What is Diabetes Mellitus?

Diabetes mellitus is a common chronic metabolic disorder with loss of the normal control of fuel use and storage, particularly affecting the sugar glucose. It causes typical symptoms and complications. Diabetes is important because of the consequences for people, who have it, and for their families. The number of new cases of diabetes is increasing rapidly. In the past, diabetes has been seen as leading to disability and premature death, but now increased understanding of the underlying disease process and advances in screening for and treatment of complications now means that disability is no longer inevitable. This site outlines the current concepts in the knowledge of the cause of diabetes, changes in diagnostic classification, current treatments and possible future developments in this important and rapidly advancing field of medicine.
Classification of Diabetes
The term “diabetes mellitus” describes the various clinical syndromes that present with raised blood glucose. It has a variety of causes, and affects the metabolism of not only glucose, but also other body fuels such as ketone bodies, fats and cholesterol. Over the years there have been many changes in the classification of diabetes. This is now largely settled with the 1997 American Diabetes Association/World Health Organisation following definitions. Insulin-dependent, formerly juvenile onset diabetes is now known as Type 1. Non-insulin dependent or maturity onset diabetes is now classified as Type 2. Diabetes induced by other causes is classified as secondary diabetes.
Type 1 Diabetes
Type 1 diabetes presents most commonly in an acute form with very raised blood glucose, which causes a severe thirst with large quantities of urine and dehydration. There is weakness and weight loss. As it progresses, there is a marked disturbance of the body chemistry known as acidosis. Fat breakdown shows as the characteristic smell on the breath of ketones, and these can be measured in the urine with a test strip. Left untreated, this results in death, and this was always the case prior to the introduction of insulin by the Canadians, Banting and Best in 1922. Type 1 diabetes most frequently presents in childhood or young adulthood, but it can occur at any age. The incidence of this type of diabetes is increasing, and it is of concern that this increase is most marked in the very young. In Type 1 diabetes, insulin production from the pancreas is much reduced and may be absent. It is now thought that Type 1 diabetes is caused by an abnormal immune response with destruction of the beta cells of the islets of Langerhans. The onset of inflammation and destruction of the pancreatic cells starts some time before the clinical onset of the disease. Only certain people with specific immunological markers appear to be prone to the development of Type 1 diabetes. However, many people with apparent genetic susceptibility to Type 1 diabetes do not go on to develop diabetes. It is therefore clear that other factors must act to precipitate pancreatic destruction. Many factors have been postulated as being the trigger of Type 1 diabetes. Suggested trigger factors include infection with Coxsackievirus B, or other virus, early exposure to cows milk, early weaning or dietary deficiency of certain trace elements. However, none of these proposed triggers to the autoimmune response has been proven at present. Once the inflammation of the islet cells occurs, there is irreversible destruction of these cells leading to the clinical syndrome. At presentation, the only treatment available for Type 1 diabetes is insulin replacement.
Type 1 diabetes is insulin replacement.
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Type 2 Diabetes
The majority of people with Type 2 diabetes may have few symptoms. The level of fasting blood sugar levels within a population is distributed as a continuum. At either end of this scale it is clear to state who has diabetes and who does not. The challenge has therefore been to describe the point on the continuum, which is associated with the future development of diabetic complications. Type 2 diabetes is now diagnosed by the presence of a fasting blood sugar of greater than 7 mmol, or a random blood sugar of greater than 11 mmol. Again, knowledge about the aetiology of this type of diabetes has also increased over recent years. Study of the molecular structure and function of cells and their genetic code has demonstrated a huge number of potential defects at almost every point of insulin production, release and action. These defects lead to the common presenting features of Type 2 diabetes. The majority of cases of Type 2 diabetes are caused by a decline in insulin production. This decline in pancreatic function is slow, and appears not to be autoimmune in origin. It may be associated with resistance to the effect of insulin at muscle and at the liver. This insulin resistant form of diabetes frequently occurs in the classic triad of obesity, hypertension and hypercholestrolemia, and is particularly associated with premature death from cardiovascular causes. As with Type 1 diabetes, the tendency to develop Type 2 diabetes is also largely inherited. Diabetes may be precipitated by obesity, reduced physical activity and increasing age. As a result of changes in behaviour of the population as a whole, the prevalence of Type 2 diabetes is increasing throughout the world. It is estimated that between 3 and 4 million people in the UK will have Type 2 diabetes by 2010.
Type 2 diabetes is treated by a combination of diet, exercise, tablets and eventually insulin
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Other Forms of Diabetes
Other causes of diabetes include, diseases of the pancreas, other hormone diseases including acromegaly, Cushing's syndrome and disease and the use of steroids medication. Diabetes can present and complicate the later part of pregnancy, this gestational diabetes, which resolves at delivery, may represent as Type 2 diabetes later in life. Finally, there is a subset of cases of diabetes in the young, who have abnormalities of insulin production and secretion or defects of recognition of blood sugar level. These are known as maturity onset diabetes of the young (MODY). These cases may initially thought to be Type 1 diabetes, but can be treated with insulin.

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