Discussion:

A long term condition “require ongoing medical care, limits what person can do, and is likely to
last longer than one year defined” by WHO. Diabetes mellitus refers to a group of metabolic
disorders characterized by the phenotype of hyperglycemia. Several different types of diabetes
exist and are caused by a complex interaction of genetic predisposition and environmental
factors. Depending of etiology of DM, the factors contributing to hyperglycemia include defects
in insulin secretion, decreased glucose utilization (insulin resistant), and increase glucose
production. The pathophysiologic changes in multiple organ system secondary to metabolic
dysregulation of DM impose a tremendous burden on the individuals and the healthcare system,
and chronic hyperglycemia often associated with secondary damage in multiple organ system,
especially kidney, eyes, nerve and blood vessels. In United states, DM is leading cause of end-
stage renal disease (ERSD), adult-onset, and non-traumatic lower-extremity amputations from
atherosclerosis disease. Type 2 DM is a group of heterogeneous and multifactorial complex
disorders characterized by combination of impaired insulin secretion (beta cell dysfunction) and
insulin resistant, several environmental risk factors, inflammatory, genetics and metabolic
defects in insulin action or secretion give rise to phenotype of hyperglycemia in T2DM. usually
type 2 diabetes symptoms takes several years to develop unlike Type 1 diabetes, however DM
present commonly with classical triad of symptoms:
Polyuria (and nocturia): glycosuria causes osmotic diuresis.
Thirst: due to fluid loss.
Weight-loss: fat and muscle breakdown secondary to insulin deficiency and fluid depletion.
Others: tiredness, mood changes, blurred vision, bacterial and fungal skin infections, genital
thrush, impaired immune resistant and tissue ischemia.
The pathogenesis of T2DM is multifactorial but however two defects characterize it: 1) insulin
resistant and 2) beta cell dysfunction. Insulin resistant is a cardinal feature of T2DM, it is
inability of insulin to exert its biological effects at physiological concentrations, it’s usually
suspected in young individuals who developed diabetes driven by insulin resistant due to obesity
and ethnicity, insulin resistant does not explain the whole story of T2DM; others especially older
patients, develops diabetes despite being non-obese they may have beta cell dysfunction.
Possible mechanisms behind beta cell dysfunction: genetic, or acquired (Glucose toxicity, lip
otoxicity, obesity, and amylin deposition). The consequences of insulin resistant are:
Skeletal muscle: decreased insulin-mediated glucose uptake.
Adipose tissue: Failure to suppress lipolysis, leading to increased circulating FFA.
Liver: Reduced inhibition of hepatic glucose output, and increased FFA stimulate
gluconeogenesis, and glucose and triglycerides production.
Vasculature: endothelial dysfunction, increased stiffness of arteries, increased coagulation.
Hyperuricemia: insulin reduces renal clearance of uric acid, preserved in insulin resistant.
 Possible complications of diabetes:
Microvascular complications:
1)diabetic nephropathy
2)diabetic ocular disease
1)Retinopathy
2)Cataract
3)Glaucoma
3)diabetic neuropathy
1)Peripheral
2)autonomic
Macro-vascular complications:
1)CVS, hypertension, IHD, MI, and atherosclerosis
2)Cerebrovascular, Stroke
3)Peripheral vascular disease, intermittent claudication, Gangrene, Diabetic foot problems liker
ulcer.
According to American Diabetes Association (ADA) and World Health organization (WHO),
diagnostic criteria of diabetes include the following:
1.A fasting plasma glucose greater than or equal to 126mg/dl.
2.A random plasma glucose greater than or equal to 200mg/dl.
3.A 2-hour plasma glucose greater than or equal to 200mg/dl, during oral glucose tolerance test
with a loading dose of 75 mg.
4.A glycated hemoglobin (HbA1C) greater than or equal to 6.5%.
Prediabetes is defined as:
1.A fasting plasma glucose between 100 and 125mg/dl
2.A 2-hour plasma glucose between 140 and 199 mg/dl during oral glucose tolerance test.
3.HbA1C between 5.7% and 6.4%.
Measures to reduce incidence of diabetes
Lifestyle modifications:
 Reducing weight by 5%-10% (Ideal BMI <25kg/m2)
 Reducing fat intake to <30% of energy intake.
 Reducing saturated fat intake to <10% of energy intake,
  Increasing fibers to >15g/1000g
 Decreasing refined grains and increasing whole grains.
 Healthy oils like olive oil.
 At least 30min/day of aerobic and resistant exercises.
Pharmacological: Metformin (Biguanides), pioglitazone (thiazidolidinedione), tolbutamide
(sulfonylureas), repaglinidine (Meglinitide), Acarbose (α-glucosidase inhibitor), stigaliptin (DPP
inhibitors), Empagliflozin (SGLT2 inhibitors) …
Myths are common stories or ideas among people they have more traditional base than a
scientific base, they are used to preserve the culture from distortion and people use it simplify the
complex and generalize the specific, in a complex disease like diabetes it’s not surprising that
many myths are there to identify who is candidate for the disease. Healthcare provider should
know about patient’s health beliefs and myths to know the gap between their and patients’
knowledge about the disease to give a treatment acceptable to patients’ expectations and needs.
Examples of myths about diabetes are T2DM only occur in elderly but the truth is even
scientifically T2DM is no longer as late-onset diabetes because it is now common in young
people due to increased incidence of obesity and unhealthy lifestyle, eating too much sugar cause
T2DM but truth is, it doesn’t directly cause diabetes but it may accelerate it incidence, and many
more. It is the role of the health care professionals to educate the patient about diabetes, risk
factors and its complication and to encourage the patient to obtain a healthy lifestyle, the health
care professionals should work as a team with patient to educate the patient about the disease and
empowering and supporting patient to change into a healthy lifestyle. Health promotion
programs have strategies for education of patients, early detection, effective of control of the
disease and prevention. It is the government role to identify those who are undiagnosed and
establishing policies that support lifestyle and dietary choices. Emotional distress and chronic
exposure to life stress have been implicated in onset of diabetes. Stress only is responsible for
poor control of diabetes. Many psychological problems are associated with engaging in health
damaging behavior, non-adherence to medications, maintenance of physical activity, unhealthy
diets, and interfering with regular self-monitoring of blood glucose levels. In 1552 B.C. the first
know symptom of diabetes was mentioned when Hesy-Ra, and Egyptian physician described a
polyuric state of unknown disease. In 150 AD a Greek physician Aretaeus give a clear
description of diabetes particularly diabetes type 1’melting down of the flesh and limbs into
urine’, also was the first one to use the term ‘diabetes’ from the Greek word for a syphon (the
fluid does not remain in the body, but uses the body as a channel to leave it). The Hindu
Physicians, Charak and sushurt, between 400 and 500 BC, were probably the first to recognize
the sweetness of urine, diagnosis was made tasting urine or not that ants congregated round it.
They also noted that disease was prevalent in those who were indolent, overweight and
gluttonous, and who enjoying sweet and fatty foods. The word mellitus from the Latin word
meaning ‘honey’ was first added by Thomas willis in 1675 in Britain who rediscovered
sweetness of the urine, however the Edinburgh-trained surgeon john Rollo in 1809 was the first
one applies adjective mellitus. In 1815, the French chemist Michel Chevreul proved that the
sugar in urine was glucose. In 1843, Glucose metabolism was clarified Claude Bernard in
France. In June 1889, the concept of “internal secretions” (the role of pancreas of removing
diabetogenic toxins, or producing an internal secretion for controlling of Carbohydrates
metabolism) publicized by the physiologist Charles - É douard Brown - S é quard. In 1893,
Gustave Laguesse suggested that internal secretion was produced by ‘islands’ of cells scattered
through the parenchyma of pancreas, which had been previously discovered by 22-year-old paul
Langerhans, Langerhans discovered this cluster of cells but didn’t speculated about their
function, Laguesses named them “islets of Langerhans”. In 1909 the Belgian Jean de Meyer
name the internal secretion insulin from the Latin word “island”. The burden of diabetes mellitus
is rising globally, at a much faster rate, in developed region like western Europe. The gender
distribution is equal, and the incidence peak at around 55 years of age. According to study done
in USA about the incidence of T2DM from the 1970s to the 1990s, the participants were free of
diabetes mellitus (n=3140, mean age 47 years, 1587) attended a routine examination in the
1970s, 1980s, and 1990s, the diabetes was identified as fasting plasma glucose more than 7.0
mmol/l. the incidence of diabetes compared across decades for participants between 40 and 55
years old of age in each decade. The age-adjusted 8 years-incidence rate was 2.0%, 3.0%, and
3.7% among women and 2.7%, 3.6%, and 5.8% among men in the 1970s, 1980s, and 1990s.
respectively. Data from 751 studies including 4,372,000 adults from 146 of 200 countries,
estimated that Global age-standardized diabetes prevalence increased from 4.3% in 1980 to 9.0%
in 2014 in men, and from 5.0% to 7.9% in women. The prevalence of diabetes rose from 108
million in 1980 to 422 million in 2014. In 2017, 462 million individuals were affected by T2DM
corresponding to 6.28% of the world population (4.4% of those aged 15-49 years, 15% of those
aged 50-69, and 22% of those aged 70+), the prevalence rate was 6059 cases per 100,000 in
2017. The global prevalence of diabetes is projected to increase to 7079 individuals per 100,000
by 2030. In 2021, 537 million adults (20-79 of age) have diabetes the total number of diabetic
patients is projected to rise to 643 million by 2030 and 783 million by 2045, in previous
references it was mention that it was mentioned that the number of cases will rise to 435 million
or (+360 million) in 2030 but in 2021 it was much higher than that. The increase in diabetes
prevalence is due to population growth, aging, ethnicity, obesity, lifestyle (physical activities and
high energy diet..), socioeconomic states, and urbanization. In study done in US about the risk
factor of diabetes for 2013-2016 for adults aged 18 years or older diagnosed with diabetes shown
that; smoking (21.6% tobacco users, 15.0% cigarrete smoking, 36.4% quit smoking), 89.0%
were overweight or obese (27.6% overweight, 45.8% obese, 15.5% extreme obese), Physically
inactive about 38.0% defined as less than 10 minute a week of moderate or vigorous activity,
50.0% had an A1C level of 7.0% of higher (22.3% A1C value of 7.0% to 7.9%, 13.2% A1C
value of 8.0% to 9.0%, 14.6% A1C value of more than 9.0%), high cholesterol 43.5% had a non-
HDL level of 130 mg/dl or higher (22.4% level of 130 to 159 mg/dl, 11.2% level of 160-189
mg/dl, 9.9 level of 190 mg/dl or higher).