diabetes mellitus classification

Classification of diabetes mellitus

Diabetes mellitus is a medical condition of a metabolic disorder resulting from a frank lack of, or diminished, effectiveness of endogenous insulin and is (diabetes mellitus) characterized by increase or rise in blood sugar or plasma glucose. A diabetic patient at first time does not know that they have diabetes as the condition does not show any symptoms as that time of onset.

As time goes on the diabetic patient will start showing some diabetes symptoms that will first bring him or her to the diabetic clinic. Such of the symptoms include but not limited to ketoacidosis, unwell, increased breathing rate, and smell of ketones on breath, weight loss, frequent urination (polyuria), fatigue, tiredness, and dehydration, increased thirst (polydipsia), which are the most common among the symptoms of diabetes.
On classification, diabetes is classified in two major types of diabetes: type 1 diabetes and type 2 diabetes. While other sub types may exist like gestational diabetes which is associated with pregnancy and most likely disappears after the pregnancy.

Type 1 – Insulin-dependent Diabetes Mellitus, IDDM: This is usually juvenile in onset but may occur at any age, and it is characterized by frank insulin deficiency. Patients suffering from type I diabetes regularly needs insulin injection through insulin pumps and other comfortable insulin devices. Patients suffering from type 1 diabetes, IDDM, are more prone to suffer weight loss and ketoacidosis. Type 1 diabetes is usually associated other immune diseases like HLA DR3 & DR4 and positive islet cell antibodies around the time of diagnosis. Type 1 diabetes, which is insulin dependent (IDDM) can as well be co-controlled using the right and appropriate diabetes diet as well as regular physical exercise upon the doctor’s attention.

Type II – Non-insulin-dependent Diabetes Mellitus, NIDDM: This type of diabetes sets in during the matured age- maturity onset of diabetes mellitus. It sets in older age group, often obese. NIDDM may eventually need insulin, but this does not mean that IDDM has developed. Insulin is likely to be needed in non-insulin diabetes mellitus, NIDDM, in those diabetic patients who may have ketonuria and with glucose level that is greater than 25mmol/L. 

Other conditions of non-insulin dependent diabetes that may warrant the use of insulin include sudden onset of the diabetes, rapid weight loss and dehydration or loss of water/or body fluid.  If the diabetic ketoacidosis persists, then IDDM exists largely due to impaired insulin secretion and/or insulin resistance.

Causes of secondary diabetes include most of the following:
1.    Drugs- such as steroid drugs and thiazides drugs
2.    Pancreatic disease such as pancreatitis, surgery in which over 90% of the pancreas is removed, haemochromatosis, cystic fibrosis, and pancreatic cancer
3.    Endocrine conditions like acromegaly, Cushing’s disease, phaechromocytoma, thyrotoxicosis)
4.    Others include acanthosis nigricans, congenital lipodystrophy with insulin receptor antibodies, and glycogen storage diseases.

Diabetes Diagnosis: According to the World Health Organization (WHO) criteria adopted by United Kingdom in June 2000. Fasting venous blood sample for glucose, and if the blood glucose level is above or equal to 7mmol/L; a glucose level of 6-7mmol/L implies impaired fasting glucose.  If the patient has no diabetes symptoms, diabetes diagnosis should not be based on a single glucose value. 

If there is any doubt about the diabetic status of the patient, the 2-hour value in an oral glucose tolerance test, OGTT should be used. The method for performing the 2-hour oral glucose tolerance test (OGTT) follows: the patient should fast overnight and in the morning should be given 75g of glucose dissolved in 300mL of water and given to drink. Then the venous blood sample collected 2 hours after drinking the glucose solution, and then tested for venous sample glucose level. Note that urine tests for glycosuria and random blood glucose tests are unreliable ( but if >11.1mmol/L and symptoms are present, this confirms diabetes mellitus, DM)

In some conditions, blood glucose or blood sugar may rise significantly. Such conditions in which this may occur include acute infection, trauma, or circulatory or other stress which may be transitory, are all conditions in which a patient may be seen presenting with severe hyperglycemia. When this happens, formal diabetes diagnosis should be delayed, but management should be followed promptly.
With reference to HbA1c values, if it is above 7%, diabetes mellitus is likely and risk of microvascular diabetic complications is higher.

The diabetes management base line borders on weight loss and exercise, manage hyperglycemia, with diabetes diet, drugs or insulin. Vitamin E improves insulin sensitivity, reducing insulin insensitivity and (Vitamin E) serves as powerful anti oxidant delaying damaging oxidation by removing free radicals of metabolism.

Diabetic patients need motivation and proper diabetes education in order to enable them cope with the new metabolic condition. Diabetes has been shown to be controlled, and managed, and even some diabetes treatment regimens are becoming widely accepted. Most of these diabetes treating course are mostly based on natural diabetes diet/diabetic diets that have the potency to regenerate new islet cells of the pancreas thereby increasing insulin secretion and insulin sensitivity.

Understanding Principles of Diabetes Management

When diabetes struck, patient motivation and diabetes education are the keys to success. This aims at reducing the chances and avoiding diabetes complications which include low blood sugar – hypoglycemia as well as the long term complications of hypoglycemia. Diabetes patient education is also vital in order to ensure tight blood sugar control in order to reduce diabetes complications of the kidney (renal neuropathy), central nervous system damage (CNS) and diabetic retinal damage.

In diabetes control, it is quiet medically important to strike a balance for each diabetic patient between lower blood glucose readings and the risk of hypoglycemia. It is quiet of interest to note that, tight blood pressure control is as effective in reducing micro-vascular disease, but also reduces macro-vascular disease and mortality among the diabetics. This underscores the benefit and gains of a global assessment of a individual risk in diabetes such as – glucose, blood pressure, cholesterol, and smoking history. It is always good to note that DM – diabetes mellitus should never be treated in isolation. The best medical care or treatment approach to DM is giving it a systemic approach.

The basic investigations needed to diagnose diabetes include checking the blood plasma for the amount of circulating or free glucose, lipids, HbA1c, cholesterol, while the urine of the diabetics should be checked for urinary protein excretion and detailed urine analysis.  Fundoscopy and foot examination should be carried out in the diabetics in order to assess the feet for diabetes foot and check for neuropathy.

The first line treatment approach if diabetes is diagnosed is to check for ketone bodies in the urine, ketonuria. If ketonuria is present alongside with dehydration, or the patient is ill, hospital admission is required. Children with diabetes are liable to become ketotic rapidly, so prompt pediatric referral becomes compulsory. If the diabetes subject is pregnant as well, care should be given alongside with an interested obstetrician, and the need for special pre-conception counseling should be made well known to the diabetic patient.

Diabetes education becomes imperative on drug therapy of diabetes. The diabetes education/negotiation becomes crucial on diabetes drugs, diet, and the following diabetes education outline should be covered: monitoring blood or urine glucose and adapting treatment accordingly, explain to the diabetic patient the need for insulin when ill more, not less, recognition and treatment of hypoglycemia with sweets or sugars, introduce the diabetic patient to a specialist nurse or dietician, chiropodist, and diabetic association, educate the diabetic patients on the health benefits of regular medical checkup, follow-up and regular physical exercise which helps to reduce the risk of insulin resistance, also educate the diabetic patient to inform their driving license authority, and above all, guide the diabetic patient on healthy eating: reduce saturated fats, reduce sugar, moderately increase starchy carbohydrates – healthy carbs (bread, potato, pasta) is taken at each meal. If there is renal impairment or micro-albuminuria, then restrict protein intake.

Diabetes treatment borders on the correct use of bio insuling and a combination of oral anti diabetic medications or oral hypoglycemic agents such as sulfonylureas (increases insulin secretion)- the drugs here are tolbutamide-short acting, useful in elderly as hypoglycemia, which is short acting, while the medium acting is glibenclamide.

Other oral anti-diabetic medications include metformin (a biguanide) which acts by increasing insulin sensitivity, decreasing liver (hepatic) gluconeogenesis, and have been seen to decrease mortality in obese diabetic patients. Metformin is not recommended to be used in renal or liver impairment. Other anti diabetic medications are acarbase (an alpha-glucosidase inhibitor) and thiazolidinediones, effects and actions of which will be discussed in detail in the next diabetes guide to be published here. 

Assessment of the established diabetic

Continuing assessment of the diabetic patient has three main aims which are to educate the diabetic patient, to find out what problems the diabetic patient is experiencing (glycemic control and morale), and to find out or pre-empt diabetic complications. 

Assessing the glycaemic control in the diabetics can be done from the glycated (glycosylated) haemoglobin levels relating to mean glucose levels over the past eight weeks. The target HbA1c must be set individually per each diabetes patient. Tight or more regular control of HbA1c is highly needed in pregnancy women that have diabetes and others that have micro-vascular complications during diabetes. The elderly diabetic patient may have need for lesser tight control of HbA1c. 

Diabetes and diabetic complications generally increase with increasing HbA1c. Also note that fructosamine in the form of glycated plasma protein relates to diabetes or blood sugar control for the past one to three weeks. This could be very helpful and useful during pregnancy state for assessing and checking shorter term control of diabetes and blood sugar, and also if there is an underlying medical condition interfering with accurate measurement of HbA1c as being observed in some form of hemoglobinopathies. Other methods of assessing glycaemic control are taking the history of hypoglycemic attacks whether with symptoms, and use of home finger stick glucose records.

Assessment of diabetes complications is very important and helpful. This can be done by checking injection sites for infection, lipoatrophy, or lipohypertrophy. 

Diabetic complication assessment needs to cover vascular disease check, which is the most common cause of death in the diabetics resulting from cerebrovascular, cardiovascular, and peripheral vascular complications. This will help to reduce the chances of stroke from occurring which is more common in the diabetes mellitus patients. The kidneys and the renal system need to be regularly checked in the diabetics, checking for the urine creatinine clearance and checking albuminuria.

 This will help to prevent diabetic nephropathy and prevent early renal/kidney diseases in diabetes. Control of hypertension/or high blood pressure in diabetes can as well be very helpful for the diabetics as it will help to reduce and out rule the chances of stroke or cardiac/heart problems from arising as much as preserving the kidneys from being injured. Blindness as one of the complications of diabetes mellitus can be prevented. Loss of sight in diabetes is called diabetic retinopathy. 

It is quiet common in diabetic individual, but it (diabetic retinopathy) is quiet preventable through regular fundoscopy for all diabetic patients , including retinal photography and possible screening to know if laser photocoagulation can be used. Other eye complications in diabetes are cataracts, rubeosis iridis, which are all preventable when the blood sugar is kept under tight control.

Diabetic complications as seen in diabetes individuals, especially type 1 diabetes are complications arising from metabolic derangement, diabetic feet and diabetic neuropathy, all which, can be very well averted or prevented if the diabetes is well managed, treated or better still given a diabetes cure approach.

Understanding diabetes medical and health complications

Complications that follow the Medical and Health Condition Called Diabetes - Diabetes Complications

Diabetes mellitus being a glucose or sugar hormone disorder of the endocrine system of the human body. It results from a total lack of endogenous insulin (frank diabetes), or diminished, reduced effectiveness of endogenous insulin and is (diabetes) is being characterized by increased blood glucose popular called high blood sugar or hyperglycemia. 

Diabetes can only become life threatening if it is not detected or diagnosed early enough or when it is not properly treated or when it is poorly managed. The baseline management for diabetes in order to prevent diabetic complications is to regulate the metabolic blood sugar or blood glucose at a physiologically normal level for glucose-energy metabolism bio-system that yields energy in the form of ATP.

The central cycle for the normal glucose utilization is to make the plasma glucose, or circulating blood glucose to be easily absorbed by the cells of the body, store it (glucose) in the cells in form of glycogen from where the body cells derive energy through the process of gluconeogenesis. 

In absence of adequate insulin secretion and /or in case of ineffective insulin utilization by the cells of the human body, diabetes results in which case, if uncontrolled or poorly managed, some complications generally called diabetic complications set in. They are generally referred to as short-term complications of diabetes which include but not limited to the following:

•    Infection/Infections: Diabetic individuals usually have a decreased ability of the white blood cells to quickly respond to invading microbes or micro organisms into the body. Owing to that, the diabetes patients have what is mostly called lazy cell syndrome. The implication here is that, the diabetics are more prone to wide range of infections than their non-diabetic counterpart. This can be reduced by closer monitoring of blood glucose, and most especially protect themselves from being injured or having an open wound. The diabetics should take care of the foot/feet very well, wear safety diabetic socks and treat every wound/injury promptly. This is due to the compromised immune functions of the diabetic patients. This condition also interferes with normal glucose metabolism and blood sugar control.

•    Hypoglycemia/Hypoglycemic complications: Blood glucose or plasma sugar levels lesser than 70 mg/dL (3.5 mmol/l) is clinically referred to as hypoglycemia. This results when there’s too much endogenous or injected insulin hormone in the body and not adequate glucose in the blood for the insulin to act upon. Hypoglycemia may occur as a result of taking excess or too much anti diabetic medications, skipping/missing meals, abrupt increase in physical exercise levels, abuse of alcohol drinks (beer, gins, vodka and other alcohol drinks), kidney disease secondary to diabetes-kidney nephropathy or renal neuropathy, and poor absorption of glucose from the intestine.

o    Other hypoglycemic frequent symptoms include but not limited to: Headache, vomiting, nausea, confusion, sweating, trembling, hunger/hunger pangs, nervousness, confusion, drowsiness, poor coordination and bizarre heart beats-cardiac palpitation.

o    The clinical condition of hypoglycemia needs to be promptly indentified and sharply recognized immediately as soon as it sets in, and quickly arrange for arresting the situation from degenerating to brain tissue or brain cells death. When hypoglycemia sets in, quickly call for a diabetes nurse or a medical personnel-doctor/physician/or endocrinologist.

o    Ketoacidosis secondary to poorly controlled diabetes: This is one of the diabetic complications that almost always require prompt medical emergency attention as it (diabetic ketoacidosis) almost always results in coma, diabetic coma. 

Diabetic ketoacidosis as a diabetic complication is mostly experienced in diabetes type 1 or type 1 diabetic’s individuals when the blood sugar/glucose level is poorly controlled. Diabetic ketoacidosis usually result as a metabolic condition whereby the decreased level of endogenous bio insulin level in the presence of endogenous catabolic bio hormones leads to excessive hepatic production (liver production) of glucose and group of ketone bodies which (ketone bodies) are the waste product of acidic conditions produced in the human liver when insulin is low, glucose is needed and other catabolic hormones on the increase. This condition is characterized by smell of acetone from the breath of the comatose diabetic person.

o    The following manifestations are the major clinical features observed during diabetic ketoacidosis – increased blood glucose levels/excess blood sugar known as hyperglycemia, excess ketone bodies in the blood known as hyperketonemia, generalized pH decrease of the blood/plasma – meaning higher acidic plasma environment known as metabolic acidosis.

o    Increased blood glucose levels (or excess blood sugar – Hyperglycemia) is a major cause of increased urinary output/urine frequency - osmotic diuresis leading to excess loss of water resulting in dehydration and loss of vital plasma electrolytes such as sodium, chloride, potassium, magnesium etc.

o    Increased reduction of extracellular fluid capacity, resulting in reduced blood pressure (hypotension) which can lead to kidney or renal ischemia diseases or renal shock and toxicity.

o    Further complication of diabetic ketoacidosis includes but not limited to brain or cerebral oedema (edema), circulatory inadequacies or circulatory incompetence/failure, severe respiratory failure or complexes manifesting as respiratory distress syndrome (RDS) and wide disseminated intra-vascular coagulations.

o    Infections secondary to diabetic ketoacidosis, stress and stress syndrome, and trauma or distress are often observed secondary to diabetic ketoacidosis especially in individuals managing type 1 diabetes.

•    There is a wide spreading syndrome among type 1 diabetics which is known as hyperglycemic Non-Ketotic Hyper-osmolar Diabetic Syndrome (HHNS): This a clinical condition in which the blood sugar or glucose levels are terrifyingly high, mostly rising above 50 mmol/L. Very high loss of water due to increased osmolar concentration of the blood plasma resulting in dehydration and presence of urea in the blood (uremia), conditions of which lead to diabetic seizures, diabetic coma and finally death if left unchecked.

•    Another diabetic complication of medical concern is what is called or known as Lactic Acidosis. This is mostly due to excess dose of anti diabetic medicine (anti-diabetic medication) called metformin. Metformin is a biguanide, an oral anti-diabetic medication used as first line therapy, and should not be used in diabetic patients who have hepatic and renal impairment.