Type 1 Diabetes [ Insulin Dependent Diabetes Mellitus]

Type 2 Diabetes is a metabolic disorder resulting from the body's inability to produce enough, or to properly use, insulin. It has previously been called non-insulin-dependent diabetes mellitus (NIDDM) or adult onset diabetes. Type 2 diabetes is the most common type of diabetes, accounting for 90 to 95 percent of diabetes cases. It is a chronic disease with no known cure. Although type 2 diabetes is typically found in adults older than 40, there has been an increase in the number of cases of type 2 diabetes in children and adolescents. The rise is mostly attributed to the increased rates of obesity and decreased physical activity.

Normally, glucose in the blood stream enters your body's cells with the help of insulin, a hormone produced by the pancreas that acts like a gatekeeper. Without insulin, glucose cannot pass through the cell wall, and the cell must rely on less efficient fuels for energy. In type 2 diabetes, the body is still able to produce insulin. The problem begins when the body's cells do not react efficiently to the insulin produced by the pancreas, a condition called insulin resistance. In people with insulin resistance, the pancreas first makes extra insulin to maintain a normal blood sugar. Eventually, as the body's insulin resistance progresses, the pancreas is unable to keep up with the demand for more and more insulin, blood glucose levels rise, and the person develops type 2 diabetes.

Being overweight, especially in the abdomen and at the waistline, greatly increases the risk of diabetes. Excess fat makes it harder for the cells to respond to insulin. And being inactive further reduces the body's ability to respond to insulin. Also, children who have reached puberty are more likely to develop the disease than younger children, probably because of normal rises in the levels of hormones that can cause insulin resistance during this stage of rapid growth and physical development. Uniquely, this type of diabetes may be prevented or delayed by following a program to eliminate or reduce risk factors - particularly losing weight and increasing exercise. The exact cause of type 2 diabetes still remains unknown. However, there is an inherited genetic susceptibility which causes it to run in families. Although a person can inherit a tendency to develop type 2 diabetes, it usually takes another factor, such as obesity, to bring on the disease.

Risk factors for type 2 diabetes include:

  • age (incidence increases with age)
  • family history of diabetes
  • being overweight
  • not exercising regularly
  • being a member of certain racial and ethnic groups, such as African-Americans, Hispanic Americans, and Native Americans
  • a low level HDL (high density lipoprotein, the good cholesterol)
  • a high triglyceride level

Symptoms

The following are the most common symptoms for type 2 diabetes. However, each child may experience symptoms differently. Symptoms may include:

  • frequent infections, especially yeast and fungus, that are not easily healed
  • frequent urination
  • extreme hunger but loss of weight
  • unusual thirst
  • blurred vision
  • extreme weakness and tiredness
  • irritability and mood changes
  • nausea and vomiting
  • dry, itchy skin
  • tingling or loss of feeling in the hands or feet

Some people who have type 2 diabetes exhibit no symptoms. In fact, about half of all persons with diabetes do not know they have the disease.

Diagnosis

Diabetes is diagnosed by testing the blood for sugar levels. Blood is taken in the morning after you have fasted overnight. Typically, the body keeps blood sugar levels between 70 and 100 milligrams per deciliter (mg/dL), even after fasting. If a blood sugar level after fasting is greater than 125 mg/dL, diabetes is diagnosed.

Children and teens with insulin resistance or type 2 diabetes are also more likely to develop hypertension (high blood pressure) or abnormal levels of blood fats (cholesterol and triglycerides). When these problems cluster together in a person, doctors call this metabolic syndrome (formerly known as Syndrome X). People with metabolic syndrome have a greater risk of developing heart disease, stroke, and other health problems. It is possible help to prevent type 2 diabetes by maintaining an ideal body weight, especially if there is a family history of diabetes. Diet and exercise have been shown to delay the onset of diabetes in people who are in the early stages of insulin resistance, identified by borderline blood sugar levels. People with blood sugar levels that are between 100 and 125 mg/dL are sometimes said to have pre-diabetes. The one of the medications used to treat type 2 diabetes - metformin (Glucophage) – may be prescribed to offer some additional protection for people with blood glucose levels that are in this range.

Treatment

The goal of diabetes treatment is to keep blood-sugar levels as close to normal as possible. Emphasis is placed on the control of blood sugar (glucose) by monitoring levels, regular physical activity, meal planning, and routine healthcare. Treatment of diabetes is an ongoing process of management and education that includes not only the child with diabetes, but also family members. In most people with type 2 diabetes, treatment begins with weight reduction through diet and exercise. A healthy diet for a person with diabetes is low in cholesterol, low in total calories, and nutritionally balanced with abundant amounts of whole-grain foods, monounsaturated oils, fruits and vegetables. A daily multivitamin is recommended for most people with diabetes.

Often type 2 diabetes can be controlled through losing weight, improved nutrition, and exercise. Sometimes, these are not enough and either oral medications and/or insulin or adjunct injected medications must be used. Oral Medicines for type 2 diabetes include:

  • Metformin (Glucophage) which improves insulin resistance in the muscle tissues and liver

  • Sulfonylureas, including Glyburide (DiaBeta, Glynase, Micronase), Glipizide (Glucotrol) which increase the amount of insulin made and released by the pancreas

  • Repaglinide (Prandin) & Nateglinide (Starlix) which cause a burst of insulin release with each meal

  • Thiazolidinediones, including Rosiglitazone (Avandia) and Pioglitazone (Actos) which decrease the conversion of fat to glucose, and which improve insulin resistance

  • Acarbose (Precose) and Miglitol (Glyset) which delay the absorption of sugars from the intestine

Injected medicines for type 2 diabetes include:

  • Insulin which adds to your own insulin supply. When you have enough insulin, you can adequately process glucose despite having insulin resistance. Treatment plans that include very long-acting Glargine insulin (Lantus) or Detemir insulin (Levemir) and very short-acting Lispro insulin (Humalog) or Aspart insulin (Novolog), are frequently the most successful ways for people with advancing type 2 diabetes to control their blood sugar. To accommodate eating patterns that vary, doses of very short-acting insulin can be adjusted depending on the amount of carbohydrates taken in with each meal.

  • Exanatide (Byetta) and pramlintide (Symlin), which slow your digestion and reduce your appetite for large meals, making blood sugar more manageable. Exanatide also causes a burst of insulin to be released from your pancreas with each meal.

Medications used to treat type 2 diabetes can have side effects. The most common side effects of metformin are nausea and diarrhea, however these are less likely to occur if the drug is taken with meals. The major side effects of sulfonylureas, repaglinide, nateglinide and insulin are low blood sugar levels (hypoglycemia) and weight gain. Rosiglitazone and pioglitazone frequently cause weight gain and can cause leg swelling or worsen heart failure. They also may cause inflammation of the liver, so liver tests should be monitored. Acarbose, which is taken before each meal, can cause excessive gas and bloating, as can other medicines that slow digestion.

During treatment, some of the laboratory tests used routinely to evaluate diabetes include:

  • Fasting glucose - a test of your blood sugar level after you have not eaten for several hours

  • Hemoglobin A1C - indicates how close to average your blood glucose has been during the previous two months

  • Blood creatinine & urine microalbumin – to check for evidence of kidney disease
  • Lipid profile (cholesterol, triglycerides, high-density lipoprotein (HDL) and low- density lipoprotein (LDL) cholesterol) - to evaluate the risk of atherosclerosis

An individual’s treatment plan is likely to require adjustment over time. Insulin resistance increases with age, and the cells in the pancreas that make insulin are likely to wear out as the pancreas tries to keep up with the body's extra insulin needs. After several years of treatment, the majority of people with type 2 diabetes require more than one medicine to keep their blood sugar controlled. About one out of three people with type 2 diabetes eventually requires insulin.

Complications

The prognosis in people with type 2 diabetes varies depending on how well an individual modifies the risk of complications Diabetes can cause long-term complications in some people, including heart disease, stroke, vision impairment, and kidney damage. Diabetes can also cause other problems in the blood vessels, nerves, and gums. Disability due to blindness, amputation, heart disease, stroke and nerve damage may occur. Four to six out of every 100 people with type 2 diabetes become dependent on dialysis treatments because of kidney failure.

Extremely high blood sugar levels can lead to a dangerous complication called Hyperosmolar Syndrome, or Hyperosmolar Coma. Hyperosmolar syndrome is a life-threatening form of dehydration that can result from untreated high blood sugar levels. Hyperosmolar syndrome can occur along with a severe acute illness, such as a stroke; it can also happen when poor fluid intake triggers dehydration. In some cases, hyperosmolar coma is the first sign that a person has type 2 diabetes. This dangerous condition causes confused thinking, weakness, nausea or more extreme symptoms such as seizure and coma.

These problems don't usually show up in kids or teens with type 2 diabetes who have had the disease for only a few years. However, they can occur in adulthood in some people with diabetes, particularly if their diabetes hasn't been well controlled.

There is a tremendous amount one can do to decrease their individual risk of complications. A healthy diet, regular exercise, careful attention to blood sugar levels, and reducing your other risks of heart disease all can help to maintain optimal health and prevent complications.

Useful Links:

Type 2 Diabetes in Children
(http://www.childrenwithdiabetes.com/d_0n_d00.htm)

Children with Diabetes – Type 2
(http://www.childrenwithdiabetes.com/type2/t2_whatistype2.htm)

American Diabetes Association
(http://www.diabetes.org/type-2-diabetes.jsp)

National Diabetes Information Clearinghouse
(http://diabetes.niddk.nih.gov/)

American Dietetic Association
(http://www.eatright.org)

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