Diabetes management - One Health

Diabetes
management

Diabetes mellitus is a chronic
disease, for which there is no known cure except in very specific situations.
Management concentrates on keeping blood sugar levels as close to normal,
without causing low blood sugar. This can usually be accomplished with a
healthy diet, exercise, weight loss, and use of appropriate medications
(insulin in the case of type 1 diabetes; oral medications, as well as possibly
insulin, in type 2 diabetes).

Learning about the disease and
actively participating in the treatment is important, since complications are
far less common and less severe in people who have well-managed blood sugar
levels.The goal of treatment is an HbA1C level of 6.5%, but should not be lower
than that, and may be set higher.
Attention is also paid to other health problems that may accelerate the
negative effects of diabetes. These include smoking, elevated cholesterol
levels, obesity, high blood pressure, and lack of regular exercise. Specialized
footwear is widely used to reduce the risk of ulceration, or re-ulceration, in
at-risk diabetic feet. Evidence for the efficacy of this remains equivocal,
however.

Diabetic
diet

People with diabetes can benefit
from education about the disease and treatment, good nutrition to achieve a
normal body weight, and exercise, with the goal of keeping both short-term and
long-term blood glucose levels within acceptable bounds. In addition, given the
associated higher risks of cardiovascular disease, lifestyle modifications are
recommended to control blood pressure

Anti-diabetic
medication

Medications used to treat
diabetes do so by lowering blood sugar levels. There are a number of different
classes of anti-diabetic medications. Some are available by mouth, such as
metformin, while others are only available by injection such as GLP-1 agonists.
Type 1 diabetes can only be treated with insulin, typically with a combination
of regular and NPH insulin, or synthetic insulin analogs.

Metformin is generally
recommended as a first line treatment for type 2 diabetes, as there is good
evidence that it decreases mortality. It works by decreasing the liver's
production of glucose. Several other groups of drugs, mostly given by mouth,
may also decrease blood sugar in type II DM. These include agents that increase
insulin release, agents that decrease absorption of sugar from the intestines,
and agents that make the body more sensitive to insulin. When insulin is used
in type 2 diabetes, a long-acting formulation is usually added initially, while
continuing oral medications. Doses of insulin are then increased to effect.

Since cardiovascular disease is a
serious complication associated with diabetes, some have recommended blood
pressure levels below 130/80 mmHg. However, evidence supports less than or
equal to somewhere between 140/90 mmHg to 160/100 mmHg; the only additional
benefit found for blood pressure targets beneath this range was an isolated
decrease in stroke risk, and this was accompanied by an increased risk of other
serious adverse events. A 2016 review found potential harm to treating lower
than 140 mmHg. Among medications that lower blood pressure, angiotensin
converting enzyme inhibitors (ACEIs) improve outcomes in those with DM while
the similar medications angiotensin receptor blockers (ARBs) do not. Aspirin is
also recommended for people with cardiovascular problems, however routine use
of aspirin has not been found to improve outcomes in uncomplicated diabetes.

Surgery

A pancreas transplant is
occasionally considered for people with type 1 diabetes who have severe
complications of their disease, including end stage kidney disease requiring
kidney transplantation.

Weight loss surgery in those with
obesity and type two diabetes is often an effective measure. Many are able to
maintain normal blood sugar levels with little or no medications following
surgery and long-term mortality is decreased. There however is some short-term
mortality risk of less than 1% from the surgery.The body mass index cutoffs for
when surgery is appropriate are not yet clear. It is recommended that this
option be considered in those who are unable to get both their weight and blood
sugar under control.

Support

In countries using a general
practitioner system, such as the United Kingdom, care may take place mainly
outside hospitals, with hospital-based specialist care used only in case of
complications, difficult blood sugar control, or research projects. In other
circumstances, general practitioners and specialists share care in a team
approach. Home telehealth support can be an effective management technique.

Diagnosis of and Prevention Diabetes mellitus

Diagnosis of Diabetes mellitus

Diabetes mellitus is characterized
by recurrent or persistent high blood sugar, and is diagnosed by demonstrating
any one of the following:

- Fasting plasma glucose level ≥ 7.0
mmol/l (126 mg/dl)

- Plasma glucose ≥ 11.1 mmol/l (200
mg/dl) two hours after a 75 g oral glucose load as in a glucose tolerance test

- Symptoms of high blood sugar and
casual plasma glucose ≥ 11.1 mmol/l (200 mg/dl)

- Glycated hemoglobin (HbA1C) ≥ 48
mmol/mol (≥ 6.5 DCCT %).

A positive result, in the absence of unequivocal high blood
sugar, should be confirmed by a repeat of any of the above methods on a
different day. It is preferable to measure a fasting glucose level because of
the ease of measurement and the considerable time commitment of formal glucose
tolerance testing, which takes two hours to complete and offers no prognostic
advantage over the fasting test. According to the current definition, two
fasting glucose measurements above 126 mg/dl (7.0 mmol/l) is considered
diagnostic for diabetes mellitus.

Per the World Health Organization people with fasting
glucose levels from 6.1 to 6.9 mmol/l (110 to 125 mg/dl) are considered to have
impaired fasting glucose. People with plasma glucose at or above 7.8 mmol/l
(140 mg/dl), but not over 11.1 mmol/l (200 mg/dl), two hours after a 75 g oral
glucose load are considered to have impaired glucose tolerance. Of these two
prediabetic states, the latter in particular is a major risk factor for
progression to full-blown diabetes mellitus, as well as cardiovascular disease.
The American Diabetes Association since 2003 uses a slightly different range
for impaired fasting glucose of 5.6 to 6.9 mmol/l (100 to 125 mg/dl).

Glycated hemoglobin is better than fasting glucose for
determining risks of cardiovascular disease and death from any cause.

Prevention of Diabetes mellitus

There is no known preventive measure for type 1 diabetes.
Type 2 diabetes — which accounts for 85-90% of all cases — can often be
prevented or delayed by maintaining a normal body weight, engaging in physical
exercise, and consuming a healthful diet. Higher levels of physical activity
(more than 90 minutes per day) reduce the risk of diabetes by 28%. Dietary
changes known to be effective in helping to prevent diabetes include
maintaining a diet rich in whole grains and fiber, and choosing good fats, such
as the polyunsaturated fats found in nuts, vegetable oils, and fish. Limiting
sugary beverages and eating less red meat and other sources of saturated fat
can also help prevent diabetes. Tobacco smoking is also associated with an
increased risk of diabetes and its complications, so smoking cessation can be
an important preventive measure as well.

The relationship between type 2 diabetes and the main
modifiable risk factors (excess weight, unhealthy diet, physical inactivity and
tobacco use) is similar in all regions of the world. There is growing evidence
that the underlying determinants of diabetes are a reflection of the major
forces driving social, economic and cultural change: globalization,
urbanization, population aging, and the general health policy environment.

Pathophysiology of Diabetes mellitus - One Health

Pathophysiology of Diabetes mellitus

Insulin is the principal hormone that regulates the uptake
of glucose from the blood into most cells of the body, especially liver,
adipose tissue and muscle, except smooth muscle, in which insulin acts via the
IGF-1. Therefore, deficiency of insulin or the insensitivity of its receptors
plays a central role in all forms of diabetes mellitus.

The body obtains glucose from three main places: the
intestinal absorption of food; the breakdown of glycogen, the storage form of
glucose found in the liver; and gluconeogenesis, the generation of glucose from
non-carbohydrate substrates in the body. Insulin plays a critical role in
balancing glucose levels in the body. Insulin can inhibit the breakdown of
glycogen or the process of gluconeogenesis, it can stimulate the transport of
glucose into fat and muscle cells, and it can stimulate the storage of glucose
in the form of glycogen.

Insulin is released into the blood by beta cells (β-cells),
found in the islets of Langerhans in the pancreas, in response to rising levels
of blood glucose, typically after eating. Insulin is used by about two-thirds
of the body's cells to absorb glucose from the blood for use as fuel, for
conversion to other needed molecules, or for storage. Lower glucose levels
result in decreased insulin release from the beta cells and in the breakdown of
glycogen to glucose. This process is mainly controlled by the hormone glucagon,
which acts in the opposite manner to insulin.

If the amount of insulin available is insufficient, if cells
respond poorly to the effects of insulin (insulin insensitivity or insulin
resistance), or if the insulin itself is defective, then glucose will not be
absorbed properly by the body cells that require it, and it will not be stored
appropriately in the liver and muscles. The net effect is persistently high
levels of blood glucose, poor protein synthesis, and other metabolic
derangements, such as acidosis.

When the glucose concentration in the blood remains high
over time, the kidneys will reach a threshold of reabsorption, and glucose will
be excreted in the urine (glycosuria). This increases the osmotic pressure of
the urine and inhibits reabsorption of water by the kidney, resulting in
increased urine production (polyuria) and increased fluid loss. Lost blood
volume will be replaced osmotically from water held in body cells and other
body compartments, causing dehydration and increased thirst (polydipsia).

Causes of Diabetes mellitus Other types

Causes of Diabetes mellitus Other types

Prediabetes indicates a condition that occurs when a person's blood glucose levels are higher than normal but not high enough for a diagnosis of type 2 DM. Many people destined to develop type 2 DM spend many years in a state of prediabetes.

Latent autoimmune diabetes of adults (LADA) is a condition in which type 1 DM develops in adults. Adults with LADA are frequently initially misdiagnosed as having type 2 DM, based on age rather than etiology.

Some cases of diabetes are caused by the body's tissue receptors not responding to insulin (even when insulin levels are normal, which is what separates it from type 2 diabetes); this form is very uncommon. Genetic mutations (autosomal or mitochondrial) can lead to defects in beta cell function. Abnormal insulin action may also have been genetically determined in some cases. Any disease that causes extensive damage to the pancreas may lead to diabetes (for example, chronic pancreatitis and cystic fibrosis). Diseases associated with excessive secretion of insulin-antagonistic hormones can cause diabetes (which is typically resolved once the hormone excess is removed). Many drugs impair insulin secretion and some toxins damage pancreatic beta cells. The ICD-10 (1992) diagnostic entity, malnutrition-related diabetes mellitus (MRDM or MMDM, ICD-10 code E12), was deprecated by the World Health Organization when the current taxonomy was introduced in 1999.

Other forms of diabetes mellitus include congenital diabetes, which is due to genetic defects of insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high doses of glucocorticoids, and several forms of monogenic diabetes.

"Type 3 diabetes" has been suggested as a term for Alzheimer's disease as the underlying processes may involve insulin resistance by the brain.

The following is a comprehensive list of other causes of diabetes:

Genetic defects of β-cell function

Maturity onset diabetes of the young

Mitochondrial DNA mutations

Genetic defects in insulin processing or insulin action

Defects in proinsulin conversion

Insulin gene mutations

Insulin receptor mutations

Exocrine pancreatic defects

Chronic pancreatitis

Pancreatectomy

Pancreatic neoplasia

Cystic fibrosis

Hemochromatosis

Fibrocalculous pancreatopathy

Endocrinopathies

Growth hormone excess (acromegaly)

Cushing syndrome

Hyperthyroidism

Pheochromocytoma

Glucagonoma

Infections

Cytomegalovirus infection

Coxsackievirus B

Drugs

Glucocorticoids

Thyroid hormone

β-adrenergic agonists

Statins

Causes of Diabetes mellitus Type 2 And Gestational diabetes

Causes of Diabetes mellitus  Type 2

Type 2 DM is characterized by insulin resistance, which may be combined with relatively reduced insulin secretion. The defective responsiveness of body tissues to insulin is believed to involve the insulin receptor. However, the specific defects are not known. Diabetes mellitus cases due to a known defect are classified separately. Type 2 DM is the most common type of diabetes mellitus.

In the early stage of type 2, the predominant abnormality is reduced insulin sensitivity. At this stage, high blood sugar can be reversed by a variety of measures and medications that improve insulin sensitivity or reduce the liver's glucose production.

Type 2 DM is due primarily to lifestyle factors and genetics. A number of lifestyle factors are known to be important to the development of type 2 DM, including obesity (defined by a body mass index of greater than 30), lack of physical activity, poor diet, stress, and urbanization. Excess body fat is associated with 30% of cases in those of Chinese and Japanese descent, 60–80% of cases in those of European and African descent, and 100% of Pima Indians and Pacific Islanders. Even those who are not obese often have a high waist–hip ratio.

Dietary factors also influence the risk of developing type 2 DM. Consumption of sugar-sweetened drinks in excess is associated with an increased risk. The type of fats in the diet is also important, with saturated fats and trans fatty acids increasing the risk and polyunsaturated and monounsaturated fat decreasing the risk. Eating lots of white rice also may increase the risk of diabetes. A lack of exercise is believed to cause 7% of cases.

Gestational diabetes

Gestational diabetes mellitus (GDM) resembles type 2 DM in several respects, involving a combination of relatively inadequate insulin secretion and responsiveness. It occurs in about 2–10% of all pregnancies and may improve or disappear after delivery. However, after pregnancy approximately 5–10% of women with gestational diabetes are found to have diabetes mellitus, most commonly type 2. Gestational diabetes is fully treatable, but requires careful medical supervision throughout the pregnancy. Management may include dietary changes, blood glucose monitoring, and in some cases, insulin may be required.

Though it may be transient, untreated gestational diabetes can damage the health of the fetus or mother. Risks to the baby include macrosomia (high birth weight), congenital heart and central nervous system abnormalities, and skeletal muscle malformations. Increased levels of insulin in a fetus's blood may inhibit fetal surfactant production and cause respiratory distress syndrome. A high blood bilirubin level may result from red blood cell destruction. In severe cases, perinatal death may occur, most commonly as a result of poor placental perfusion due to vascular impairment. Labor induction may be indicated with decreased placental function. A Caesarean section may be performed if there is marked fetal distress or an increased risk of injury associated with macrosomia, such as shoulder dystocia.

Causes of Diabetes mellitus Type 1 - One Health

Causes of Diabetes mellitus

Diabetes mellitus is classified
into four broad categories: type 1, type 2, gestational diabetes, and
"other specific types". The "other specific types" are a
collection of a few dozen individual causes.

Diabetes is a more variable
disease than once thought and people may have combinations of forms. The term
"diabetes", without qualification, usually refers to diabetes
mellitus.

Causes of Diabetes mellitus  Type 1

Type 1 diabetes mellitus is
characterized by loss of the insulin-producing beta cells of the islets of
Langerhans in the pancreas, leading to insulin deficiency. This type can be
further classified as immune-mediated or idiopathic.

The majority of type 1 diabetes
is of the immune-mediated nature, in which a T-cell-mediated autoimmune attack
leads to the loss of beta cells and thus insulin. It causes approximately 10%
of diabetes mellitus cases in North America and Europe.

Most affected people are
otherwise healthy and of a healthy weight when onset occurs. Sensitivity and
responsiveness to insulin are usually normal, especially in the early stages.
Type 1 diabetes can affect children or adults, but was traditionally termed
"juvenile diabetes" because a majority of these diabetes cases were
in children.

"Brittle" diabetes,
also known as unstable diabetes or labile diabetes, is a term that was
traditionally used to describe the dramatic and recurrent swings in glucose
levels, often occurring for no apparent reason in insulin-dependent diabetes.
This term, however, has no biologic basis and should not be used.

 Still, type 1 diabetes can be accompanied by
irregular and unpredictable high blood sugar levels, frequently with ketosis,
and sometimes with serious low blood sugar levels. Other complications include
an impaired counterregulatory response to low blood sugar, infection,
gastroparesis (which leads to erratic absorption of dietary carbohydrates), and
endocrinopathies (e.g., Addison's disease). These phenomena are believed to
occur no more frequently than in 1% to 2% of persons with type 1 diabetes.

Type 1 diabetes is partly
inherited, with multiple genes, including certain HLA genotypes, known to
influence the risk of diabetes. The increase of incidence of type 1 diabetes
reflects the modern lifestyle. In genetically susceptible people, the onset of
diabetes can be triggered by one or more environmental factors, such as a viral
infection or diet.

Several viruses have been
implicated, but to date there is no stringent evidence to support this
hypothesis in humans. Among dietary factors, data suggest that gliadin (a
protein present in gluten) may play a role in the development of type 1
diabetes, but the mechanism is not fully understood.

Signs and symptoms of diabetes mellitus

Signs and symptoms of diabetes mellitus

The classic symptoms of untreated diabetes are weight
loss, polyuria (increased urination), polydipsia (increased thirst), and
polyphagia (increased hunger). Symptoms may develop rapidly (weeks or months)
in type 1 DM, while they usually develop much more slowly and may be subtle or
absent in type 2 DM.

Several other signs and symptoms can mark the onset of
diabetes although they are not specific to the disease. In addition to the
known ones above, they include blurry vision, headache, fatigue, slow healing
of cuts, and itchy skin. Prolonged high blood glucose can cause glucose
absorption in the lens of the eye, which leads to changes in its shape,
resulting in vision changes. A number of skin rashes that can occur in diabetes
are collectively known as diabetic dermadromes.

Several other signs and symptoms can mark the onset of
diabetes although they are not specific to the disease. In addition to the
known ones above, they include blurry vision, headache, fatigue, slow healing
of cuts, and itchy skin. Prolonged high blood glucose can cause glucose
absorption in the lens of the eye, which leads to changes in its shape,
resulting in vision changes. A number of skin rashes that can occur in diabetes
are collectively known as diabetic dermadromes.

Diabetic emergencies

Low blood sugar is common in persons with type 1 and type
2 DM. Most cases are mild and are not considered medical emergencies. Effects
can range from feelings of unease, sweating, trembling, and increased appetite
in mild cases to more serious issues such as confusion, changes in behavior
such as aggressiveness, seizures, unconsciousness, and (rarely) permanent brain
damage or death in severe cases. Moderate hypoglycemia may easily be mistaken
for drunkenness; rapid breathing and sweating, cold, pale skin are
characteristic of hypoglycemia but not definitive. Mild to moderate cases are
self-treated by eating or drinking something high in sugar. Severe cases can
lead to unconsciousness and must be treated with intravenous glucose or
injections with glucagon.

People (usually with type 1 DM) may also experience
episodes of diabetic ketoacidosis, a metabolic disturbance characterized by
nausea, vomiting and abdominal pain, the smell of acetone on the breath, deep
breathing known as Kussmaul breathing, and in severe cases a decreased level of
consciousness.

A rare but equally severe possibility is hyperosmolar
nonketotic state, which is more common in type 2 DM and is mainly the result of
dehydration

Complications

All forms of diabetes increase the risk of long-term
complications. These typically develop after many years (10–20) but may be the
first symptom in those who have otherwise not received a diagnosis before that
time.

The major long-term complications relate to damage to
blood vessels. Diabetes doubles the risk of cardiovascular disease and about
75% of deaths in diabetics are due to coronary artery disease.Other
"macrovascular" diseases are stroke, and peripheral vascular disease.

The primary complications of diabetes due to damage in
small blood vessels include damage to the eyes, kidneys, and nerves. Damage to
the eyes, known as diabetic retinopathy, is caused by damage to the blood
vessels in the retina of the eye, and can result in gradual vision loss and
blindness. Damage to the kidneys, known as diabetic nephropathy, can lead to
tissue scarring, urine protein loss, and eventually chronic kidney disease,
sometimes requiring dialysis or kidney transplant. Damage to the nerves of the
body, known as diabetic neuropathy, is the most common complication of
diabetes. The symptoms can include numbness, tingling, pain, and altered pain
sensation, which can lead to damage to the skin. Diabetes-related foot problems
(such as diabetic foot ulcers) may occur, and can be difficult to treat,
occasionally requiring amputation. Additionally, proximal diabetic neuropathy
causes painful muscle wasting and weakness.

There is a link between cognitive deficit and diabetes.
Compared to those without diabetes, those with the disease have a 1.2 to
1.5-fold greater rate of decline in cognitive function. Being diabetic,
especially when on insulin increases the risk of falls in older people.

What is diabetes mellitus?

Diabetes mellitus (DM), commonly referred to as diabetes, is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period. Symptoms of high blood sugar include frequent urination, increased thirst, and increased hunger. If left untreated, diabetes can cause many complications. Acute complications can include diabetic ketoacidosis, nonketotic hyperosmolar coma, or death. Serious long-term complications include heart disease, stroke, chronic kidney failure, foot ulcers, and damage to the eyes.



Diabetes is due to either the pancreas not producing enough insulin or the cells of the body not responding properly to the insulin produced.  There are three main types of diabetes mellitus:

• Type 1 DM results from the pancreas's failure to produce enough insulin. This form was previously referred to as "insulin-dependent diabetes mellitus" (IDDM) or "juvenile diabetes". The cause is unknown.

• Type 2 DM begins with insulin resistance, a condition in which cells fail to respond to insulin properly. As the disease progresses a lack of insulin may also develop. This form was previously referred to as "non insulin-dependent diabetes mellitus" (NIDDM) or "adult-onset diabetes". The most common cause is excessive body weight and not enough exercise.

• Gestational diabetes is the third main form and occurs when pregnant women without a previous history of diabetes develop high blood-sugar levels.



Prevention and treatment involve maintaining a healthy diet, regular physical exercise, a normal body weight, and avoiding use of tobacco. Control of blood pressure and maintaining proper foot care are important for people with the disease. Type 1 DM must be managed with insulin injections. Type 2 DM may be treated with medications with or without insulin. Insulin and some oral medications can cause low blood sugar. Weight loss surgery in those with obesity is sometimes an effective measure in those with type 2 DM. Gestational diabetes usually resolves after the birth of the baby.



As of 2015, an estimated 415 million people had diabetes worldwide,  with type 2 DM making up about 90% of the cases. This represents 8.3% of the adult population, with equal rates in both women and men. As of 2014, trends suggested the rate would continue to rise. Diabetes at least doubles a person's risk of early death. From 2012 to 2015, approximately 1.5 to 5.0 million deaths each year resulted from diabetes. The global economic cost of diabetes in 2014 was estimated to be US$612 billion. In the United States, diabetes cost $245 billion in 2012.