Diabetes mellitus

Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood or hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Normally a certain amount of glucose circulates in the blood. The major sources of this glucose are absorption of ingested food in the gastrointestinal tract and formation of glucose by the liver from food substances (Kozier et. l, 2002). Client’s name is Mr. Harvey, 48 years old and has three children and he is newly diagnosed having Type 1 Diabetes. He is a college undergraduate and has experienced working in a restaurant as chief cook until now where in he works for 6 hours. He is also a small businessman and is greatly affected by the economic condition as of the present.He only earns enough for his kids since he is a single parent; he earns about 350 dollars a day including his earnings in his small business. These factors aforementioned greatly influence to his ability to access the necessary healthcare that he should have. Yes, he has a job but his earnings is not enough for him to be thoroughly be checked by healthcare professionals, and also because he has three kids which are all studying as well.As a single parent, it is his job also to look after his children and this means all his extra time will be devoted to them and he will not be able to attend to his own needs and other self- care practices needed for his condition. Although he can do some modification in his diet still he cannot manage to consistent all throughout because he still has a lot of things to attend to, but nevertheless as a college undergraduate he has some basic knowledge about the condition he has which is Type 1 Diabetes.Although he has a job and a business of his own it still does not erase the fact that he is a single parent of three kids, maybe he can buy some medicine for his condition but it will not be continuous because he will tend to prioritize other things. Prognosis of his condition would be poor because he cannot focus on the treatments that he should be getting to alleviate his condition; Diabetes is such a silent killer especially when complications arise. Lastly, diabetes can be fatal. Diabetes Mellitus Diabetes Mellitus (DM) is a common and potentially serious, chronic metabolic condition which is characterized predominantly by hyperglycemia and other manifestations. Diabetes can be a devastating condition with long lasting hazardous consequences since due to its chronicity it affects almost all the major organs of the body including the eyes, the kidneys, the nerves, heart and blood vessels (Jennifer, 1998).There are two main types of Diabetes Mellitus viz. Type 1 Diabetes Mellitus (also termed as Insulin Dependent Diabetes Mellitus or IDDM and juvenile Diabetes Mellitus) and Type 2 Diabetes Mellitus (also known as Non-Insulin Dependent Diabetes Mellitus or NIDDM and adult-onset Diabetes Mellitus) (Jennifer, 1998). Type 1 DM is more common as compared to type 2 DM in younger age groups and accounts for almost two-thirds of the cases of diabetes diagnosed amongst individuals less than 19 years of age (Levitsky & Misra, 2008).Epidemiology of DM – The magnitude of the problemI n the United States, Diabetes Mellitus is the fourth leading cause of death and accounts to 178,000 deaths per year (Do I Have Diabetes?, 1998). Individuals with DM have been shown to have a 5-10 years shorter lifespan as compared to their normal counterparts (Lipsky & Sharp, 2004). Moreover, DM also contributes to significant morbidity and remains amongst the leading cause of blindness in adults in the 20-74 years age group. Similarly, it also remains as one of the most common causes of non-traumatic lower-limb amputation and end-stage renal disease (ESRD) (Votey & Peters, Diabetes Mellitus, Type 1 – A Review, 2007).It was estimated that about 7% of the U.S population (20.8 million individuals) were inflicted with this condition in the year 2005. Amongst these, 14.6 million were diagnosed as having DM while the rest were undiagnosed. Moreover, an additional 54 million people were shown to have pre-diabetes’ (defined below) (Votey & Peters, Diabetes Mellitus, Type 1 â €“ A Review, 2007). It is alarming to note that over the past decades, the incidence of DM has been increasing and it was observed that the percentage of adults in the U.S diagnosed with DM increased by 49% (from 4.9 to 7.3%) during the period 1990-2000 (Lipsky & Sharp, 2004).Diabetes Mellitus is also important from an economic and public health perspective as well since it leads to both direct and indirect costs of health care. The magnitude of the problem can be judged by the fact that in the year 2002, the per-capita healthcare cost for diabetic individuals was $13,243 as opposed to $2560 for non-diabetics (Votey & Peters, Diabetes Mellitus, Type 2 – A Review, 2009).Type 1 and Type 2 DM – A comparisonAs discussed above, there are two main types of Diabetes mellitus – type 1 DM and type 2 DM – which differ in etiologies and pathogenesis. DM was classified into two major subtypes viz. IDDM and NIDDM in 1979 by the National Diabetes Data Group and thi s classification was later endorsed by WHO (Jennifer, 1998). However, this classification had certain limitations and therefore the recent guidelines classify DM into four main groups viz. type 1 DM, type 2 DM, â€Å"other specific types† and gestational diabetes (Jennifer, 1998).According to the recent guidelines, the diagnosis of DM requires two fasting plasma glucose levels of 126 mg per dL (7.0 mmol per L) or greater. Moreover, if after a glucose load of 75 g a patient has two two-hour postprandial plasma glucose (2hrPPG) readings of 200 mg per dL (11.1 mmol per L) or higher or two random blood sugar levels of 200 mg per dL (11.1 mmol per L) or higher, he/she can be diagnosed as being diabetic.It is preferable to use the fasting plasma glucose level, due to its better reproducibility and easier administration, however, in clinical practice, a combination of any two abnormal test results can be employed (Jennifer, 1998). In addition to full blown DM, the American Diabetes Association has defined another category, pre-diabetes. This is a state in which ‘the blood glucose levels are higher than normal but not high enough to be diagnosed as diabetes’ (Votey & Peters, Diabetes Mellitus, Type 1 – A Review, 2007).Type 1 DM is a metabolic disorder resulting from the autoimmune destruction of the pancreatic beta cells located in the Islets of Langerhans which results in a progressive disability to secrete insulin (Votey & Peters, Diabetes Mellitus, Type 1 – A Review, 2007). Type 1 DM can present at any age the most common presentation being in childhood but one-fourth of cases are diagnosed in adults. (Levitsky & Misra, 2008). This late presentation of type 1 diabetes mellitus has been termed as latent autoimmune diabetes of the adult (LADA). Studies have suggested that type 1 DM occurs in individuals who are genetically predisposed to developing this disease and its onset may be triggered by certain environment agents such as viru ses and toxins (Votey & Peters, Diabetes Mellitus, Type 1 – A Review, 2007).Once the onset is triggered, there is progressive destruction of the beta cells and a subsequent decrease in insulin production. However, during this period the individual is asymptomatic and euglycemic (Eisenbarth & McCulloch, 2009). Overt hyperglycemia is manifested when more than 80-90% of the beta cells have been destroyed (Votey & Peters, Diabetes Mellitus, Type 1 – A Review, 2007). Recently, a newer subtype of type 1 DM has been identified which is characterized by a non-immune mediated destruction of pancreatic islet cells and has been termed as Type 1B DM (Eisenbarth & McCulloch, 2009).It is a well established fact that type 1 DM is genetically determined. Several genes have been implicated to play a role in the pathophysiology of type 1 DM including polymorphisms in HLA-DQalpha, HLA-DQbeta, HLA-DR, preproinsulin, the PTPN22 gene, CTLA-4, interferon-induced helicase, IL2 receptor (CD25) , a lectin-like gene (KIA0035), ERBB3e, and an undefined gene at 12q (Eisenbarth & McCulloch, 2009).In individuals with type 1 DM, genetic markers are present since birth. However, it has been elucidated that immune markers develop after the onset of the autoimmune process of beta cell destruction and metabolic derangements can be identified once a significant proportion of beta cells have been destroyed but before the occurrence of symptoms (Eisenbarth & McCulloch, 2009).The immune markers which have been identified for type 1 DM include antibodies to the islet cell (IA2) and to insulin (IAA). Moreover, autoantibodies to islet–glutamate decarboxylase (GAD) including anti-GAD65 have been found in patients with type 1 DM and are of particular importance in adults with this disease since these antibodies are clinically detectable and can be used to aid in the detection and diagnosis of type 1 DM in adults (Votey & Peters, Diabetes Mellitus, Type 1 – A Review, 2007).Type 2 DM is relatively far more common than Type 1 DM, especially amongst adults accounts for almost 80-90% of all the cases of DM in various regions of the world (Gerich, 1998). Over the past few decades, epidemiologic studies have identified an alarming increase has been observed in the cases of Type 2 DM to an extent that type 2 DM is now being regarded as an epidemic. In a study conducted in a Japanese population comprising of children of school going age, type 2 DM was found to be seven times more common as compared to type 1 DM and a 30-fold increase in its incidence was noticed over the last two decades (Rosenbloom, 1999).Type 2 DM typically affects individuals aged greater than 40 years but more recently it has been observed to be occurring more frequently in younger age groups and has been found in individuals who are as young as two years of age and have a positive family history of this disorder. There are various factors which have led to an increase in the incidence of type 2 DM in younger age groups. These include increasing incidence of obesity and a sedentary lifestyle amongst children and an increase in the life expectancy, with more individuals surviving past the age of 65 years (Votey & Peters, Diabetes Mellitus, Type 2 – A Review, 2007).The etiology of Type 2 DM is a multifactorial and it arises from a complex interplay of both genetic and environmental influences. The inheritance of this disorder does not follow the simple Mandelian patterns. Infact, this disorder has a polygenic inheritance requiring multiple gene polymorphisms (Gerich, 1998). Lipsky describes the genetic-environmental interaction which is implicated in the development of type 2 DM as â€Å"A good analogy is that although genetics loads the gun, environment pulls the trigger (Lipsky, 2004).†Several genes have been implicated in the causation of type 2 DM. Amongst these the three most consistently identified genes include TCF7L2, KCNJ11, and PPARG (Lyssenko, 2008 ). However, more recently, a number of novel genes which increase an individual’s susceptibility to type 2 DM have been identified including CDKAL1, IGF2BP2, the locus on chromosome 9 close to CDKN2A/CDKN2B, FTO, HHEX, SLC30A8, WFS1, JAZF1, CDC123/CAMK1D, TSPAN8/LGR5, THADA, ADAMTS9, and NOTCH2 (Lyssenko, 2008).The pathogenesis of Type 2 DM is different from type 1 DM in that it results from both an impairment in insulin sensitivity and insulin secretion as opposed to Type 1 DM which results solely from impaired insulin secretion (Gerich, 2009). Individuals with type 2 DM have end-organ or peripheral resistance to insulin and additionally a defect in the production of insulin and recent data suggests that both must co-exist for causing manifestations of type 2 DM. Several risk factors have been identified which increase a person’s susceptibility to developing type 2 AM.These include a positive family history of DM, and increase in the Body Mass Index (BMI), impaired or elevated Liver Function Tests (LFTs), comorbid conditions such as current smoking status and hypertension, decreased measures of insulin secretion and action, Hispanic, Native American, African American, Asian American, or Pacific Islander descent , a history of GDM or of delivering a baby with a birth weight of >9 lb and Polycystic ovarian syndrome (Lyssenko, 2008 and Votey & Peters, Diabetes Mellitus, Type 2 – A Review, 2007).Amongst other risk factors, obesity is one of the most consistently identified and the strongest risk factor for the development of type 2 DM. Moreover, studies have shown that intraabdominal obesity is of particular significance in causing insulin resistance (Gerich, 2009). Most of these risk factors are modifiable and current public health strategies focus on targeting these modifiable risk factors in addition to pharmacologic intervention for the control of type 2 DM.The complications of DM are numerous and diverse and include increased susceptibil ity to infections, microvascular complications including nephropathy, neuropathy and retinopathy which can lead to subsequent end-organ failure and macrovascular complications, which include stroke and coronary artery disease (Diabetes Mellitus, Type 2 – A Review, 2007).In conclusion, DM is a common disorder and affects a large proportion of the population globally. There are two main types of DM viz. type1 and type 2 and both differ in etiology and pathogenesis. DM can lead to several manifestations and complications and hence is a major public health concern. Although extensive research has been conducted in order to identify the underlying etiology of both types of DM, there is a pressing need to explore the arena of prevention measures for this disorder and devise strategies to control the increasing incidence of Type 2 DM in the younger age groups.ReferencesDo I Have Diabetes? (1998, October 15). Retrieved April 20, 2009, from American Family Physician: http://www.aafp.o rg/afp/AFPprinter/981015ap/981015b.htmlEisenbarth, G. S., & McCulloch, D. K. (2009, February 11). Pathogenesis of type 1 diabetes mellitus. Retrieved April 20, 2009, from Uptodate online: http://www.uptodate.com/patients/content/topic.do?topicKey=~JYHFR94z4VP3LY&selectedTitle=4~150&source=search_resultGerich, John E. (1998) The Genetic Basis of Type 2 Diabetes Mellitus: Impaired Insulin Secretion versus Impaired Insulin Sensitivity. Endocrine Reviews 19(4): 491–503Jennifer, M. (1998). Diagnosis and Classification of Diabetes Mellitus: New Criteria. American Famil Physician .Levitsky, L. L., & Misra, M. (2008, November 18). Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents. Retrieved April 20, 2009, from Uptodate Online: http://www.uptodate.com/patients/content/topic.do?topicKey=~0babJ4CniXpnXAf&selectedTitle=12~150&source=search_resultLipsky, M. S., & Sharp, L. K. (2004). Preventive Therapy for Diabetes: Lifestyle Changes and th e Primary Care Physician. American Family Physician .Lyssenko Valeria et al. (2008) Clinical Risk Factors, DNA Variants, and the Development of Type 2 Diabetes. The New England Journal of Medicine 359; 21Rosenbloom, Arlan L. and Joe Jenny R. (1999). Emerging epidemic of Type 2 Diabetes Mellitus in Youth. Diabetes Care 22:345–354Votey, S. R., & Peters, A. L. (2007, October 2). Diabetes Mellitus, Type 1 – A Review. Retrieved April 2, 2009, from emedicine: http://emedicine.medscape.com/article/766036-overviewVotey, S. R., & Peters, A. L. (2009, February 2). Diabetes Mellitus, Type 2 – A Review. Retrieved April 20, 2009, from emedicine: http://emedicine.medscape.com/article/766143-overview