Diabetes Mellitus: Vital Information and Management

Introduction

All countries, irrespective of their economic developmental, epidemiological, and demographical variability, are facing an increasing burden of non-communicable diseases including diabetes mellitus (DM). Diabetes is a chronic metabolic state in which there is sustained raised blood glucose (hyperglycemia) resulting from absolute or relative insulin deficiency, which leads over time to severe damage to the heart, blood vessels, eyes, kidneys, and nerves.

It can also be defined as a serious, chronic metabolic disorders that is characterized by sustained hyperglycemia either when the pancreas does not produce enough insulin, or when the body cannot effectively utilize insulin.

The Burden of Diabetes Mellitus

As of 2021, an estimated 537 million people had diabetes worldwide, with Type 2 Diabetes Mellitus (T2DM) making up about 90% of all cases. It is estimated that by 2045, approximately 783 million adults, or 1 in 8, will be living with diabetes. Currently, in sub-Saharan Africa, Nigeria has the highest number of diabetics, estimated at 1.2 million. The prevalence of the disease continues to increase, most dramatically in low- and middle-income nations. The driving factors for this increase are due to urbanization, westernization, rapid socio-cultural changes, obesity, ageing populations, and unhealthy lifestyle.

Diabetes is associated with psychological distress, social challenges, and reduction in the quality of life of individuals. It is a major cause of mortality, disability, morbidity, and 7^th leading cause of death globally.

The burden of diabetes is often compounded by comorbidity or multi-morbidity that contribute to worse outcomes, multiple organ systems involvement, complex treatment approaches and decreased adherence to treatment, especially after 45 years. The global expenditure on diabetes-related healthcare is an estimated US$760 billion a year.

Types of Diabetes Mellitus

Type 1 Diabetes (T1DM): It is autoimmune or idiopathic chronic condition in which the pancreas produces little or no insulin by itself. It is insulin-dependent and is diagnosed in childhood. The most common treatment for T1DM is insulin replacement therapy.

Type 2 Diabetes (T2DM): Also referred to as adult-onset DM, accounts for about 90% of all diagnosed cases of diabetes among adults. It results from interaction between genetic, environmental, and behavioral risk factors. It has a more insidious onset as patient can remain asymptomatic for years. T2DM can be controlled with lifestyle modification and medications.

Other specific types (Monogenic diabetes): Distinct types of diabetes, previously called secondary diabetes, are caused by other illnesses, infections, or medications, e.g., diseases of the pancreas that destroy the pancreatic beta cells (e.g., hemochromatosis, pancreatitis, cystic fibrosis, and pancreatic cancer), maturity-onset diabetes of the young (MODY), neonatal diabetes, and acromegaly.

Gestational diabetes: This occurs during pregnancy but resolves shortly after. If not professionally managed, gestational DM can lead to big babies ≥ 4kg, difficult labor, stillbirth, pregnancy wastage, and maternal death.

The distinction between T1DM and T2DM has historically been based on age at onset, degree of loss of β cells function, degree of insulin resistance, presence of diabetes-associated autoantibodies and requirement for insulin treatment for survival.

Causes of Diabetes Mellitus

The causes of diabetes mellitus are unclear. However, hereditary (genetic factors), lifestyle, and environmental factors are implicated.

Symptoms

Symptoms of DM include polyuria (frequent urination), polydipsia (excessive thirst), polyphagia (excessive eating), weight loss, blurred vision, poor wound healing, and fatigue. These symptoms may occur suddenly in T1DM, whereas in T2DM, there may be slow onset of symptoms. Many people (50%) with T2DM may remain asymptomatic for years.

Risk Factors of Diabetes Mellitus and Occurrence of Complications

The presence of chronic hyperglycemia impairs the metabolism of carbohydrates, lipids, and proteins. The major risk factors in the development of T2DM are positive family history of DM, history of gestational DM or macrosomia (large babies), unhealthy lifestyle (lack of exercise, processed food, smoking, alcohol use), obesity, race/ethnicity, age increment (≥40 years), history of previous Impaired Glucose Tolerance (IGT) or Impaired Fasting Glucose (IFG) and polycystic ovarian syndrome (PCOS).

The common risk factors for occurrence of complications are co-morbidity or multi-morbidity (hypertension, hyperlipidemia), long duration of uncontrolled diabetes, poor and inadequate glycemic control, negative attitude towards diabetes, poor treatment adherence, and poor knowledge about the disease and its management.

Complications Of Diabetes Mellitus

Short term complications include diabetic hypoglycemia, diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS).

Long term complications are categorized as microvascular (nephropathy, neuropathy, and retinopathy) or macrovascular (stroke, coronary artery disease, peripheral artery disease).

These can manifest as blindness, sexual disorder (loss of libido, erectile dysfunction), sensory loss, neuropathic pain, diarrhea, postural hypertension, diabetic foot, amputation, Charcot joints, kidney failure, hyperlipidemia, hypertension, myocardial infarction, and cognitive decline.

Management of Diabetes Mellitus

The goals of management of diabetes concentrates on keeping blood sugar levels within normal to eliminate symptoms, prevent complications and improve health and longevity. These can be achieved with patient education, dietary changes, regular exercise, weight loss, prevention of leg ulcers/use of protective footwear and use of appropriate medications (insulin, oral medications). Lifestyle modification is highly recommended.

Attention is also paid to other health problems that may accelerate the negative effects of diabetes e.g., smoking, high blood pressure, metabolic syndrome obesity and sedentary lifestyle.

Care for patients with diabetes mellitus is Patient-centered, Family-focused, and Community-oriented. The patient is viewed as an integrated biopsychosocial being at a given stage of their life-cycle.

Diagnostics criteria: Four diagnostic tests for diabetes currently recommended include:

1. A fasting plasma glucose (FPG) level of ≥7.0 mmol/L (126 mg/dL) or higher

2. A 2-hour plasma glucose level of 11.1 mmol/L (200 mg/dL) or higher during a 75g oral glucose tolerance test (OGTT)

3. A random plasma glucose of 11.1 mmol/L (200 mg/dL) or higher
4. Glycosylated (Glycated) hemoglobin (HbA1c) level of ≥ 7%

For diagnosis, diabetic testing must be repeated at least in two separate occasions. Glycated hemoglobin is better than fasting glucose for determining risks of cardiovascular disease and death from any cause. HbA1c also helps in monitoring treatment outcome. One of the goals of treatment is HbA1c level below 7%.

Medications: The four major groups of antidiabetic agents are:

1. Biguanides – Metformin is one of the biguanides. Biguanides reduce gluconeogenesis in the liver. Metformin is the first and most widely used pharmacological treatment. It lowers blood sugar levels and helps to reduce cardiovascular risk without increased risk of hypoglycemia and weight gain.
2. Sulfonylureas – They are insulin secretagogues which stimulate the pancreas to secrete endogenous insulin.
3. Thiazolidinediones or the Glitazones – These medications are insulin sensitizers; they improve sensitivity of peripheral tissues to insulin. An example is pioglitazone.
4. Insulin – These are insulin analogs. They provide insulin exogenously.

New medications with different mechanisms of actions include:

1. Incretin analogs (e.g., Exenatide and Liraglutide).
2. DPP-IV inhibitors (e.g., Linagliptin [Tradjenta], Vildagliptin, and Sitagliptin).
3. SGLT2 inhibitors, also called Gliflozins. Examples are Dapagliflozin and Canagliflozin.
4. Alpha-Glucosidase Inhibitors e.g., Acarbose.

International guideline supports keeping BP below 130/80mmHg with use of angiotensin converting enzyme inhibitors (ACEIs) which protects the kidneys, and administration of statins and low-dose acetylsalicylic acid (Aspirin).

Prevention: Unlike T2DM, T1DM cannot currently be prevented. Diabetic screening, early diagnosis, prompt treatment and lifestyle modification are important preventive measures.

Good policies on wellness and promotion of healthier lifestyle, regular exercise, avoidance of alcohol and smoking, healthy eating, control of high blood pressure and lipids, patient education and medication adherence are also important in the prevention of diabetes. Treatment of complications, care of the feet, regular visual examination and urine test for microalbuminuria are equally important for prevention.

Preventive measures should be applied vigorously to prediabetics (blood sugar is at the upper limit of normal).

Patient-centered care is advocated for the management of diabetes. Defined as a deliberately planned comprehensive care intervention that offers patients the knowledge and abilities necessary for efficient self-management of the condition in accordance with their preferences to achieve optimal glycemic control by enhancing self-care behaviors in addition to medication.

It is informative to note that, due to continuous loss of β-cells (at the rate of 4% per year), patients with T2DM may require insulin in addition to oral medication in their later stages of life. 

Can Diabetes Mellitus Be Cured?

Diabetes mellitus is a life-long condition. There is no cure but it can be controlled.

T2DM can be reversed with medication and strict application of lifestyle medicine measures. Lifestyle medicine is a branch of evidenced-based medicine in which comprehensive lifestyle changes (like plant-based nutrition, physical activity, restorative night time sleep, stress management, positive social connectedness, avoidance of alcohol and substance abuse, and limitation or avoidance of adverse environmental exposures) are used to manage and reverse the progression of chronic diseases by addressing the underlying cause(s).

Some specific types of DM (secondary diabetes) can be terminated if their causes or underling factors are eliminated.

The “cure” of diabetes mellitus regarding use of supplements, traditional, complementary, stem cell and alternative products are unproven.

Bariatric surgery is recommended for morbidly obese patients who are refractory to treatment. It is not a guarantee for cure because of significant beta cell loss, malnutrition, hypovitaminosis, and weight regain. It has its own pros and cons.

Diabetes mellitus is not a single disease but is a clinical syndrome that includes multiple diseases that have different etiologies, pathogeneses, and rates of progression. Thus management may require different therapeutic approaches.

While the concept of a cure is motivating, it is believed that claims by alternative care providers including herbalists of “unproven cure” derail and distract diabetic patients from seeking scientific treatment advances that reduce the disease burden, improve health outcomes, and restore physiology.   

Conclusion

Early detection, lifestyle modification, therapeutic intervention, patient-centered and family-focused approaches to care, and treatment of complications, regular blood glucose check, patient education and self-monitoring of blood glucose are indispensable in the management of DM. The key to living well with diabetes is proper management anchored on “well informed self-care practices.”   

References

1. Diabetes Management: Current Guidelines and Goals. https://www.hemocue.com/en/health-areas/diabetes/guidelines-and-goals (Accessed 15/02/2024)

2. National Guideline for Management of Diabetes for Secondary and Tertiary healthcare level. file:///C:/Users/Dr%20Inyang%20Asibong/Desktop/final_dm_DM_for_secondary_and_tertiary__health_care_providers_feb3rd.pdf (Assessed 15/02/2024)

3. WHO. Diabetes. https://www.who.int/health-topics/diabetes?gclid=EAIaIQobChMIg8XVyu2ihAMVpUNBAh2X8gHHEAAYASAAEgKhwfD_BwE#tab=tab_3 (Accessed 15/02/2024)