Diabetes Mellitus is a disorder of glucose dysregulation leading to elevated blood glucose levels. This defect occurs as a result of impaired insulin production and effect. Commonly called “sugar” or “sugar diabetes”, this disorder has become increasingly prevalent in the past decade, leading to greater worldwide focus on the disorder. It has devastating complications, which lead to significant morbidity and mortality among affected patients, and therefore warrants this attention. Also, the economic impact of the disease is quite staggering with billions of dollars needed each year for associated health care cost, not mentioning the ravaging effects on affected patients and families.
The disease state is caused and modulated by various factors. These include impaired production of insulin, the resistance to insulin action, and the dysregulation of hepatic (liver) glucose output. Insulin is a hormone produced in the beta cells of the pancreas for metabolism of glucose. Consequently, any disorder that affects the pancreas leading to a reduction in insulin secretion will lead to hyperglycemia (Diabetes Mellitus). Most commonly, such causes are genetic and immunologic, but infections and also pancreatic toxins (alcohol) can also play a significant roll. Type 1 Diabetes is associated with severe insulin deficiency, whereas Type 2 Diabetes is mostly characterized by a combination of insulin resistance, insulin lack, and dysregulation of hepatic glucose output. Fat and muscle cells contain large numbers of insulin receptors through which insulin can readily facilitate glucose absorption into these cells, thereby maintaining normal blood glucose levels. However various conditions (obesity, pregnancy, lack of exercise) can lead to decreased receptor number and availability thereby worsening blood sugar levels. Hepatic glucose output also influences blood sugar levels. The liver secretes glucose in the fasting state; but with the development of diabetes, the ability to modulate the level of glucose production is lost and the hyperglycemic state is worsened.
The onset of hyperglycemia is subsequently followed by an entourage of debilitating symptoms. However it should be noted that when these symptoms do occur, the process of glucose dysregulation has been ongoing for some ten to fifteen years, and the body has already been adversely affected by the disease. Symptoms include fatigue, increased thirst, frequent urination, a sensation of constant hunger and overeating, and drinking lots of fluids. Some patients however, may present with catastrophic events such as heart attacks, strokes, or even coma.
The diagnosis of Diabetes Mellitus is made when the fasting blood sugar is 126mg/dl or greater, or a random blood sugar is 200mg/dl or higher. If these results are noted medical attention is essential and urgently needed. There are prodromal phases that occur before overt diabetes develops, namely, Impaired Glucose Tolerance, and Impaired Fasting Glucose. These stages also need to be monitored medically in order initiate treatment and to prevent the development of morbid complications from the disease.
Treatment is initiated on three fronts, namely diet, exercise, and medications. Compliance with an appropriate meal plan, which has been made in consultation with a dietician, is absolutely essential. Diet compliance is the foundation of excellent diabetes care, without it the battle is lost. Concurrently, and of almost equal importance, an exercise regimen should be started based on patient tolerance. This should begin slowly (10-15 minutes per day) and should extend to greater than 30 minutes per day as tolerated. If one is not able to control blood glucose levels with diet and exercise alone, then medications becomes necessary.
There are medications which stimulate the pancreas to produce more insulin, others that improve the cell’s absorption of glucose, some that block glucose absorption in the intestine, and still others that block hepatic glucose output. Also, insulin is available to replace the deficiency in patients who are unable to produce it. The best therapeutic decisions to accomplish optimal glucose control are made in conjunction with a trained physician, a well educated patient, and a diabetes management team. Multiple studies have demonstrated that good glucose control retards the development of the devastating complications that can result from this disease.
Finally, Diabetes Mellitus is an incurable but controllable disease that requires constant self-monitoring to maintain optimal control of the disease. Home glucose monitoring devices are currently available and recommended target blood glucose levels as follows: fasting 70-100, pre-prandial 90-120mg/dl, with two hour post-prandial peak glucose levels less than 180. A three month measure of glycemic control called Glycohemoglobin or Hemoglobin A1C level is available and should be less than 7%. Repeated studies have shown that if these levels are maintained diabetic complications can be significantly retarded thereby leading to a better quality of life for affected individuals.
Selwyn Carrington MD