Diabetes Mellitus: Types and Causes

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Diabetes Mellitus

• A chronic metabolic condition characterized by hyperglycemia caused by the impaired metabolism of carbohydrates, fats, and proteins.
• Once diagnosed, diabetes is typically a lifelong condition, as opposed to a temporary ailment.
• Heredity is strongly linked to type II diabetes.
• Obesity contributes to insulin resistance in adipose tissues, hindering glucose uptake by cells.
• Stress elevates epinephrine, norepinephrine, and glucocorticoids, leading to increased serum carbohydrates.
• Viral infections heightened the risk of autoimmune disorders.
• Autoimmune disorders are closely linked with type I diabetes mellitus.
• Women who have had multiple pregnancies or large babies are at greater risk.

Types of Diabetes Mellitus

• Type I: Insulin Dependent Diabetes Mellitus (IDDM) or Juvenile Onset
• Type II: Non Insulin Dependent Diabetes Mellitus (NIDDM) or Maturity Onset
• Gestational diabetes occurs during pregnancy.
• Diabetes may be linked to conditions/syndromes like pancreatic disease or Cushing's.
• Certain medications, including steroids, thiazide diuretics, and oral contraceptives, can cause diabetes.

Type I Diabetes

• Juvenile Onset, Brittle DM, Unstable DM
• Typically appears before age 30.
• Frequently affects children and non-obese individuals.
• The pancreas produces no insulin due to the fact that it has been destroyed
• Prone to Diabetic Ketoacidosis (DKA) due to absolute insulin deficiency, leading the body to burn fat and protein, producing ketones.
• Management involves diet, exercise, and Insulin for life

Type II Diabetes

• Maturity Onset, Stable DM, Ketosis Resistant (some insulin production but cells don't respond)
• Commonly appears after age 40.
• More common for obese individuals.
• Inadequate insulin production or non-responsive cells.

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNKS)

• Prone for HHNKS, involves elevated blood pressure, but not necessarily high ketone bodies (still circulating insulin).
• DKA may occur, but is rare (only with severe stress).

Diabetes Management

• Focuses on diet, exercise, and oral hypoglycemic agents, or insulin in stressful situations.
• In patients with diabetes, absorption of food nutrients is functional.
• Beta cells produce insulin and bind to enhance glucose’s use in the body. Pancreas malfunctions or problems with receptors cause diabetes (Types I or II).

Hyperglycemia

• Polyuria: frequent urination
• Polydipsia: increased thirst
• Polyphagia: increased hunger

Pathophysiology of Diabetes

• Stomach converts food to glucose
• Glucose enters the bloodstream.
• Pancreas produces insulin -> Glucose enters body cells effectively, blood sugar in balance

Complications of Uncontrolled Diabetes

• Causes sluggish blood circulation
• Increases microorganisms, infections, periodontal, UTI, vasculitis, cellulitis, vaginitis, furuncles, carbuncles, poor healing of wounds
• Daily foot inspections are an essential part of regular hygiene

Macroangiopathy

• Refers to damage to large blood vessels
• Can manifest as cerebrovascular accident (brain), myocardial infarction (heart), peripheral vascular disease (peripheral arteries).

Microangiopathy

• Refers to damage of smaller blood vessels
• Can manifest as kidney damage through nephropathy, cataracts and retinopathy in the eyes

Neuropathy

• Can involve spinal cord/autonomic nervous system (ANS)
• Peripheral neuropathy involves PNS damage, impacting movement/sensation. Commonly causes numbness and/or tingling

Long term Symptoms

• Eventually leads to paralysis, gastroparesis, neurogenic bladder dysfunction, decreased libido, and/or impotence.

Diagnostic Tests for Diabetes

• Random Blood Sugar (RBS): Blood drawn without fasting; suggestive of DM if ≥ 200mg/dl + symptoms.
• Fasting Blood Sugar (FBS): Blood drawn after 8-hour fast; Normal: 70-100 mg/dl, pre-diabetes: 101 but < 126mg/ dl; Diabetes-> 126 mg/dl.
• Postprandial Blood Sugar: after high-CHO meal; No DM (70-140mg/dl), prediabetes (≥140 but <200 mg/dl).
• Oral Glucose Tolerance Test (OGTT): 3-day high-CHO diet, 8-hour fast, baseline blood/urine, oral glucose solution ingestion, blood/urine samples at 30 min & 1, 2, and 3 hours after

Normal OGTT Results

• Glucose returns to normal in 2-3 hours
• Urine is negative for glucose
• DM: Glucose returns to normal slowly, urine is positive for glucose

Glycosylated hemoglobin (HbA1c)

• A single sample of venous blood is withdrawn.
• The level of glucose retained in hemoglobin is above 7% in DM clients, in those noncompliant, and/or in clients inadequately treated.
• HbA1c = glucose attaches to red blood cells
• An excess indicates that the body is not properly using sugar

Diabetes Management

• Diet: Low-calorie (especially if obese), proportionate (20% fat, 50% complex carbs, high fibre to inhibit glucose absorption), regular meals to increase CHO uptake, reduce insulin requirements, maintain body weight, serum carbs and lipids.
• Always allow snacks to prevent hypoglycemia
• Exercise 1-2 hours after eating to prevent hypoglycemia
• Follow regular patterns, and do not be sporadic, to stabilize blood sugar

Medications

• Used for Type I diabetes and Type II Diabetes
• Can be a mix of short and long acting insulin

Rapid Acting Insulin

• Lispro (Humalog), Aspart (Novalog)
• Onset in 5 minutes
• Peak in 30 min - 1 hour
• Duration: 2-4 hours

Short Acting Insulin

• Regular (Humulin R), (Novolin R), (Iletin II regular)
• Onset in 30 minutes to an hour, peak in 2 to 4 hours, and lasts 6 to 8 hours

Intermediate Acting Insulin

• NPH, Humulin N, Lente, Humulin L
• Onset in 1-2 hours peak in 6 to 12, and 18 to 24 hours

Long Acting Insulin

• Ultralente, Glargine (Lantus)
• Onset in 5 to 8 hours, peak lasts 14 to 20 hours, duration 30 to 36 hrs

Oral Hypoglycemic agent

• For Type II
• Sulfonylureas, Nonsufonylureas, BiguanidesAlpha-glucosidase inhibitors, Thiazolidinediones, Meglitinides

Hypoglycemia

• Causes: too much insulin, skipping meals, strenuous exercise, GI upset (N&V)
• Signs: shaking, sweating, anxious, dizzy, hungry. fast heart rate, impaired vision, weak and/or fatigued, irritable, headache

Interventions for Hypoglycemia

• Measure blood sugar
• In conscious patient, administer simple sugars such as 3-4 oz regular soft drink, 8 oz fruit juice, 5-7 lifesaver candies, 3-4 hard candies, 1 tbsp sugar, 5 ml pure honey/ karo, or 10-15 gm CHO
• In unconscious patients, administer D50 by IV (20-50 ml) or 1 mg glucagon, and monitor blood sugar

Hyperglycemia

• stress (infection, surgery), overeating, under dose of insulin
• Signs: thirst, polyuria, dry skin, hunger, blurred vision, drowsy, nausea
• Assessment: 3P's, dry flushed skin, soft eyeballs, fast heart rate, fruity breath, altered LOC, Urine (+) glucose & Ketones

Interventions for Hyperglycemia

• Aim for a clear airway.
• Administer/monitor oxygen IV, NSS, regular insulin, D10W
• Keep tabs every hour on temperature, cardiovascular status, and I&O

Diabetic Ketoacidosis (DKA)

• Acute complication of DM caused by hyperglycemia, accumulation of ketones -> metabolic acidosis
• Caused by undiagnosed diabetes, neglect of treatment, infection, stroke, emotional stresses.
• Symptoms: 3P's, N&V, abdominal pain, warm flushed dry skin, dry mucous membranes, soft eyeballs, Kussmaul’s respiration/fruity breath, altered LOC, Hypotension, Tachycardia
• Diagnostics : Serum glucose (up to 600 mg/dL) and ketones elevated (positive urine ketones); BUN, Creatinine, Hematocrit; Serum sodium decreased, potassium may be elevated

Type I NIDDM routes

• Subcutaneous; slow, less painful, 90deg if thin, 45deg if obese, don't aspirate, no massage, but rotate and administer in room temperature to manage cold
• IV for those with DKA (emergency only)
• Animal insulin causes lypodistrophy (loss of subcutaneous fat, fibrofatty use

HHNKS (Hyperosmolar Hyperglycemic Non Ketonitic)

• A complication of DM, which included with Hyperglycemia. Hyperosmolar state without ketosis.
• treatment is similar to DKA, excluding the part that treats metabolic acidosis, and ketosis

Side Notes

• Avoid alcohol consumption, stress while on medication
• Do not omit insulin
• Monitor urine and blood, blood sugar
• Admin for hypo and hyper