Diabetes mellitus (DM) is a disease caused by deficiency or diminished effectiveness of endogenous insulin. It is characterized by hyperglycaemia, deranged metabolism and sequelae predominantly affecting the vasculature. Life expectancy is reduced by 15 years in Type 1 diabetes; 5-7 years in Type 2 diabetes.
93 points are available for diabetes care in the QOF.

Prevalence

QOF data suggests that there are 1,766,391 patients registered as diabetic in England. This gives a prevalence of 3.55%. Prevalence models suggest the true prevalence is closer to 4.67%. 

The incidence of diabetes is increasing in all age groups. Type 1 diabetes is increasing in children (especially <5 years), and type 2 diabetes is increasing particularly in black and minority ethnic groups.

Risk Factors

People of South Asian, African and African-Caribbean and Middle-Eastern descent are at greater risk of type 2 diabetes, compared with the white population.
People who are obese, are inactive or have a family history are also at increased risk of type 2 diabetes.

Other factors predisposing to DM

• Gestational Diabetes and impaired glucose tolerance
• Drugs: steroids and thiazides
• Pancreatic disease: acute and chronic pancreatitis (including surgery if 90% pancreas removed), haemochromatosis, cystic fibrosis.
• Endocrine disease: Cushing’s, acromegaly, phaeochromocytoma, thyrotoxicosis.
• Others: acanthosis nigricans, congenital lipodystrophy with insulin receptor antibodies, Wolfram syndrome (DIDMOAD), and glycogen storage diseases.

Genetic factors

These are complex and interact with environmental factors6 in a poorly understood fashion. Future research may clarify the situation.
The metabolic syndrome, akin to insulin resistance – Syndrome X- has recently come to notice and is thought of as a precursor to Type 2 diabetes. It is poorly defined and represents a heterogeneous collection of various propensities to diabetes. Its identification as a single syndrome and its relevance are uncertain. It has been suggested that lifestyle-intervention and treating metabolic manifestations of this pre-diabetic state can reduce the chance of progression to frank diabetes and the risk of complications.

Classification of diabetes

Type 1 (old terms: insulin-dependent DM, IDDM)
Approximately 15% of diabetics; usually juvenile onset, but may occur at any age. It may be associated with other autoimmune disease. It is characterized by insulin deficiency.
Concordance is >30% in identical twins;  genes are thought to be important. One (6q) determines islet sensitivity to damage (eg from viruses or cross-reactivity from cows milk-induced antibodies). Associated with HLA DR3 and DR4 and islet cell antibodies around the time of diagnosis. Patients always need some insulin: they are prone to ketoacidosis.
Risks of developing type 1 diabetes are broadly similar in all ethnic groups, but environmental factors may also play a role. The term ‘Type 1 diabetes is being applied to the development of Type 1 diabetes in adulthood. It is thought to result from a chronic auto-immune T-cell mediated islet cell destruction. Research may elucidate the underlying mechanisms, giving hope of prevention through identification and treatment of those at risk.

Type 2 (old terms: non-insulin-dependent DM, NIDDM, maturity onset DM)
Approximately 85%. Mostly an older age group and often obese. Approximately 100% concordance in identical twins. It is due to impaired insulin secretion and insulin resistance; Syndrome X. Gradual onset. Type 2 diabetics may eventually need insulin. This does not mean that type 1 diabetes has developed. Insulin is likely to be needed in those with:

• Ketonuria
• Glucose >25mmol/l
• Sudden onset weight loss, dehydration, ketoacidosis

Maturity onset diabetes of the young (MODY) includes several forms of diabetes with monogenetic defects of β-cell function (impaired insulin secretion); usually manifesting as mild hyperglycaemia at a young age, and usually inherited in an autosomal dominant manner.

Presentation
Patients may be asymptomatic.

Acute:

Ketoacidosis – unwell, hyperventilation, ketones on breath. Few weeks of weight loss, polyuria and polydipsia.

Subacute:

History as above, but longer. In addition lethargy, infection, pruritis vulvae, boils. Complications may be the presenting feature: infections, neuropathy and ulcers, retinopathy, arterial disease (eg MI or claudication).

Diagnosis

The World Health Organisation (WHO) considers a patient to be diabetic if:

• Blood pressure levels of ≤130/80 mm Hg;
• HbA1c levels of 6.5% or below;
• Fasting blood glucose levels of 4 – 7 mmol/l;
• Self monitored blood glucose levels before meals between 4 and 7 mmol/l;
• Total cholesterol level should be ≤4.0 mmol/l, LDL level ≤2.0 mmol/l;

Note : Better to prevent than treat. becarefull with Diabetes Mellitus

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Posted on March 23rd, 2009 by Dr. Lung
Filed under: Diabetic, Disease