DIABETES MELLITUS
Diabetes is a systemic disease characterized by hyperglycemia, hyperlipidemia, and
hyperaminoacidemia. Diabetes alters the metabolism of all the energy nutrients
(carbohydrates, fats and proteins) and affects most organ systems, often leading to
specific problems with microcirculation, neuropathic disorders, and an increased
predisposition to atherosclerosis. In that, Diabetes can contribute to or cause the
development of blindness, kidney disease, heart disease, leg pains and ulcers (often
requiring amputation), complications of pregnancy etc.
The two major forms of diabetes are Type I (insulin dependent or juvenile onset) and
Type II (non-insulin dependent or maturity onset). They share a central feature: elevated
blood sugar levels due to absolute or relative insufficiencies of insulin and/or cellular
resistance to the actions of insulin.
Insulin is a key regulator of blood glucose levels. After a meal, food is digested in the
stomach and intestines; carbohydrates are broken down in to glucose (and other sugars),
and proteins are broken down into amino acids. Glucose and amino acids are absorbed
directly into the bloodstream, and their blood concentration levels rise. Normally, this
triggers release of insulin from the beta cells of the pancreas. Insulin, in turn, increases
the permeability of cells (especially muscle cells) to glucose and amino acids, where
there are burned for energy, converted into proteins, or stored for later use. Insulin also
facilitates storage of excess glucose as glycogen in the liver and muscle for later use
when food nutrients are not available. As blood glucose levels fall to pre-meal levels, the
pancreas reduces its production of insulin and the body uses its stored energy until the
next meal provides additional nutrition.
 Type I: Insulin Dependent Diabetes Mellitus (IDDM)
In Type I diabetes, the beta cells are gradually destroyed; eventually insulin deficiency is
absolute. Without insulin, blood glucose levels rise excessively and hyperglycemia
ensues. Glucose levels eventually rise above the “threshold” levels of absorption
capability by the kidneys and glucose is lost in the urine. Water moves with glucose,
which leads to polyuria. Type I diabetes is associated with an abrupt onset of symptoms
such as weakness, weight loss, excessive hunger and thirst as well as physiologic signs of
low to absent levels of insulin in the blood, proneness to ketosis, and (injected) insulin
dependence.
Type I diabetes is believed to be a progressive autoimmune disease which leads to
destruction of the insulin secreting beta cells of the pancreas. It is suggested that genetic
predisposition coupled with environmental factors trigger the autoimmune reaction. In
most cases, it is felt that by the time symptoms are evident enough to seek medical
attention, 80-90% of the beta cells have been destroyed.
Type I Diabetes involves about 10% of the diabetic population. Up to 80,000 people in
the U.S. are estimated to have type I diabetes with about 30,000 new cases being
diagnosed each year. It primarily affects younger (under 40, typically in childhood) and
thinner patients, but may be seen at any age.
 Type II: Non-Insulin Dependent Diabetes Mellitus (NIDDM)
Type II disease usually has a more gradual onset and is associated with inadequate
production of insulin and/or a reduced sensitivity or responsiveness of cells to the
presence of insulin. Most type II diabetics produce variable, even normal amounts of
insulin, but they have abnormalities in liver and muscle cells that resist its actions. Insulin
attaches to receptor sites, but glucose does not get in. Many type II diabetics can control
their disease with diet modifications, or with medications that stimulate insulin secretion
from the pancreas. The condition often worsens, however, and (injected) insulin support
becomes necessary.
Type II Diabetes is caused by a complex interplay of genes, environment, insulin
abnormalities (reduced secretion and resistance of cells), increased glucose production in
the liver, and increased fat breakdown. Type II Diabetes tends to be more prevalent in
persons who are overweight, and incidence increases with age. Early symptoms may be
present or diagnosis may occur with routine screening. Symptoms include excessive
thirst, increased urination, fatigue, and blurred vision and weight loss. Because diagnosis
may be delayed, complications from the disease may already be present (retinopathy, foot
ulcers, renal disease etc).
Inheritance plays a much stronger role in Type II Diabetes. Autoimmunity is not a factor.
Environmental factors, particularly obesity and a high carbohydrate diet will precipitate
the disease in those who are already predisposed.
Type II diabetes involves about 90% of the diabetic population; mainly in adulthood
(over 40) and in the obese, but may be seen in young patients. About 16 million
Americans have Type II diabetes and about half are unaware they have it.
Diagnosis / Testing for Diabetes:
Current medical guidelines recommend that everyone over 45 be tested regularly for
Diabetes and that younger adults be tested when risk factors are present such as: 20%
overweight, hypertension, low HDL levels, high triglyceride levels, family history etc.
Current methods of testing for Diabetes include:
 Fasting Plasma Glucose:
A simple blood test taken after 8 hours of fasting. Normally, the upper limit of glucose
concentrations in the blood when fasting is 115 mg/dl. Diabetes is diagnosed when
fasting glucose levels are above 126 mg/dl.
 Oral Glucose Tolerance Test:
This is the most sensitive test for Diabetes. The test begins with a Fasting Plasma
Glucose test. A second blood test is then performed two hours after the client drinks a
special glucose rich solution. Normally, blood glucose levels will rise after drinking the
solution, but will decrease after two hours (after the body would normally “burn” or store
the excess glucose). In the Diabetic, the initial increase is excessive and remains high,
generally above 200 mg/dl.
Emergency Conditions Associated with Diabetes:
 Hypoglycemia [Also known as Insulin shock]:
Hypoglycemia can be caused by administration of too much insulin, not enough food
intake, excessive exercise or alcohol consumption (alcohol affects the liver’s ability to
release stored glycogen). Usually, the condition is manageable but occasionally becomes
quite severe or even life threatening, especially if the symptoms are not recognized by the
patient.
Mild symptoms include sweating, trembling, hunger, and rapid heartbeat.
Severely low blood sugar levels can lead to neurologic symptoms: confusion, weakness,
disorientation, combativeness, and in rare and worst-case scenarios, coma, seizure and
death.
Patients that are prone to hypoglycemic events are encouraged to carry hard candy, juice
or sugar packets with them. In case of a hypoglycemic event, 3-5 pieces of candy, 2-3
sugar packets, or ½ cup of fruit juice should be given. If there is inadequate response
within 15 minutes, additional oral sugar should be given or immediate medical attention
should be sought.
 Ketoacidosis:
Diabetic ketoacidosis is a life-threatening complication caused by insulin depletion that
results in excessive blood glucose concentration levels. With extreme hyperglycemia, fat
breakdown accelerates and increases the production of fatty acids. Fatty acids are
converted into ketones which are toxic at high levels.
Ketoacidosis is almost always associated with Type I Diabetes and is generally thought to
be rare in Type II where some insulin is still present, although it is not impossible for a
Type II diabetic to develop ketoacidosis. In Type I patients, ketoacidosis is almost always
caused by noncompliance with treatment and is usually preceded by stressful events,
especially illness. It is not clear what causes total insulin depletion or triggers
ketoacidosis in Type II diabetics. Risk of ketoacidosis is much higher in adolescents
because they are less likely to be fully compliant with treatment parameters.
Symptoms of ketoacidosis include nausea and vomiting. Breathing may be abnormally
deep and rapid with frequent sighing, and heart rate may be rapid. If the condition
persists, coma, and eventual death may occur.
Clinical Considerations:
It is very difficult (clinically, without lab tests) to differentiate between these two
conditions (presenting symptoms are similar). As a general rule, if your client destabilizes, ALWAYS GIVE SUGAR in an attempt to reverse the situation. Why??
The client is more likely to be hypoglycemic than hyperglycemic, in which case, giving
them sugar will help raise their blood glucose levels and reverse their symptoms. If their
symptoms do not reverse or improve, then assume hyperglycemia/ketoacidosis and call
911.