Diabetes is an iceberg disease where the unknown morbidity far exceeds the known morbidity. The global prevalence of diabetes is highest in Eastern Mediterranean Region and the Region of the Americas(11% for both sexes). More than 80% of diabetes deaths occur in low- and middle-income countries. World Health Organization projects that diabetes will be the 7th leading cause of death in 2030.
Diabetes is an important cause of blindness and visual impairment in adults in developed countries. People with diabetes are 15-40 times more likely to require lower limp amputation and 2-4 times more likely to develop cardiovascular diseases than normal people.
Generally, the occurrence of diabetes mellitus increases with advanced age. In middle age, generally there is no sex predilection proved for DM.
Persons at risk differ according to the type of diabetes.
- For type 1 diabetes:
- Age: the incidence rises gradually from early childhood to a peak at 10-12 years of age, and then starts to decline from early adolescence.
- Defective immunological mechanisms: some people appear to have defective immunological mechanisms, and under the influence of some environmental trigger, they attack their own insulin producing cells. The presence of damaging immune system cells that make auto-antibodies increased the risk of developing type 1 diabetes.
- Ethnicity : type 1 diabetes is more common in whites than in other ethnic groups.
- Nationality : residents in Finland and Sweden have higher rates of type 1 diabetes than those living in other countries.
- Diet : those consuming diet low in vitamin D and early exposed to cow`s milk or cow`s milk formula; or to cereals before 4 months of age are more at risk.
- Exposure to viral infection: exposure to rubella, mumps and human coxackie virus will lead to beta cell destruction causing the disease.
- Exposure to chemical agents: exposure to drugs, chemicals and poisons as rodenticides are toxic to the beta cells. This will cause the disease.
- For type 2 diabetes:
- age: the risk of diabetes increases with age. This may be attributed to less physical exercise, loss of muscle mass and weight gain with age. In recent years type 2 diabetes is also increasing among adolescents and younger adults.
- Obesity: it is the single most important cause of type 2 diabetes. The more fatty tissue a person has the more resistant his/her cells become to insulin. The main cause of type 2 diabetes mellitus pandemic is the growing prevalence of obesity worldwide. In USA and Europe obesity is considered to be responsible for up to 70-90% of the disease in adult population.
- Physical inactivity: physical inactivity is associated with greater risk of type 2 diabetes. Physical activity helps to control body weight, uses up glucose as energy and makes cells more sensitive to insulin. Exercising less than three times a week may increase the risk of type 2 DM.
- Smoking: smokers are roughly 50% more likely to develop diabetes than nonsmokers, and heavy smokers have an even higher risk.
- Family history: the risk increases if a parent or sibling has type 2 diabetes. Aggregation of diabetic cases is observed in families. Studies have showed that offspring of one diabetic parent manifest 2-3 times higher incidence than general population. This is partially explained by genetic predisposition together with shared environmental influences.
- Ethnicity: Blacks, Hispanics, American Indians are at higher risk of type 2 diabetes.
- Gestational diabetes: Gestational diabetes during pregnancy increases the risk of developing impaired glucose intolerance and type 2 diabetes later. Giving birth to a baby weighing more than 4KGs is a sign for increased risk of developing type 2 diabetes for the mother.
- Polycystic ovary syndrome : for women, having polycystic ovary syndrome ( a common condition characterized by irregular menstrual periods, excess hair growth and obesity ) increases the risk of diabetes.
- High blood pressure: blood pressure over 140/90mm Hg is linked to an increased risk of type 2 diabetes.
- Abnormal cholesterol levels: low levels of high-density lipoprotein (HDL below 35 mg/dl). Increases the risk of type 2 diabetes.
- High levels of triglycerides: the risk of diabetes increases if triglyceride levels are above 250 mg/dl.
- For gestational diabetes:
Any pregnant woman can develop gestational diabetes, but some women are at greater risk than others. They include:
- Age: women older than age of 25 are at increased risk.
- Ethnicity: women who are black, Hispanic, American Indian or Asian are more likely to develop gestational diabetes.
- Those having family or personal history: the risk increases if a woman has impaired glucose intolerance a precursor to type 2 diabetes or if a close family member such as a parent or sibling has type 2 diabetes. If she had gestational diabetes during a previous pregnancy, if she delivered a very large baby or if she had an unexplained stillbirth.
- Weight: Being overweight before pregnancy increases the risk of having gestational diabetes.
A pandemic of diabetes mellitus is established since the second half of 20th century. Where it became obvious that a persistent increase in type 2 diabetes mellitus (T2DM), affecting the economically affluent countries, is gradually affecting also the developing world. In the Eastern Mediterranean Region diabetes is highly prevalent among both sexes, especially I countries of Gulf Cooperation Council. The prevalence in Egypt is 15.6%.
Many countries in the region are now reporting the onset of type 2 diabetes at an increasingly young age. Some factors play a role in this respect, mainly: changing lifestyles
- Higher life expectancy
- Better diagnosis and improved medical care
- Primordial prevention
This is prevention of the emergence of risk factors in countries in which they have not yet appeared. This will include maintenance of normal body weight through the adoption of healthy nutritional habits and physical exercise.
- Identification of those at risk
Potential diabetics are those considered at high risk for the development of the disease they include:
- Individuals with positive family history in twins, parents and siblings.
- Those over 40 years of age.
- Obese individuals.
- Females with suggestive obstetric history as those delivering babies over 4.5Kgs. Also females with excess weight gain during pregnancy.
- Cases with premature atherosclerosis.
- Health education: health education should be directed towards the public with special emphasis on high-risk groups. Health education messages should include:
- Control body weight by balancing food intake with energy consumption.
- Promotion of physical exercise. Working your muscles more often and making them work harder improves their ability to use insulin and absorb glucose e.g. walking briskly for a half hour every day.
- Diet modification: four dietary changes can have a big impact on the risk of type 2 diabetes. The dietary messages include:
- Choose whole grains and whole grain products over highly processed carbohydrates.
- Skip the sugary drinks, and choose water, coffee, or tea instead.
- Choose good fats( as the polyunsaturated fats found in liquid vegetable oils, nuts and seeds) instead of bad fats ( margarines, packaged backed goods, fried foods in most fast-food restaurants, and any product that lists ” partially hydrogenated vegetable oil ” on the label).
- Limit red meat and avoid processed meat; choose nuts, whole grains, poultry, or fish instead.
- Avoidance of diabetogenic drugs, by prone individuals like contraceptive pills, corticosteroids.
- Reduce factors that promote atherosclerosis, as smoking, high blood pressure, elevated cholesterol and triglycerides. If you smoke, try to quit!!
- Family life education, may enhance avoidance of marriage among diabetics. Also it should encourage use of family planning services.
- Screening and case finding: screening of the whole population for diabetes is not considered as a rewarding exercise. Screening of high risk groups is more appropriate. Any organized group of the community can be the target of a screening program for diabetes. Example: workers covered by health insurance, mothers attending MCH centers, school children, laborers in factories….etc.
- Blood sugar testing: standard oral glucose test remains the cornerstone of diagnosis of diabetes. Mass screening programs have used glucose measurements of fasting, post-prandial or random blood sample.
- Urine examination: most studies now confirm that although glucose is found in the urine of severe cases of diabetes, It is often absent in milder forms of the disease. This is known as lack of sensitivity. It yields too many false negatives. Indeed the sensitivity of the test varies between 10-15%. For this reason urine testing is not considered an appropriate tool for case finding or epidemiological surveys in the population.
The aim of the treatment is to A) maintain blood glucose levels as close within the normal limits as practical, and B) to maintain ideal body weight.
Proper treatment is important to prevent complications.
– Routine checking of blood glucose should be done. There should be an estimation of glycosylated hemoglobin at half yearly intervals to provide an index of glucose control.
– Routine checking of urine for proteins and ketones, of blood pressure, visual acuity and weight should be done periodically.
– The feet should be examined for any defective circulation, loss of sensation and the health of the skin.
- Health education:
There is a need to educate diabetics and their families.
- Health personnel responsible of health education should motivate diabetics to:
- Maintain ideal body weight
- Attend periodic check ups
- To train diabetics to:
- Carry self-care. So diabetics should take a major responsibility for his/her own care with medical guidance (adherence to diet, drug regimens, examination of his own urine and home blood glucose monitoring, self-administration of insulin if needed.
- Recognize symptoms associated wit glycosuria and hypoglycemia as well as that related to complications.
- Family planning
- High parity diabetics
- Diabetics with vascular complications.
- Diseases of duration more than 25 years.
- Females with habitual fetal loss.
- Early diagnosis and management of complications:
e.g. blindness, kidney failure, coronary thrombosis …etc. there will be a need to rehabilitate those having complication in order that they lead a life as normal as possible.
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