Diabetes

Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes tends to progress in severity, and is due to either a reduced production of the hormone insulin by the pancreas or unresponsiveness of bodily cells to insulin's effects. Classic symptoms include the three Ps: polydipsia (excessive thirst), polyuria (excessive urination), and polyphagia (excessive hunger), together with weight loss and blurred vision. If left untreated, the disease can lead to many health complications, including disorders of the cardiovascular system, eye, kidney, and nerves.

The major types of diabetes are type 1 and type 2. The most common type is type 2. The most common treatment for type 1 is insulin replacement therapy (insulin injections), while anti-diabetic medications (such as metformin and semaglutide or tirzepatide) and lifestyle modifications can be used to manage type 2. Gestational diabetes, a form that sometimes arises during pregnancy, normally resolves shortly after delivery.

Type 1 diabetes is an autoimmune condition in which the body's immune system attacks the beta cells (β-cell) in the pancreas, preventing the production of insulin. This condition typically is present from birth or develops early in life. Type 2 diabetes occurs when the body becomes resistant to insulin and thus glucose remains in the bloodstream instead of being absorbed by the cells.

Additionally, diabetes can result from other specific causes, such as genetic conditions (monogenic diabetes syndromes like neonatal diabetes and maturity-onset diabetes of the young), diseases affecting the pancreas (such as pancreatitis), or the use of certain medications and chemicals (such as glucocorticoids or other specific drugs, including those used after organ transplantation).

The number of people worldwide diagnosed as living with diabetes has increased sharply in recent decades, from 200 million in 1990 to 828 million in 2024. Diabetes accounts for some two million deaths each year, and more than half of those affected are unaware of their condition. It affects one in seven of the adult human population, with type 2 diabetes accounting for more than 95% of cases.

These numbers have already risen beyond earlier projections of 783 million adults by 2045. The prevalence of the disease continues to increase, most dramatically in low-middle income nations, where it is now the seventh leading cause of death. Rates are similar in women and men. The global expenditure on diabetes-related healthcare is an estimated US$760 billion a year.

Signs and symptoms

Common symptoms of diabetes include increased thirst, frequent urination, extreme hunger, and unexplained weight loss. Several other non-specific signs and symptoms may also occur, including fatigue, blurred vision, sweet smelling urine/semen and genital itchiness due to Candida infection. About half of affected individuals may also be asymptomatic.

Type 1 presents abruptly following a pre-clinical phase, while type 2 has a more insidious onset; patients may remain asymptomatic for many years.

Diabetic ketoacidosis is a medical emergency that occurs most commonly in type 1, but may also occur in type 2 if it has been longstanding or if the individual has significant β-cell dysfunction. Excessive production of ketone bodies leads to signs and symptoms including nausea, vomiting, abdominal pain, the smell of acetone in the breath, deep breathing known as Kussmaul breathing, and in severe cases decreased level of consciousness.

Hyperosmolar hyperglycemic state is another emergency characterized by dehydration secondary to severe hyperglycemia, with resultant hypernatremia leading to an altered mental state and possibly coma.

Hypoglycemia is a recognized complication of insulin treatment used in diabetes. An acute presentation can include mild symptoms such as sweating, trembling, and palpitations, to more serious effects including impaired cognition, confusion, seizures, coma, and rarely death. Recurrent hypoglycemic episodes may lower the glycemic threshold at which symptoms occur, meaning mild symptoms may not appear before cognitive deterioration begins to occur.

Acanthosis nigricans on the skin may also be a sign of insulin resistance, which is a symptom of type 2 diabetes.

Long-term complications

The major long-term complications of diabetes relate to damage to blood vessels at both macrovascular and microvascular levels. Diabetes doubles the risk of cardiovascular disease, and about 75% of deaths in people with diabetes are due to coronary artery disease. Other macrovascular morbidities include stroke and peripheral artery disease.

Microvascular disease affects the eyes, kidneys, and nerves. Damage to the retina, known as diabetic retinopathy, is the most common cause of blindness in people of working age. The eyes can also be affected in other ways, including development of cataract and glaucoma. It is recommended that people with diabetes visit an optometrist or ophthalmologist once a year.

Diabetic nephropathy is a major cause of chronic kidney disease, accounting for over 50% of patients on dialysis in the United States. Diabetic neuropathy, damage to nerves, manifests in various ways, including sensory loss, neuropathic pain, and autonomic dysfunction (such as postural hypotension, diarrhea, and erectile dysfunction).

Loss of pain sensation predisposes to trauma that can lead to diabetic foot problems (such as ulceration), the most common cause of non-traumatic lower-limb amputation.

Hearing loss is another long-term complication associated with diabetes.

Based on extensive data and numerous cases of gallstone disease, it appears that a causal link might exist between type 2 diabetes and gallstones. People with diabetes are at a higher risk of developing gallstones compared to those without diabetes.

There is a link between cognitive deficit and diabetes; studies have shown that diabetic individuals are at a greater risk of cognitive decline, and have a greater rate of decline compared to those without the disease. Diabetes increases the risk of dementia, and the earlier that one is diagnosed with diabetes, the higher the risk becomes. The condition also predisposes to falls in the elderly, especially those treated with insulin.

Types

• Sudden — Gradual, Insidious
• Any age; average age at diagnosis being 24. — Mostly in adults
• Thin or normal — Often obese
• Common — Rare
• Usually present — Absent
• Low or absent — Normal, decreased or increased
• 0.69 to 0.88 — 0.47 to 0.77
• <2 per 1,000 — ~6% (men), ~5% (women)

Diabetes is classified by the World Health Organization into six categories:

• Type 1 diabetes
• Type 2 diabetes
• Hybrid forms of diabetes
  (including slowly evolving, immune-mediated diabetes of adults and ketosis-prone type 2 diabetes)
• Hyperglycemia first detected during pregnancy
• Other specific types
• Unclassified diabetes

Diabetes is a more variable disease than once thought, and individuals may have a combination of forms.

Type 1

Type 1 accounts for 5 to 10% of diabetes cases and is the most common type of diabetes diagnosed in patients under 20 years; however, the older term "juvenile-onset diabetes" is no longer used as onset in adulthood is possible. The disease is characterized by loss of the insulin-producing beta cells of the pancreatic islets, leading to severe insulin deficiency, and can be further classified as immune-mediated or idiopathic (without known cause).

The majority of cases are immune-mediated, in which a T cell-mediated autoimmune attack causes loss of beta cells and thus insulin deficiency. Patients often have irregular and unpredictable blood sugar levels due to very low insulin and an impaired counter-response to hypoglycemia.

Type 1 diabetes is partly inherited, with multiple genes, including certain HLA genotypes, known to influence the risk of diabetes. 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.

The genes that are responsible for diabetes are still being researched, but scientists have narrowed them down by investigating the gene mutations related to the capability of the body's β-cells to produce insulin. Genes related to environmental responses (metabolism, pregnancy symptoms, autoimmune disorder development, etc.) also contribute to a person's amount of genetic risk for diabetes.

The occurrence of diabetes in monozygotic and dizygotic twins has been tested, and these rates can give insight into the genetic component of diabetes. In type 1 diabetes, the chance of monozygotic twins both developing the disease was greater than the risk for dizygotic twins. However, the rate of any siblings contracting the disease was much greater with type 2 diabetes.

This indicates that there must be a large environmental factor involved in type 2, and some genetic factor with type 1. Type 1 diabetes has only about a 50% concordance rate (the percentage of two identical twins both having the condition). Thus, it is not fully genetic, but the results from the twin studies point to some inherited risk.

Type 1 diabetes can occur at any age, and a significant proportion is diagnosed during adulthood. Latent autoimmune diabetes of adults (LADA) is the diagnostic term applied when type 1 diabetes develops in adults; it has a slower onset than the same condition in children. Given this difference, some use the unofficial term "type 1.5 diabetes" for this condition.

Adults with LADA are frequently initially misdiagnosed as having type 2 diabetes, based on age rather than a cause. LADA leaves adults with higher levels of insulin production than type 1 diabetes, but not enough insulin production for healthy blood sugar levels.

Type 2

Type 2 diabetes 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 diabetes is the most common type of diabetes mellitus, accounting for 95% of diabetes. Many people with type 2 diabetes have evidence of prediabetes (impaired fasting glucose and/or impaired glucose tolerance) before meeting the criteria for type 2 diabetes. The progression of prediabetes to overt type 2 diabetes can be slowed or reversed by lifestyle changes or medications that improve insulin sensitivity or reduce the liver's glucose production.

Type 2 diabetes is primarily due to lifestyle factors and genetics. A number of lifestyle factors are known to be important to the development of type 2 diabetes, including obesity (defined by a body mass index of greater than 30), lack of physical activity, poor diet such as Western Pattern Diet, and stress. Excess body fat is associated with 30% of cases in people 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 may have a high waist–hip ratio.

Dietary factors such as sugar-sweetened drinks are associated with an increased risk. The type of fats in the diet is also important, with saturated fat and trans fats increasing the risk and polyunsaturated and monounsaturated fat decreasing the risk. Eating white rice excessively may increase the risk of diabetes, especially in Chinese and Japanese people.

Adverse childhood experiences, including abuse, neglect, and household difficulties, increase the likelihood of type 2 diabetes later in life by 32%, with neglect having the strongest effect.

Antipsychotic medication, SSRI, and SNRI side effects (specifically metabolic abnormalities, dyslipidemia and weight gain) are also potential risk factors.

Gestational diabetes

Gestational diabetes resembles type 2 diabetes 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. It is recommended that all pregnant women get tested starting around 24–28 weeks gestation.

It is most often diagnosed in the second or third trimester because of the increase in insulin-antagonist hormone levels that occurs at this time. However, after pregnancy approximately 5–10% of women with gestational diabetes are found to have another form of diabetes, 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 infant 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.

As the risk of developing type 2 diabetes is about 10 times higher in women with a history of gestational diabetes, postpartum screening may involve dietary, lifestyle, and drug interventions to prevent or delay its progression.

Maturity-onset diabetes of the young

Maturity-onset diabetes of the young (MODY) is a rare autosomal dominant inherited form of diabetes, due to one of several single-gene mutations causing defects in insulin production. It is significantly less common than the three main types, constituting 1–2% of all cases. The name of this disease refers to early hypotheses as to its nature.

Being due to a defective gene, this disease varies in age at presentation and in severity according to the specific gene defect; thus, there are at least 14 subtypes of MODY. People with MODY often can control it without using insulin.

Type 5 (malnutrition-related)

Malnutrition-related diabetes, also termed Type 5 diabetes, involves decreased insulin production, similar to Type 1 diabetes, but is primarily related to malnutrition rather than autoimmune damage of pancreas beta cells. Unlike in Type 1 diabetes, patients with Type 5 diabetes do not develop ketonuria or ketosis. The ICD-10 (1992) diagnostic entity, malnutrition-related diabetes mellitus (ICD-10 code E12), was previously deprecated by the World Health Organization (WHO) when the current taxonomy was introduced in 1999.

Other types

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, whereas others increase insulin resistance (especially glucocorticoids which can provoke "steroid diabetes").

Yet another form of diabetes that people may develop is double diabetes. This is when a type 1 diabetic becomes insulin resistant, the hallmark for type 2 diabetes or has a family history for type 2 diabetes. It was first discovered in 1990 or 1991.

The following is a list of disorders that may increase the risk of diabetes:

Unofficial

Insulin resistance in the brain caused by Alzheimer's disease has been termed by some researchers as Type 3 diabetes, though this label is also rejected by some to avoid confusion with other types classified as Type 3. "Type 4 diabetes" has been used to describe age-related insulin resistance in lean mice. Neither of these terms are commonly used in human health care.

Pathophysiology

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 play a central role in all forms of diabetes mellitus.

The body obtains glucose from three main sources: the intestinal absorption of food; the breakdown of glycogen (glycogenolysis), 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 regulating 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, or if cells respond poorly to the effects of insulin (insulin resistance), or if the insulin itself is defective, then glucose is not absorbed properly by the body cells that require it, and is not 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 metabolic acidosis in cases of complete insulin deficiency.

When there is too much glucose in the blood for a long time, the kidneys cannot absorb it all (reach a threshold of reabsorption) and the extra glucose gets passed out of the body through 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 is replaced osmotically from water in body cells and other body compartments, causing dehydration and increased thirst (polydipsia). In addition, intracellular glucose deficiency stimulates appetite leading to excessive food intake (polyphagia).

Diagnosis

Diabetes mellitus is diagnosed with a test for the glucose content in the blood, and is diagnosed by demonstrating any one of the following: