Diabetes

One of the fastest growing medical conditions today, why diabetes is on the rise and why we should care.

Diabetes is a collection of metabolic disorders that result in high amounts of sugar in the blood. Elevated blood sugar is known as hyperglycemia and is the key element in the diagnosis of Diabetes.

The main forms of diabetes include type 1, type 2, and gestational. Some forms of diabetes can be cured or prevented with lifestyle changes such as early stage type 2, while others are chronic such as type 1 and require life long insulin injections.

Diabetes occurs either due to a lack of insulin being produced by the pancreas or a lack of the body’s response to insulin, known as insulin resistance. Glucose, which is a form of sugar that is used as energy by the body, cannot enter the cell without insulin.

Thus when insulin is not being used or produced properly the sugar stays in the bloodstream causing high blood sugar. Chronic elevations in blood sugar over time lead to complications in the vascular systems of the kidneys, heart, eye, feet, nerves, and significantly increases the risk for heart disease and stroke.

The most simple way to understand this

Unlike the fat cells, which can keep growing, sugar cells in the body can get full. What this means is that when you eat sugar and carbs, the excess sugar that is not being used at that moment will be stored in the liver and muscle cells as glycogen, but once those glycogen stores are filled, then the excess leftover sugar will be stored as fat.

In diabetes, insulin resistance is the key player. So when the sugar cells are full and the body consumes more sugar and carbs, then insulin is released from the pancreas but, since the sugar cells are already full the cells, those cells will be nonresponsive to insulin. Basically, the sugar cells will tell insulin to bug off cause no more sugar is getting in here.

In this case, the pancreas will pump out even more insulin until it is exhausted and can’t produce insulin enough anymore, or in the case of insulin injections, external insulin will be introduced into the system. In both causes the excess insulin will work to try to shove more sugar into those already full sugar cells, leading to cell death and this is where we see complications in diabetes. This is why diet control along with medications like insulin are imperative.

Global Estimates

Diabetes is considered an epidemic because the number of people diagnosed with DM is steadily growing each year. It is now estimated that about 1 in 10 people in the United States have Diabetes, which is almost doubled from 15 years ago.

Making Diabetes not only the most common endocrine disorder, but one of the most common diseases. Diabetes is also one of the top 10 leading causes of death. Even worse, the CDC is now predicting that 1 in 3 Americans will have Diabetes by 2050. According to the CDC, the worldwide diabetic population accounts for 4.4% of the population.

The Projected Prevalence for 2030 according to Diabetes Research and Clinical Practice says “Between 2010 and 2030, there will be a 69% increase in numbers of adults with diabetes in developing countries and a 20% increase in developed countries.”

Diabetes used to be a disease that was associated with older patients (excluding type 1, which classically presents in youth), but tragically has been growing rapidly in the younger generations due to unhealthy life choices. Nearly 30% of people over 65yrs are diagnosed with Diabetes, while 10-11% of the younger population is diagnosed with Diabetes.

The highest risk groups for Diabetes are Hispanic, Black, and American Indian. Asian and White communities have a lower risk.

Why should we care?

Diabetes not only is a leading cause of death on its own merit, but also increases the chances of getting other life-threatening diseases such as kidney disease, stroke, and heart disorders. As a result, the majority of people with Diabetes die from either heart disease or stroke. Diabetes leads to complications of many body systems and is the leading cause of new-onset blindness and lower limb amputations.

Type 1 Diabetes

Type 1 Diabetes is much less common than type 2, accounting for only 5-10% of diabetes cases. Unlike type 2 which is more common in older adults, type 1 is typically diagnosed before the age of 30.

Diabetes type 1 is an autoimmune disease in which the beta cells (insulin-producing cells) located in the pancreas are destroyed over a period of time. The more beta cells are destroyed the less insulin that can be made. This results in a lifelong deficiency of insulin and dependency on insulin from external sources.

Autoimmune refers to a condition in which the body mistakes its own cells (the beta cells) for invader cells and destroys them. While the exact cause is unknown, the autoimmune process is thought to be the result of genetic predisposition and an environmental trigger. This event sets off a chain reaction that causes the B cells of the immune system to creates proteins called antibodies that mark the beta cells and signal for their destruction by other parts of the immune response team. The CD4 and CD8T Cells are the soldiers who sniff out and destroy the tagged beta cells

Progression of Type 1

Before overt diabetes occurs the patient will be in a phase called pre-diabetes. In pre-diabetes, the pancreas will work double time to maintain normal blood glucose levels. The hallmark of pre-diabetes is the presence of GAD, ICA, IAA antibodies. In addition, there will be evidence of beta cell injury and a decrease in the amount of insulin being produced.

The patient is considered to be in overt diabetes once the number of beta cells is reduced to less than one fourth and the body is no longer able to produce enough insulin to keep up with the demands of the body. At this point, blood sugar will be significantly elevated.

Symptoms

Symptoms of type 1 diabetes vary per person, but typically include:

  • Frequent urination: including waking at night to urinate and bed wetting
  • Weight loss: since glucose is not being used as an energy source, the body must find other energy sources and does so by breaking down fat and muscle
  • Thirst
  • Hunger
  • Blurred Vision
  • Drowsiness
  • Nausea
  • Vomit
  • Skin, bladder, vaginal infections

The classic 3 P’s of Diabetes; polyuria (frequent urination), polydipsia (excessive thirst), polyphagia (hunger). Thirst is due to dehydration. Frequent urination is due to the body trying to expel the excess sugar through the urine. Both high and low blood sugar cause hunger.

Treatment of Type 1 Diabetes

Once diagnosed with type 1 diabetes patients will be started on insulin treatments for life. The amount of insulin needed will be individualized, but the typical starting dose is 0.4-1.0 units/kg/day.

Insulin

Insulin injections can be given in long, intermediate, short, or rapid-acting formIn most cases insulin is given in a long or intermediate form for maintenance and then a “bolus” or rapid-acting insulin is given at mealtime

Basal/ Bolus schedules

Basal: half of the daily insulin is given in long acting form

Bolus: half of daily insulin is split into 3 and rapid acting is given 3x per day to cover every meal

Calculating insulin doses

Patient weighs 60kg (pounds/2.2= kg) and the insulin dose prescribed is 0.5 units per kg

To calculate the daily insulin dose amount of units needed x kg0.5units/kg= 30 units insulin per day.

To calculate the basal bolus dose, if the total daily insulin coverage needed is 30, then

50% of that needs to be basal dose= 15 units of long acting 50% of that 30 needs to be bolus, then divided by 3 meals= 5 units of rapid acting per meal

How to administer insulin

90 degree injection angle, inject then count to 10 before removing the needle. Injection sites include: abdomen, thighs, back of arms, buttock. Choose an injection site, such as the abdomen, and rotate where you insert the needle within that same site to provide a consistent rate of absorption as well as prevent skin breakdown. Do not change body site locations daily as different body parts absorb the medication at different rates, the abdomen absorbs most quickly.

Storage of insulin

Refrigerate insulin for prolonged storage. May be left at room temp for up to 1 month. DO NOT keep in hot temperatures

Insulin Side Effects

Hypoglycemia (low blood sugar) from too much insulin or not enough food, weight gain, injection site skin breakdown from not rotating the site enough.

Type 2 Diabetes

Occurs when the body is unable to produce enough insulin to keep blood sugar at a healthy level and/or when the cells of the body are no longer responsive to the insulin that is being produced. Like Type 1 diabetes, the exact cause is unknown, but thought to result from a combination of genetic predisposition and lifestyle factors. Lifestyle factors such as weight, food choices, substance use, physical activity level, and environment.

Accounts for greater than 90% of diabetes cases. Type 2 used to be associated with older patients, but due to western lifestyles and increasing obesity rates in all ages is now becoming an epidemic in the youth as well.

Progression of Type 2 Diabetes

Early in this disease the pancreas is able to overcome the bodies cellular resistance to insulin and maintain normal blood sugar levels by producing extra amounts of insulin (hyperinsulinemia).

Over time the beta cells of the pancreas become fatigued and are unable to keep up with the insulin demand, which results in impaired (decreased) insulin production. This leads to chronically elevated blood sugar levels and the diagnosis of diabetes.

Pre Diabetes: the beta cells are fatigued and there is an impairment in the secretion of insulin. Blood sugar begins to rise.

Overt Diabetes: Beta cell impairment continues with an even greater deficiency of insulin. The body is even less responsive to insulin leading to decreased uptake of glucose into the cells. Blood sugar level well above normal range. In addition the liver begins releasing excess glucose in between meals.

Risk Factors of Type 2 Diabetes

Factors include: obesity, sedentary lifestyle, high blood pressure, high triglycerides, high alcohol intake, family history, ethnicity (African American, Indian American, Hispanic), mother who had gestational diabetes or giving birth to a baby >10lbs.

Hallmarks of Type 2 Diabetes

  • Fasting Hyperglycemia occurs >6 hours after meals due to the increased glucose production by the liver.
  • Postprandial Hyperglycemia occurs directly after meals is caused by the decreased uptake of glucose by the cells.
  • Insulin Resistance: decreased cellular receptor sensitivity to insulin that results in decreased uptake of glucose into the cell.

Symptoms of Type 2 Diabetes

Symptoms vary per person but typically include the following:

  • Thirst
  • Frequent urination
  • Hunger
  • Dry mouth
  • Headaches
  • Fatigue
  • Weight loss or gain

The classic 3 P’s; polyuria (frequent urination), polydipsia (excessive thirst), polyphagia (hunger). Thirst is due to dehydration. Frequent urination is due to the body trying to expel the excess sugar through the urine. Both high and low blood sugar cause hunger.

Treatment of Type 2 Diabetes

According to the ADA (American Diabetes Association), those diagnosed with Type 2 Diabetes should start with metformin medication and lifestyle changes at diagnosis (unless metformin contraindicated). Then you can add second oral/ injection anti-diabetic medication GLP-1 receptor agonist or insulin if oral anti-diabetic medication maximum tolerated dose does not reach blood glucose goals over 3-6 months. Consider insulin therapy (with or without other agents) at diagnosis of patients symptoms of diabetes and/or elevated blood glucose levels.

Diagnosis

Confirming the diagnosis of Diabetes will be based on one of the following lab values

  • 1c levels of 6.5% or higher indicate diabetes
  • Fasting plasma glucose (FPG) > 126mg/dL
  • 2-hour plasma glucose level of >200mg/dL during an oral glucose tolerance test using glucose load containing the equivalent to 75g of glucose dissolved in water
  • Classic symptoms of hyperglycemia (polyuria, polydipsia, polyphagia) or hyperglycemic crisis, with a random plasma glucose of >200 mg/dL

Dangerously high blood sugar

When blood sugar levels become dangerously high it is considered a medical emergency and immediate medical attention is needed. Do not wait until your blood sugar is dangerously high to call your doctor. Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome can cause dangerously high blood sugar.

Diabetic Ketoacidosis

A potentially life-threatening condition that results from a lack of insulin and elevated blood glucose. Since glucose is not being used for energy the body begins to break down fats which lead to ketoacidosis. In addition, the excess glucose is excreted in the urine, taking water with it, which leads to dehydration.

Causes: lack of insulin, illness, dehydration.

Symptoms: polyuria, polydipsia, polyphagia, fruity breath, abdominal pain, rapid breathing, decreased level of consciousness, hot flushed skin. Plasma glucose > 250 and positive for ketones in the urine

Treatment: goal is to hydrate the patient and reduce blood glucose

Hyperosmolar Hyperglycemic Syndrome

A dangerous condition caused by extremely high blood sugar that leads to severe dehydration as the kidneys attempt to excrete the excess glucose in the urine. Dehydration results in an increase electrolytes in the blood that pulls the fluid in other vital organs into the bloodstream, which can lead to many complications including coma and death.

Causes: undiagnosed diabetes, illness, untreated hyperglycemia, prolonged IV nutrition without insulin.

Symptoms: severe dehydration, neurological manifestations, plasma glucose >600Ketones absent or slightly elevated serum osmolality >320

Treatment: hydrate then bring down blood sugar

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