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DIABETES MELLITUS

 

 

Diabete

All sugars we absorb through food are transformed into glucose which is the main form of energy for our muscles and other organs, and it is the only one for the brain. The concentration of glucose in the blood is defined as glycemia and it is measured in mg/dL or mmol/L.Since nourishment is the main source of glucose, we would expect the levels of glycemia to be unstable. In reality, our body has a fine-tuned mechanism that regulates these levels. The main protagonist of this mechanism is our liver . When glycemia levels increase (for example after meals), the liver captures the excess glucose and stores it under the form of another substance called glycogen . When glycemia levels decrease (for example on an empty stomach), the liver converts the glycogen into glucose and releases it into blood circulation.The muscles, brain and kidneys can only store small amounts of glucose and therefore they obtain their requirement from the blood, generating a continuous exchange between the liver and other organs that is regulated by the pancreas .The pancreas is the largest gland in the body and it is involved in many processes, among which the production of two hormones: insulin and glucagon .Insulin is produced by the beta cells of the pancreas and it has many functions.One of these is the transportation of glucose into the cells where it is then utilized or stored.Glucagon is produced by the alpha cells of the pancreas and it has the function of stimulating the release of glucose (conversion of glycogen into glucose). Diabetes mellitus is a chronic disease where this regulating mechanism does not function properly. Glycemia, or the concentration of glucose in the blood, increases ( hyperglycemia ), it is caused by the reduced secretion of insulin by the pancreas or by the combination of reduced insulin secretion and the resistance of peripheral tissues to insulin.Part of the excess sugar is eliminated by the kidneys through the urine (called ( glycosuria ),In diabetes, glycemia does not increase only after meals, but also on an empty stomach because glucose is produced by the liver. Hyperglycemia can cause damage to practically all tissues ( complications ).

 

 

GLYCEMIC GOALS FOR ADULTS WITH TYPE 1 AND TYPE 2 DIABETES

 

(Italian Standards of Medical Care in Diabetes 2007 - AMD, SID, GISED)

 

HbA 1c <7,0% ^ (<6,5% for individual patients)

Fasting plasma glucose and preprandial plasma glucose 90-130 mg/dl °

Postprandial plasma glucose* <180 mg/dl °

 

^ Referenced to a non diabetic range of 4,0-6,0% using a DCCT-based assay
* Postprandial glucose measurements should be performed 2 hours after the beginning of the meal
° Fasting plasma glucose values <110 mg/dl and postprandial plasma glucose values <145 mg/dl should be reached in type 2 diabetes (IDF 2005)

 

 

KINDS OF DIABETES

 

 

diabetes

Diabetes is mainly classified in two forms: Diabetes type I and Diabetes type II .

Diabetes type I (or insulin-dependent, IDDM) is characterized by the progressive destruction of pancreatic beta cells that produce insulin. Its onset occurs usually before the age of thirty.
Various factors have been attributed to its cause:

  1. generic factors;
  2. immune factors (relating to a particular defense of our body against infection);
  3. environmental factors (which depend on the action against our body by bacteria, viruses, chemical substances).

The destruction occurs through an autoimmune mechanism. A triggering event of an environmental nature (virus, toxins, etc.) begins the autoimmune process. Antibodies are formed that attack the pancreatic cells. We say that the body has lost immune tolerance with the pancreatic cells and therefore produces autoantibodies or “self-destruction” molecules.
Diabetes type II (non-insulin dependent diabetes mellitus, NIDDM) is characterized by a reduced or absent production of insulin as well as by a resistance of the body tissues to the action of insulin which continues to be produced by the pancreas. In this case genetic factors are important, but genetic predisposition must be combined with acquired or environmental factors in order for the disease to manifest itself. When we refer to acquired factors we mean age, diet, excess weight and obesity, fat distribution, dyslipidemia, stress, drugs, alcohol abuse, and scarce exercise.The persistence of exposure to these factors explains the importance of age.

Diabetes type II is highly diffused and is calculated that up to 3% of the population is affected.
Regardless of the kind of diabetes manifested, the diagnostic methods are the same: evaluation of glycemia on an empty stomach and OGTT (Oral Glucose Tolerance Test).
Once diabetes is diagnosed, only self monitoring (at-home measuring of glycemia via glucometers ) allows glycemia levels to be verified, thus permitting the physician to suggest the right kind of intervention (therapeutic or change in life style) in order to delay the onset of complications.


     
     

 

 

 

Diabete

  Definition of terms

 

Glucose : A simple sugar obtained through hydrolysis scission of carbohydrates ingested with food; it is the body’s resource for obtaining quick energy after meals.

Glycemia : The concentration of glucose in the blood. It is the most important value the diabetic patient must control. Maintaining normal glycemia levels is the purpose of glycemic self-monitoring and is the best way for the diabetic patient to avoid complications.

Liver : The largest gland of the human body that plays a major role in metabolism and has a number of functions in the body, including glycogen storage, plasma protein synthesis, and detoxification. It also produces bile which aids in digestion.

Glycogen : The form in which glucose is stored in the liver and muscles. Glycogen is the main energy reserve immediately available to the body.
Pancreas : Large gland located horizontally behind the stomach. It produces an external secretion containing numerous digestive enzymes and two internal secretions: insulin and glucagon, respectively secreted by the beta and alpha cells of the islets of Langerhans.

Insulin : A hormone secreted by the beta cells of the islets of Langerhans in the pancreas at an average of 0.6 U/Kg/24h. It signals the liver to block glucose production. By reaching peripheral tissues through the blood, it helps glucose to penetrate the cells where it is then transformed into energy.

Glucagon : A hormone secreted by the alpha cells of the islets of Langerhans in the pancreas. It signals the liver to free glucose in the blood. Artificial glucagon is used to combat severe hypoglycemia.

Diabetes mellitus : Medical term for diabetes. Of ancient Greek origin, “mellitus” means sweet and derives from the fact that the urine of diabetes patients has a sweet taste given the high concentrations of blood glucose passed into the urine.

Hyperglycemia : Excessive increase of sugar in the blood. If not correctly treated, in the long-term it can cause permanent damage to organs such as the eye, kidneys, and to the limbs (circulation).

Glycosuria : The presence of glucose in the urine. It is sign of an abnormal condition given that glucose should not be present in urine. It “overflows” from the blood to the urine only if it reaches a certain level in the blood (180mg/dl), otherwise known as the renal threshold.
Complications : classified as acute and chronic:

  • Acute complications:
     
    Hypoglycemia – low concentration of glucose in the blood under “normal” levels (80mg/dl). There are three levels of hypoglycemia: mild (80-50mg/dl), moderate (50-40mg/dl) and severe (‹ 40mg/dl).
    Ketoacidosis – increased concentration of ketone bodies (chemical by-products the body produces when cells burn fat instead of sugar) in all body liquids. Being metabolic acids, they alter the physiologic pH level with consequences such as coma and death.
    Hyperosmolar coma – state of extreme confusion or stupor corresponding to severe dehydration; caused by the lack of insulin and the presence of high blood glucose levels yet without ketoacidosis. Hyperosmolar coma derives from severe dehydration in diabetes type II patients, and usually in the elderly, more than from the poor control of blood glucose levels.
  • Chronic complications:
     
    the various diseases a diabetic patient risks developing due to the persistence of hyperglycemia in the blood over long periods of time. Several organs can be affected: eyes (retinopathy), kidneys (nephropathy), nerves (neuropathy), and the circulatory apparatus. In some cases these are typical diseases of the diabetic patient and in others they are diseases or conditions that can also affect non-diabetic subjects (i.e. cardiovascular problems, obesity). Recent studies confirm that the risk of complication is notably reduced by maintaining stable glucose levels in the blood.

 

Diabetes type I : a chronic condition in which the pancreas produces little or no insulin due to the destruction of pancreas beta cells by a faulty immunology process (autoimmune disease). The body is no longer able to use glucose (sugar in the blood) to produce energy. Unfortunately the symptoms of diabetes type I usually appear when the destruction of beta cells has practically been completed. The symptoms are: increase of frequency and quantity of urine, weight loss, hunger, thirst. In order to successfully control diabetes, the patient must administer several insulin injections daily, follow a strict diet and exercise as much as possible. The patient must also frequently control glycemia levels in the blood. Usually the onset of the disease occurs in childhood and rarely after 40 years of age. For this reason it is also known as “juvenile diabetes.”

Diabetes type II : the most common form of diabetes mellitus. It is estimated that about 90-95% of people affected with diabetes have the type II kind. Contrary to insulin-dependent diabetes where the pancreas does not produce insulin, those affected with non-insulin dependent diabetes mellitus are able to produce insulin in the pancreas. Nevertheless, their body does not produce a sufficient quantity and their cells have a certain resistance to insulin action. People with non-insulin dependent diabetes mellitus often are able to control their condition by simply losing weight, following an adequate diet and exercising regularly. If this is not enough, they must use oral hypoglycemic drugs together with diet and exercise. In some cases it is also necessary to administer insulin externally. Generally non-insulin dependent diabetes mellitus strikes those over 40 years of age and is called “adult diabetes.” Most of these patients are overweight.

OGTT (oral glucose tolerance test): an oral test to measure glucose metabolization in the bloodstream. It determines the presence or tendency towards diabetes. Performed at the medical office, a blood sample is taken on an empty stomach. The patient is then given a glucose solution to drink and other blood samples later are taken at fixed intervals. The concentration of sugar (glycemia) is measured in each blood sample. The resulting curve informs us how the patient responds to glucose assumption.

Self-monitoring : measurement of the concentration of glucose in the blood, done by the patient at home using capillary blood. Self-monitoring is performed by pricking the fingertip (there are less nerve endings near the edges so pricking hurts less) to obtain a small amount of blood. The sample is placed on a disposable “strip” and the glucose in the blood triggers a chemical reaction that is read and translated by an instrument called the “glucometer.”

Glucometer : also called “glycemia reader” or “reflectometer,” is an instrument that measures the glucose level in the blood through the use of a strip upon which a small drop of blood is placed or absorbed. The instrument measures the quantity of glucose present in the blood, evaluating the variation of color created by the chemical reaction set off by the glucose on the strip (reflectometer) or by measuring the variation of the electrical current provoked by the glucose (with potentiometric technology).

 

 

 

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