Diabetes – Types and Treatment

Diabetes refers to a group of diseases that affect how the body uses blood sugar (glucose) or regulates fluids.

There are 2 types of namely

1. Diabetes Mellitus.
2. Diabetes Insipidus.

Diabetes Mellitus (DM)

Diabetes mellitus, commonly called DM, is a chronic metabolic disease that causes high blood sugar. The hormone insulin produced by the pancreas moves sugar from the blood into the cells to be stored or used for energy but with DM, the body either doesn’t make enough insulin or can’t effectively use the insulin it does make.

Types of Diabetes Mellitus (DM)

1. Type 1 DM

Type 1 DM is an autoimmune disease. That is, the immune system that normally protects the body and fights harmful bacteria and viruses now destroy insulin-producing cells in the pancreas thus resulting in the production of little insulin or no insulin. 

It looks like the body is fighting itself. As a result, sugar builds up in the bloodstream. It’s unclear what causes this attack. About 10% of people have this type.

Here, the symptoms develop very rapidly and start from a young age. Adults may also develop type 1 DM.

2. Type 2 DM

In type 2 DM, the body isn’t able to effectively use insulin to bring glucose into the cells. This causes the body to rely on alternative energy sources in the tissues, muscles, and organs. This is a chain reaction that can cause a variety of symptoms.

Thus it is said that Diabetes is a pan systemic (global) disease. Here, Symptoms usually begin to develop in the adult, although on the rise in all age groups.

3. Pre Diabetic 

This type is the stage before Type 2 DM. Here the blood glucose levels are higher than normal but not high enough to be officially diagnosed with Type 2 diabetes.

4. Gestational Diabetes

This type develops in some women during their pregnancy. Gestational diabetes usually goes away after pregnancy. However, if one has gestational diabetes the higher the risk of developing Type 2 diabetes later on in life.

5. Other non-common types

• Monogenic diabetes syndromes:

These are rare inherited forms of diabetes accounting for up to 4% of all cases. Examples are neonatal diabetes and maturity-onset diabetes of the young.

• Cystic fibrosis-related diabetes:

This is a form of diabetes-specific to people with this disease.

• Drug or chemical-induced diabetes:

Examples of this type happen after an organ transplant, following HIV/AIDS treatment or are associated with glucocorticoid steroid use.

Diabetes Insipidus (DI)

Diabetes insipidus is caused by problems with a hormone called vasopressin (AVP), also called antidiuretic hormone (ADH). ADH is a hormone is made by the Hypothalamus in the brain, stored in the posterior pituitary gland and tells the kidneys how much water to conserve.

So there could be a deficiency of the hormone being produced called Central DI or resistance to the actions of ADH in the kidneys called Nephrogenic DI.

“Insipid “means colourless and odourless urine.

In Diabetes insipidus (DI), there is the passage of large volumes (>3 L/24 hrs) of diluted urine (< 300 mOsm/kg). Three types are known:

1. Central Diabetes Insipidus

Here there is a deficiency in being produced 

2. Nephrogenic Diabetic Insipidus

Here there is resistance to the actions of ADH in the kidneys.

3. Gestational DI

Diabetes insipidus developed during pregnancy. Diabetes insipidus is a rare condition that has nothing to do with the pancreas or blood sugar.

Symptoms of Diabetes

Both Diabetes mellitus and insipidis present alike with the 3 Ps:

1. Increase Thirst (polydipsia)
2. Increase Urination (polyuria)
3. Increases appetite (Polyphagia). 
4. Weak, tired feeling.
5. Blurred vision.
6. Numbness or tingling in the hands or feet.
7. Slow-healing sores or cuts.
8. Unplanned weight loss.
9. Frequent unexplained infections.
10. Dry mouth.
11. Dry and itchy skin, and frequent yeast infections or urinary tract infections in women 
12. Decreased sex drive, erectile dysfunction, and decreased muscle strength in men.

What are the Risk Factors?

Risk factors are things that increase the chances of one getting Diabetes and they include the following:

Risk factors for Type 1 diabetes 

1. Presence of autoantibodies.
2. Physical stress (such as surgery or illness).
3. Exposure to illnesses caused by viruses.
4. Having a family history, parent or sibling with Type 1 diabetes.
5. Injury to the pancreas (such as by infection, tumour, surgery or accident).

Risk factors for pre-diabetes and Type 2 diabetes

1. Have a family history of a parent or sibling with pre-diabetes or Type 2 diabetes.
2. Obesity.
3. Hypertension.
4. Raised cholesterol especially when the good cholesterol (HDL) is low and the triglyceride (TG) is high.
5. Being physically inactive.
6. Age. The older the higher the chances of developing type 2 DM
7. Gestational Diabetes and previous history of big babies.
8. Polycystic ovarian syndrome (PCOS).
9. History of stroke.

Risk factors for gestational diabetes include

1. Family history of parent or sibling with pre-diabetes or Type 2 diabetes.
2. Obesity before pregnancy

Investigations

1. For Diabetes Mellitus

• Fasting Blood Sugar (FBS)

This test is best done in the morning after an eight-hour fast (nothing to eat or drink except sips of water).

• Random Blood sugar (RBS)

This test can be done any time without the need to fast.

• Glycosylated Hemoglobin (HbA1C)

Provides your average blood glucose level over the past two to three months. Fasting is not required.

• Oral Glucose tolerance test (OGTT)

In this test, the blood glucose level is first measured after an overnight fast. Then you drink a sugary drink. Your blood glucose level is then checked at hours one, two and three.

• Glucose Challenge

Here the glucose level is checked an hour after ingestion of a sugary liquid drink. Fasting is not required. If this test shows a higher than normal level of glucose (over 140 ml/dL or 7.8 mmol/L), then an oral glucose tolerance test 

• Autoantibodies

The presence of autoantibodies is a sign that your body is attacking itself

• Urinalysis

The presence of ketone in the urine is an indication that the body is seeking an alternative energy supply.

2. For Diabetes Insipidus

• Water deprivation test

The patient is allowed fluids overnight and after that is deprived of fluids for 8 hours or until 5% of the body mass has been lost. The patient needs to be weighed hourly. Plasma osmolality is measured 4-hourly and urine volume and osmolality every 2 hours. If ADH is being produced, the kidneys will concentrate the urine.

• Brain MRI

Abnormalities, like growths, are looked for in the pituitary gland.

• Genetic screening

If there are other members of the family with similar problems.

Diabetes Diagnosis

A blood sample will be taken after an overnight fast. A fasting blood sugar level of less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it’s 126 mg/dL (7 mmol/L) or higher on two separate tests, you have diabetes mellitus (DM)

Type of Test	Normal Values (MMOL/L)	Pre-Diabetic (MMOL/L)	Diabetes (MMOL/L)
FBS	<5.5	5.5-6.9	>7
RBS	7.8	7.8-11	>11
HbA1C	5.7%	5.7-6.4%	> 6.5%
OGTT	7.8	7.8-11	>11
Glucose Challenge Test	7.8	7.8-11	>11

But for DI diagnosis, a water deprivation test backed by Brain MRI is used.

How to Prevent Diabetes

1. Diet.

The best kind of diet to prevent type 2 diabetes is a diet rich in fruits, vegetables, healthy carbs, healthy fats, and very little refined sugar.

2. Exercise.

Physical activity is encouraged

3. Weight management.

Keeping a moderate weight.

4. Wear a medical alert bracelet or carry a medical alert card in your wallet.

If you have a medical emergency, a health care professional will recognize immediately your need for special treatment.

5. Prevent dehydration.

Don’t wait until you feel thirsty before you drink water. Increase your fluid intake.

Diabetes Treatment

For DI

1. Hormone Treatment

Desmopressin (DDAVP, Nocturna), is a synthetic hormone that replaces the missing anti-diuretic hormone (ADH) and thus decreases urination. Desmopressin comes in tablets, as a nasal spray or by injection.

2. Diuretic drugs

Treatment with hydrochlorothiazide (Microzide), a diuretic, may improve the symptoms in people with nephrogenic diabetes insipidus.

FOR DM

1. Drug Treatment

Several classes of drugs have been approved for the treatment of DM more than 40 classes but the few common ones are below

• Sulfonylurea – These drugs lower blood glucose by causing the pancreas to release more insulin.
• Biguanides- These drugs reduce how much glucose the liver produces. It also improves how insulin works in the body, and slows down the conversion of carbohydrates into sugar. Metformin (Glucophage®) is an example.
• Thiazolidinediones – These drugs improve the way insulin works in the body by allowing more glucose to enter into muscles, fat and the liver. Examples include pioglitazone (Actos®) and rosiglitazone (Avandia®).

2. Insulin Injections

• Rapid-acting insulins:

These insulins are taken 15 minutes before meals, they peak (when it best lowers blood glucose) at one hour and work for another two to four hours. 

• Short-acting insulins:

These insulins take about 30 minutes to reach your bloodstream, reach their peak effects in two to three hours and last for three to six hours. An example is insulin regular (Humulin R®).

• Intermediate-acting insulins:

These insulins reach your bloodstream in two to four hours, peak in four to 12 hours and work for up to 18 hours. An example is NPH.

• Long-acting insulins:

These insulins work to keep your blood sugar stable all day. Usually, these insulins last for about 18 hours. Examples include insulin (Lantus®

2. Surgery

• Pancreas transplant

This option is for a select number of patients who are diagnosed with Type 1 DM. Please note that this procedure requires the patient to take immune suppressive drugs for the rest of his life and with the resultant side effects. 

• Pancreatic islet transplant. 

In this transplant, clusters of islet cells (the cells that make insulin) in the pancreas are transplanted from an organ donor into the patient’s pancreas to replace those that have been destroyed.

• Type 1 diabetes is immunotherapy 

Another treatment under research for Type 1 diabetes is immunotherapy. Since Type 1 is an immune system disease, immune therapy holds promise as a way to use medication to turn off the parts of the immune system that cause Type 1 disease.

• Bariatric Surgery

This is considered for Type 2 DM who are morbidly obese (Body Mass Index of >35) and have difficulty losing weight.

Complications

The complications of DM are widespread involving virtually every organ of the body. This is why we earlier said that it is a pan systemic disease.

1. Cardiovascular issues including

• Coronary Artery Disease
• Chest pain
• Heart attack
• Stroke
• High Bp
• High Cholesterol levels
• Narrowing of the arteries

2. Nerve damage (neuropathy) causes numbing and tingling that starts at the toes or fingers and then spreads.
3. Kidney Damage (Nephropathy). This can lead to Kidney damage.
4. Eye damage (Retinopathy) that can lead to blindness, Cataracts Glaucoma
5. Foot damage, including nerve damage, poor blood flow and poor healing of cuts and sores.
6. Skin infections.
7. Erectile dysfunction
8. Hearing loss
9. Depression
10. Dementia
11. Dental problems
12. Low blood sugar levels (Hypoglycemia)
13. High blood sugar levels (Hyperglycemia
14. Hyperglycemic Hyperosmolar non-ketotic syndrome
15. Hyperglycemic hyperosmolar Syndrome (HHNS) develops more slowly (over days to weeks) It occurs in patients with Type 2 diabetes, especially the elderly and usually occurs when patients are ill or stressed. This makes the blood glucose level rise above 33mmol/l. Symptoms include frequent urination, drowsiness, lack of energy and dehydration. HHNS is not associated with ketone in urine.

Conclusion

If you have any of the above-discussed symptoms, please, kindly see your GP for a proper diagnosis. The earlier diabetes is diagnosed and the steps taken to treat and control it better the outcome.