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What this article will tell you about diabetes

Diabetes became a huge health problem in developed countries and is in countries in transition today one of the major noninfectious chronic diseases. Diabetes is linked to a sedentary lifestyle with lack of physical activity and obesity.

This article will discuss questions like what diabetes is, which types of diabetes there are, early signs of diabetes and symptoms of diabetes and etc. It will hopefully provide more answers to you regarding connection between diabetes and other diseases, risks involved and other related questions.  Finally, the text will mention diabetes management, testing, and ways to prevent diabetes and also discuss what options there are on how to test for diabetes at home.

What is diabetes?

Diabetes mellitus (DM, diabetes ICD10) is non-infectious metabolic chronic disease which is defined by the presence of high blood sugar. The main reason behind this is the lack of response from and or production of a protein called insulin, which is produced by a gland in our body called pancreas.  There are two types of diabetes mellitus recognized by medical authorities: type 1 and type 2 diabetes.

What types of diabetes are there?

Diabetes comes under a few different names and types. Beneath we have summed up the most common ones.

• Diabetes mellitus Type 1 (Type 1 DM)
• Diabetes mellitus Type 2 (Type 2 DM)
• Other less common diabetes types/forms

Diabetes mellitus Type 1 (Type 1 DM)

Diabetes mellitus type 1 is not that common and only affects around 5% diagnosed with diabetes. It presents as lack of insulin since the pancreatic cells that produce it are destroyed by the immune system. Due to this and its early start is also called childhood diabetes. Usually it affects people younger than age of 30.

The characteristic symptoms in children are: polyuria (frequent urination), polydipsia (excessive thirst) and weight loss, combined with elevated blood sugar. This type is associated with a severe complication called ketoacidosis, presented with loss of consciousness, heavy and laboured breathing, stomach pain and etc. It arises because body starts to build up substances called ketones, which replace sugar in body’s energy production.

Diabetes type 1 is managed by applying insulin shots to replace the deficit of natural insulin.

Diabetes mellitus Type 2 (Type 2 DM)

Type 2 diabetes is far more frequent than type 1. Unlike type 1 it affects adults, when the bodies tissue (muscle and liver) doesn’t respond to insulin. This phenome is called insulin resistance. People with type 2 diabetes (T2D) are usually overweight and have a BMI (Body Mass Index) higher than 25 or more. It is thought that immune system doesn’t play a decisive role in onset of the disease. The potential for getting T2D is greater if one or both parents have diabetes.

Since the pancreas in these patients is still working, there is a small amount of insulin still produced. This means that for a long time, the disease is usually without any symptoms, so special test need to be done in order to diagnose it. Nevertheless, some symptoms of diabetes type 2 are:

• frequent urination (polyuria),
• feeling very thirsty,
• constant hunger even though you are eating enough
• extreme fatigue,
• blurry vision,
• tingling, pain or numbness in the hands and/or feet

Type 2 is generally treated with lifestyle changes, oral medications (pills), and insulin according to individual needs (1). More on that later in this text.

Other less common diabetes types/forms

There are also some diabetes types that are not so usual, but these will be also mention sparsely here.

It is very important that we differentiate prediabetic state and real diabetes. As a rule, blood sugar level after fasting is less than 5.6 mmol/L in healthy people. A prediabetic state is when your blood sugar after fasting is between 5.6 and 6.9 mmol/L. It is a state in which your body is telling you that something is wrong. This state is still reversible, but these individuals have 25-40% risk over next 5 years to develop diabetes type 2. They also have increased risk of cardiovascular (heart and blood vessels) disease.

To determine if you are in the risk zone there are two common tests you can do:

• a fasting plasma glucose test and
• a oral glucose tolerance test

The fasting test relatively easy to do. You measure your sugar in a blood drop taken from your finger after some time of fasting. This test is easy and you can do it at home, although these test results can vary by 10% in accuracy.

The other test is usually done by your doctor in the hospital. They give you a glass of water with a lot of sugar to drink, and then measure sugar in your blood from vain after 0, 30, 60 and 120 minutes from drinking. This is more precise and decisive as it is analyzed in the laboratory (5).

WHAT IS GESTATIONAL DIABETES?

Gestational diabetes or diabetes during pregnancy occurs around 24th week of pregnancy. In America around 9.2% are complicated with this disease. The possible cause is insulin resistance caused by placenta’s activity. Although not dangerous as diabetes that mother has before pregnancy, it needs to be treated as well. Most common consequence on baby is so called macrosomia or a “fat” baby. These babies often have breathing problems, low blood sugar level, injuries during birth and have higher risk for being obese or developing type 2 diabetes in childhood. You can diagnose it by doing diabetes test during pregnancy (1, 6).

SECONDARY DIABETES

Secondary diabetes is usually caused by other diseases that influence secretion of pancreatic gland, or destroy gland tissue. As a consequence diabetes may occur among other symptoms of missing other pancreatic enzymes and hormones. This can occur in:

• autoimmune diseases
• infectious diseases
• injury to pancreas
• Alcoholism etc.

New proposed classification of diabetes based on newest research divides diabetes patients into 5 clusters, three severe and two mild forms of disease, since type 2 is highly variable (2). One cluster represents diabetes mellitus type 1, it is called severe autoimmune diabetes (SAID), and the other four; cluster 2 called severe insulin-deficient diabetes (SIDD), cluster 3 called severe insulin-resistant diabetes (SIRD), cluster 4 called mild obesity-related diabetes (MOD) and cluster 5 called mild age-related diabetes (MARD) correspond to type 2. Significance of these clusters, demonstrates in possibility that future diabetes therapy is going to be adapted to individual needs.

Classification is based on six variables (glutamate decarboxylase antibodies, age at diagnosis, BMI, HbA1c, and homoeostatic model assessment 2 estimates of β-cell function and insulin resistance) measured in patients that showed their response to medication, and also risk of diabetic complications.

There are also special entities called LADA (latent autoimmune diabetes in adults), MODY (maturity-onset diabetes in young), and before mentioned secondary diabetes. LADA is linked with antibodies GADA (glutamate decarboxylase antibodies). The importance to distinguish this entity from diabetes type 2 comes from fact that these two diseases are usually mixed. Although LADA has the same symptoms as diabetes type 2, it should be treated as diabetes type 1 (2, 5).

ALZHEIMER’S DISEASE AND DIABETES

Alzheimer’s disease (AD) is the most common cause of dementia. This happens because microscopic changes occur in brain tissue which in turn causes brain cells to work less effectively and ultimately cause loss of cells. Doctors and researchers are not sure why these changes occur. New evidence suggest that AD should be considered as type 3 diabetes, since there are some interesting facts found about underlying mechanisms of this disease (3).

This is evident in mechanism that begins the changes behind the disease, which is claimed to have similar frame as type 2DM and type 1 DM. Scientists involved believe that basically AD is a type of brain selective diabetes sharing many of the biochemical and molecular traits as DM. This has led to a theory that treatment for type 2 DM can be used to treat AD (3).

What causes diabetes?

Type 1 diabetes (type 1 DM)

The exact cause of type 1 DM is unknown. Scientists suggest theory in which immune system mistakenly destroys the insulin producing cells in the pancreas gland. There are some other possible causes such as:

• Genetics
• Exposure to viruses and microbes
• Other environmental factors

The way these factors work is by making your autoimmune system sensitive to your tissue by mimicry. Immune cells kill bacteria or viruses, which present our immune system with targets that are similar at molecular level to our tissue. This causes our immune cells to recognize tissue like pancreas beta cells which produce insulin to be attacked by our own immune cells (9, 10).

There are also some other factors that can contribute to the beginning of the disease. There are several risk factors:

• Presence of DM type 1 in family
• Genetic
• Geography – further from equator the risk is higher
• Age – first peak occurrence is between ages 4-7, second is between 14-16 but can occur at any age (7)

Type 2 diabetes (type 2 DM)

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Figure 3. Overweight and obese people are at risk of developing diabetes

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Obesity, Diabetes risk factors, BMI and obesity, BMI, BMI and diabetes, Waistline

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This type of DM occurs when the body becomes resistant to insulin, or when the pancreas stops producing enough insulin. Scientist are not familiar with exact cause of this phenomenon, but it is known that genetic and environmental factors such as lifestyle (overweight and physical inactivity), and having one of parents with type 2 DM, can contribute to disease occurrence.

So far, both types of DM are not curable. But a normal life can be managed once the good therapy is chosen and sugar in blood is under control (8).

Table 2. List of known and suggested causes of diabetes types

Foods that cause and won’t cause diabetes (type)

Diet is a crucial for prevention and management of all diabetes types. More and more resources and money is spent towards educating general population about proper foods to include in diet in order to avoid developing this disease. It is very important to instil these healthy habits in children since early age as onset of Type 2 Diabetes in young age is on the rise (8).

If you are looking out for your health and trying to manage diabetes you should avoid eating foods like: processed meat, fatty meat, refined sugar (e.g. candies, cakes, and sweets), sweet fizzy drinks, pastries, dried fruit and alcohol. Increased risk of developing Type 2 Diabetes is associated with diet consisting mainly of these foods. These foods are rich in calories, which in turn can lead to gaining weight which is a pathway to metabolic disorders. It is important to know that eating these foods in healthy balanced diet will likely not cause the problem (11).           

Other studies suggest that a Mediterranean diet characterized by a high intake of vegetables, fruits, legumes, extra virgin olive oil, nuts, fish, whole grain and red wine show a great decrease of risk for developing Type 2 Diabetes (11).

Apart for this special regional diet, a general rule is that high intake of vegetables, fruits and fat from vegetables with low saturated fat should be favoured. Fish, legumes, nuts and dairy should be base of protein intake. Unrefined whole grain products with high natural fibre content are also stressed out as healthier choice which lowers the risk of developing diabetes.

Also, vitamin C can decrease fasting blood sugar, and the HbA1c level, while carotene may reduce bad cholesterol levels. Food rich with these are citrus fruits, vegetables like carrots and etc (11).

Table 3. Examples of foods recommended eating or avoiding when diagnosed with diabetes.

One important thing to take from this is that healthy and balanced diet is more important than eating certain types of food or restraining yourself to have a treat sometimes.

The connection between diabetes risk of getting other diseases

• Diabetes and the risk of Alzheimer’s disease

To add further to the subject we already discussed above, Alzheimer’s and diabetes seem to share a deeper link on molecular level, as scientists now explore the fact that some of the pathways for these diseases cross.

• Diabetes and the risk of dementia

In diabetes, small blood vessels in the brain are damaged by the disease and high blood sugar. These small vessels they are important since they bring nutrients and oxygen to the brain, and transport away bad brain metabolites. If they are damaged, brain cells don’t have enough food and oxygen, and bad metabolites will pile up in them.

This leads to gradual loss of very valuable brain cells. Since these vessels do not reproduce, damaged brain cells are replaced with less valued connective tissue. When this happens, and the damage to the brain is great enough, disease called dementia can occur.

• Diabetes and the direct associated cancers

Studies show that some cancers are more commonly developed in patients with diabetes. Type 1 diabetes is usually associated with cancer of the stomach or cervix. As for Type 2 Diabetes, link is established between the disease and cancer of the breast, uterus, pancreas, liver, colon and kidney (16).

The connection between diabetes and cancer is considered to be hidden in chronic inflammation, hyperinsulinemia (due to insulin resistance or huge doses of medical insulin) or high bloods sugars when all of these are present in diabetes (13).

• To have diabetes during cancer

Having diabetes can complicate cancer treatment due to a number of factors. Generally, patients with diabetes handle cancer therapy not as good as other because their natural body reserves are depleted by combating diabetes (14). Usually, potent and often toxic drugs, and surgical or radiation treatment are used to treat cancer. These can additionally make your blood sugar level hard to maintain.

Along with all of that, surgery recovery as well as wound healing takes longer, and the risk of post-operative infections are greater in patients who suffer from diabetes (17). Also, some new treatments for cancer and drugs can spur the development of diabetes (14).

• Diabetes and its effect on lifespan and a lengthy long life

Life length depends on many factors, but the fact is that men with Type 1 Diabetes lose 11 years of life, while women lose as much as 13 years of life in comparison to general population.

Younger people with Type 1 Diabetes often die because of poor management of disease. Before 50 years of age, disease often complicates with diabetic coma, caused by low blood sugar. Ketoacidosis as a complication is also described. All of this happens because of bad blood sugar control, and unregulated insulin.

Populations over 50 are however in risk of premature death due to cardiovascular disease which accompanies Type 1 Diabetes (19).

Type 2 Diabetes diagnosed people usually have life expectancy lower by 10 years than general population. Unlike Type 1 Diabetes, the changes type 2 causes are slow and take long time to develop into life threatening conditions. This is also why Type 2 Diabetes is dangerous, not giving any symptoms until the damage to organs is too great to revert or slow down (21).  

But early deaths can be avoided by intensive blood management. An early diagnose is very important for this. It will help in developing fewer diabetic complications and organ damages, and therefore give a better life expectancy and life quality.

• Diabetes and the risk of cardiovascular disease

Diabetes is linked with increased risk of cardiovascular disease in numerous studies. It is one of the main risk factors in cerebral stroke and hugely increases the risk of heart attack.

High blood sugar which is not under control can cause accelerated atherosclerosis and damages our blood vessels, big and small ones alike. If the big ones are damaged, then some organs suffer too. Such organs are heart, kidney, eye, brain, or even parts of body like leg.

If the small blood vessels are damaged, it is usually presented as peripheral diabetic neuropathy; damage to the nerves. Symptoms are pain, tingling in hands and feet, losing sensitivity for hot and cold, and pain. This can result in accidental injuring of the feet or hands. Since small blood vessels are damaged, circulation of the feet and legs is poor, and those injuries heal slowly, or they don’t heal at all. That is called diabetic ulcer and can lead to loss of extremities.

Further, small blood vessels in the retina of the eye suffer and this leads to early blindness if disease is left unchecked and uncontrolled. Another organ which suffers from changes to blood vessels are the kidneys. People with Type 2 Diabetes suffer from kidney failure if the disease is left without proper management.

• BMI and overweight

We already discussed that one of the best predictors of Type 2 Diabetes is overweight or obesity, with more than 90% people having both. With obesity, insulin resistance develops, and it causes Diabetes Mellitus. But for these people, losing weight is not that simple. It is proved that in obesity, fat cells produce hormones called leptin and ghrelin. The first hormone gives sign to the brain that we are full, the other one that we are hungry. In prolonged obesity there is also decreased sensitivity to leptin, and that is why these people feel hungry. With this situation, it is very difficult to lose weight, but easy to get metabolic problems such as diabetes itself (12).

• Infections

It is familiar that high blood sugar weakens the immune system. It also slows the healing process and increases possibility for infection of the injured spots. Also damage to blood vessels causes less food and oxygen to come to the cells so they lack in energy.

If blood sugar level is higher than 11.1 mmol/L, glucose appears in the urine. This decreases antibacterial activity of the urine, and makes urine nice environment for bacteria to live. This is the basis for frequent bladder infections. All urinary tract infections (UTI infections) are important to treat, since bacteria can spread and damage the kidneys. It is presented by urinary urgency, frequency, night urination, and incontinence (15).

• Inflammation

Research showed evidence that obesity is associated with a low level chronic inflammation state of the whole body. From that, further is extracted that the metabolic an immune pathways cross paths and that a deeper link can be established. This link seems to be found in that immune pathways blocks the insulin receptor path and interferes with the insulin function, and thereby enhancing the insulin resistance (23).

To add further, diabetes is linked to numerous diseases with most notable ones being:

• Coeliac disease
• Polycystic ovary syndrome
• Thyroid disease
• Dental health
• Carpal tunnel syndrome and
• Sleep apnea etc.

Figure 4. Scientifically proved relations of diabetes with other diseases.

Genes associated with increased diabetes risks

Family heritage has a big influence on occurring Diabetes Mellitus Type 2 in a individual. According to the American Diabetes Association, risk of developing Type 2 Diabetes is:

• 1 in 7 if one of your parents was diagnosed before the age of 50
• 1 in 13 if one of your parents was diagnosed after the age of 50
• 1 in 2 if both of your parents have diabetes.

It is important to understand that DM type 2 is caused by both genetic and environmental factors. Several gene mutations are linked to a higher diabetes risk. But we need to differ RISK from CAUSE. Risk means that not all people who have mutation will get disease. But many people with diabetes have mutations.

Sometimes these genes do not represent a risk for developing diabetes, but for obesity, and by being obese on a long run you can develop diabetes eventually.

Several mutations of genes that are involved in controlling glucose levels can increase your risk of Type 2 Diabetes. Some of these genes control:

• Production of glucose
• Production and regulation of insulin
• How glucose levels are sensed in the body

And these genes are:

• TCF7L2, which affects insulin secretion and glucose production,
• ABCC8, which helps regulate insulin
• GLUT2, which codes transport protein which move glucose into pancreas gland
• GCGR, which codes glucagon hormone, which regulates glucose in between meals.

The genetic aspect is important, yet this doesn’t mean that you cannot reduce the risk by changing you lifestyle and habits. It is important that you keep the balance between healthy diet and physical activity – which means your weight. Physical activity does not reduce the risk only by keeping your weight in the normal range, but it is proved that physical activity itself reduce insulin resistance and can prevent or delay Type 2 Diabetes (18).

People who have no family history of diabetes, yet have this disease, probably have some lifestyle factors that can activate genetic risk factors, that lead to the development of type 2 diabetes:

• BMI higher than normal, overweight or obese
• Sedentary lifestyle.
• Not enough exercise (it can help lower blood glucose)
• Having high blood pressure, high levels of fats (triglycerides) in the blood, low HDL (“good” cholesterol), history of cardiovascular disease
• Having diabetes during pregnancy
• Depression or polycystic ovarian syndrome
• Advancing age (over 45 years) (20)

The connection between diabetes risk and intelligence

To assume that there is relation between IQ and BMI or diabetes may benefit in future family planning and interventions at an early age. However, this feat is not so easy to prove, as factors that can influence both overlap and differ. So in order to make sure that these do not interfere in findings a lot of research and huge amount of data needs to be gathered. Despite that, some early findings suggest that there might be a connection between IQ and chronic diseases like diabetes (33).

What scientists know for now is that chronic low blood sugar, peripheral insulin resistance, accumulation of by-products, and increase in pro-inflammatory substances in body coupled with vascular brain damage are all potential reasons that can increase the risk of lower cognitive function. This means that your memory, processing and thinking abilities can deteriorate if you suffer from diabetes or obesity (4, 22).

One thing that can be interesting is that both diabetes/obesity and intelligence have another thing in common – genetic factors. It remains to be seen if these can have a relationship and impact on each other on that level. This could prove beneficial in predicting risks and applying proper preventive measures and family planning.

ADD and ADHD and the association to developing diabetes

Connection to ADHD and obesity, and consequently Diabetes Mellitus Type 2 is sure to captivate scientists as it is shown that kids that often present with ADHD have obesity. While this relation is better established for obesity, same research needs to be done for Type 2 Diabetes.          

Some studies have shown that children diagnosed with ADHD were more likely to develop Type 2 Diabetes down the line than kids without ADHD. As much as the correlation between these two is interesting, proof that ADHD can cause Type 2 Diabetes in kids is something that needs further research (25).

Association between ADHD and Type 2 Diabetes might go both ways, as one research study reveals that in group of tested kids with Type 2 Diabetes were more likely to develop ADHD than kids without Type 2 Diabetes. These results also need further academic proof but show a new perspective to both of these conditions (24).

As for Type 1 Diabetes, low blood sugar which leads to coma, a serious complication of this condition has been shown to increase the risk for ADHD in young people (26). This, along with new proof of correlation between parents diagnosed with Type 1 Diabetes and their children having a higher risk for developing ADHD makes for an exciting new field from which function of our body can be researched (28).

Important thing to consider about this is that both of these diseases occur because a lot of factors come into play, environmental and genetic as well. Mapping of genes involved in both is an on-going process so link to these two on genetic level is a possibility which requires huge resources and many trials to establish.

Diabetes risk associated to your social circle

There are some theories that support opinion that people who one chooses as closest friends influence their future BMI and body weight. One study performed in high school on students showed that there was a significant link between obesity and a student’s circle of friends.

For example, if a borderline overweight student had slim friends (average BMI 20), there was a 40 % chance the student’s BMI would fall in the future and a 27 % chance it would increase. But if a borderline overweight student had obese friends (average BMI 30), there was a 15 % chance the student’s BMI would decline and a 56 % chance it would increase (33).

The signs of diabetes or pre-diabetes

An early diagnosis and therapy are the best ways to combat diabetes no matter which type. Pre-diabetes as a state is when your blood sugar is at level not enough to be diagnosed to diabetes but higher than normal. It normally doesn’t present itself with any symptoms, but people can experience thirst, blurred vision or fatigue. If so these pre-diabetes signs can mean that you need testing for diabetes and you should consult your doctor.

As for diabetes, different types have different special signs and symptoms but what is characteristic for both is the 3 Ps:

• Polyuria (frequent urination)
• Polydypsia (thirst)
  • Polyphagia (eating a lot, hunger)

• Listed below are most common signs and symptoms related to each diabetes type. Early signs of diabetes often give you a warning that something is wrong with your body, and it is wise to seek medical attention and test for diabetes.

  Table 4.  The difference between signs and symptoms of Diabetes Mellitus Type 1 and 2

How to test if you have diabetes?

Smelling or tasting urine is not a precise method to determine whether your urine contains sugar or not. This because sugar appears in urine when its concentration in blood is 11 mmol/L or more, and that is probably not enough for our senses to feel it.

A way better method is using urine test strips. They are easy to use and do not cost much. You need a midstream urine sample. Dip the strip into the urine sample, remove it and wait for one minute or so. A change in color indicates the presence of sugar in your urine. 

Another type of test you can do either in clinic or at home is blood glucose level. It is direct sign of your body’s ability to metabolise sugar. This can be further improved with tests like oral glucose tolerance test (OGTT). This test, strictly approved by doctors and done in clinic is meant to show how your body uses sugar ingested during meal, and if there is problem in sugar metabolism.

Apart from that, diabetes patients need to look out for the ketone levels, which can be measured in clinic or at home. These get high if your body is ‘starving’ for sugar which cannot be utilised so your body starts using fat stored as fuel. Ketones are toxic in high amounts and can lead to complications like diabetic coma or ketoacidosis.

It is highly beneficial that patients with diabetes keep their blood lipids in check, which helps manage vascular damage caused by diabetes.

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Figure 5. Testing for diabetes can be done in laboratory or from home

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Diabetes home testing, Home tests, blood sugar levels, testing for diabetes

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Home test kits that can be used to check your diabetes status

All of these home test kits are very easy to use. You get a small device, lancet and sometimes glucose test strips for testing in the package. By stinging tip of your finger with a lancet and applying gentle pressure so that drop of blood appears, you make a sample for analysing.

A drop of blood should be pressed against the strip. Then you put the strip with blood drop in device, and it will calculate your blood sugar level. Some of home test kits show some other blood substances than glucose, such as ketone bodies.

By doing test before breakfast, when you wake up, you can measure how your therapy works during the night. Also important is to follow how your body manages sugar 2 hours after each meal, so that you know that blood sugar level is back to normal. Checking your blood sugar level, a couple times a day is recommended for proper management of disease, helps planning your meals and therapy.

It is also a good suggestion to do a home test kit if you feel bad, or have symptoms such as increased thirst, headaches, trouble concentrating, blurred vision, frequent peeing, and weak or tired feeling. This means that your blood sugar level is probably high, and signs of hyperglycemia appear (27).

Also, some symptoms like dizziness, feeling of extreme hunger, headache, confusion, inability to concentrate, sweating, shaking, blurred vision and personality changes can indicate that you have a low blood sugar level (29).

In this situation it is good to know that these symptoms come from a abnormal blood sugar level. by doing these easy home test kits you can be sure if this is your problem, and fix it immediately, or visit your doctor.