Diabetes - Endocrinology Overview
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List of Diabetes-Related Disorders Treated in the Department
Type 1 Diabetes (“Juvenile” Diabetes)
Type 1 diabetes, sometimes called “juvenile” diabetes, begins most commonly in childhood or adolescence. In this form of diabetes, the body produces little or no insulin. In the United States, about 3 out of 1000 people develop Type 1 diabetes. This diabetes usually has a sudden onset, and occurs when the immune system, which is the body’s defense against infection, is triggered to destroy insulin-producing cells in the pancreas. Type 1 diabetes is also known as “insulin dependent diabetes", as individuals with this condition need daily insulin injections.
Type 2 Diabetes (“Adult Onset” Diabetes)
Type 2 diabetes is more common than Type 1 diabetes. In fact, about 90% of all diabetes found in the United States is Type 2 diabetes. Type 2 diabetes usually develops in adulthood, hence its name “adult onset” diabetes, and most often in people who are overweight and do not exercise. It has a more gradual onset than Type 1 diabetes. In this version of diabetes, the pancreas may still able to produce enough insulin, but the body becomes less sensitive to the effects of insulin so that it is unable to work properly, a state known as “insulin resistance.” Individuals with type 2 diabetes should start with changes to their diet and lifestyle, but many people with this type of diabetes require oral medication to help control the raised blood glucose levels. Some people with Type 2 diabetes may eventually require insulin injections if oral medication fails.
Gestational diabetes (GDM) is diabetes that occurs during pregnancy in a woman who has not previously had diabetes. This happens in about 3-4% of all pregnancies. Gestational diabetes usually begins in the second half of pregnancy, and goes away after the baby is born. This makes it different from type 1 and type 2 diabetes which are permanent.
If gestational diabetes is not properly controlled, it can lead to harmful effects on both the mother and the baby. Gestational diabetes carries an increased risk of congenital problems such as heart defects, and a slightly higher chance of stillbirth or death as a newborn. Having high blood glucose levels during pregnancy can cause the baby to grow larger, potentially making delivery difficult. In some cases, a caesarean section may be necessary. After delivery, these babies are more likely to develop jaundice (yellowing of the skin and whites of the eyes). There may also be an increased risk of these babies developing Type 2 diabetes or being overweight later in life. Mothers with gestational diabetes are more likely to develop the same condition in future pregnancies, and are also at a higher chance of developing Type 2 diabetes later in life.
A woman may or may not be screened for gestational diabetes during the course of her pregnancy, depending on the presence of some risk factors including:
- Maternal obesity
- Maternal age >35 years
- Having a past history of gestational diabetes
- Having previously given birth to a large baby
- Having previously had a stillbirth late in pregnancy
- Having a family history of Type 2 diabetes
- Having an African American, Hispanic, Native American, Asian or Pacific Islander background
Women with these risk factors may be screened for gestational diabetes either at their first doctor visit, or between their 24th to 28th week of pregnancy. This is performed with an oral glucose tolerance test.
The most important part of treatment for gestational diabetes is strict control of blood glucose levels. For many women, this will include a special meal plan, exercise and regular blood glucose testing. If lifestyle changes are insufficient, the woman may require daily insulin injections. Diabetic pills are generally not used in pregnancy as they may not be safe for the baby. About six weeks after delivery, the woman is rechecked to see if she still has diabetes. In most cases, glucose levels normalize on their own. However, the woman is still at higher risk for developing diabetes later in life. This risk can be reduced by regular exercise and maintaining a healthy diet.
Diabetes following pancreatic disease or surgery
The pancreas is an organ hidden behind the stomach. It produces juices and enzymes that flow into the intestine to mix with food. The enzymes digest fat, protein and carbohydrates so that they can be absorbed by the intestine. The pancreas also produces insulin, the hormone which regulates the amount of glucose in the blood stream. The pancreas can be severely damaged by certain types of pancreatic disease, for example pancreatitis. In this condition, there is an extensive inflammation of the pancreas, usually caused by gallstones or alcohol. Most of the pancreas may also have to be surgically removed if a pancreatic tumor is found to be present. In these cases, patients may develop diabetes after such extensive damage or removal of the pancreas. They usually require daily insulin injections, just like people with Type 1 diabetes.
Metabolic syndrome and insulin resistance
Metabolic syndrome is a collection of health risks that increase your chances of developing heart disease, stroke and diabetes. It is also known as insulin resistance syndrome, dysmetabolic syndrome or syndrome X. Insulin resistance means that the body is less sensitive to the effects of insulin. This often leads to the development of diabetes. About 20% of all people in the United States have the metabolic syndrome, and the number of people with this syndrome increases with age.
Patients meet the criteria for metabolic syndrome if they have three or more of the following health risks:
- A waistline of = 40 inches in men and = 35 inches in women
- A blood pressure of; = 130/80 mmHg
- A fasting glucose level = 100 mg/dL
- A fasting triglyceride level = 150 mg/dL
- A high density lipoprotein level (HDL) = 40 mg/dL in men and = 50 mg/dL in women
This syndrome is caused by a combination of our genetic make-up as well as lifestyle choices including eating food with too much saturated fat, becoming overweight and not exercising enough. Hence, a healthy diet, exercise and weight loss are the main ways to prevent and treat this condition.
“Pre-diabetes” is an asymptomatic condition that occurs before individuals develop Type 2 diabetes. These people have blood glucose levels that are higher than normal, but not high enough to be classified as diabetes. This condition is important to recognize because treating it may prevent Type 2 diabetes as well as its complications, especially heart disease and stroke. People who should be tested for pre-diabetes include individuals with the following risk factors: obesity, over 45 years of age, a history of gestational diabetes and belonging to one of the following ethnic groups (African American, Hispanic, Native American, Asian or Pacific Islander). This condition is diagnosed by doing a fasting glucose level, or performing an oral glucose tolerance test. People who are found to have pre-diabetes need to lose weight, exercise more and stop smoking. If they are found to have high blood pressure or elevated cholesterol levels, these should be treated as well.
Complications of diabetes: Type 1 and Type 2
Eye complications (Retinopathy)
Diabetic retinopathy is a leading cause of blindness. It occurs when diabetes damages the tiny blood vessels inside the retina, the light sensitive tissue at the back of the eye. A healthy retina is needed for good vision, and if it is progressively damaged; can result in visual loss and even blindness. Retinopathy derived from diabetes usually affects both eyes. Everyone with diabetes should get a comprehensive eye exam at least once a year. If diabetic retinopathy is diagnosed, treatment can be performed by an eye care professional to prevent its progression.
Kidney complications (Nephropathy)
Diabetic nephropathy is kidney damage due to chronically raised blood glucose levels. The kidney usually acts like a filtering system; but once it is damaged, it allows substances like protein to leak out into the urine. If this is allowed to progress, it eventually leads to chronic renal failure. There are few symptoms in early nephropathy, but in the late stages people may experience swelling (edema) of their feet, nausea, lethargy and a decrease in the amount of urine passed. It is very important for people with diabetes to be checked at least once a year for nephropathy, so that the necessary treatment can be given to try and prevent its progression. Treatment usually consists of medication to control blood glucose levels and treat high blood pressure, if hypertension is present. Currently, diabetes is the single most common cause of chronic renal failure in the United States. People with chronic renal failure eventually either require dialysis, or a kidney transplant.
Nerve complications (Neuropathy)
Diabetic neuropathies are a family of nerve disorders caused by diabetes. They most commonly develop in the hands, arms, feet and legs, causing numbness, pain or weakness. They can also develop in other organ systems, such as the heart, the urinary tract and sex organs. This can lead to dizziness or faintness when standing up, problems with urination, and impotence in men. The risk of developing diabetic neuropathy increases with time and with poor control of blood glucose levels. The best way to prevent neuropathy is to keep blood glucose levels as close to normal as possible.
Stomach complications (Gastroparesis or Gastropathy)
Gastroparesis is a disorder in which the stomach takes too long to empty its contents. Diabetic gastropathy is due to neuropathy of the nerves supplying the stomach. Symptoms include heartburn, abdominal bloating, nausea and vomiting. The risk of developing gastropathy derived from diabetes increases with chronically raised blood glucose levels. Treatment may include improving diabetic control, using drugs to help promote stomach muscle contractions, special meal plans and food changes.
Feet complications (Foot ulcers and deformities)
Feet complications are common in people with diabetes. These may include blisters, ulcers, wounds, and deformities. This is because high blood glucose levels damage the nerves in the feet, causing you to lose feeling in them. This means that you may not be aware that you have hurt yourself. In addition, diabetes damages the tiny blood vessels in the feet, meaning that any blister or cut that develops in your feet will also take much longer to heal. Slow healing wounds are at a higher risk for infection, which also tends to spread more quickly in diabetics. This means that diabetics are at a much higher risk of losing their limbs if an amputation is required to treat a life-threatening infection. All diabetics should inspect their feet every day for wounds, and seek treatment promptly if any injury is found.