Diabetes

I. CONDITION

Diabetes mellitus is a desease in which the level of glucose in blood is high because the body can not release nor use proper amount of insulin. Base on PERKENI’s (Indonesian Endocrinology Society) diagnostic criteria in 2006, someone has diabetes when glucose level in blood reach more than 126 mg/dL after all night fasted (abstain from food) and more than 200 mg/dL in sudden test. The glucose level in the blood increase after meal and back to normal 2 hours later. Normal glucose level in the morning after all night fasted is 70-110 mg/dL. Glucose level usually less than 120-140 mg/dL in 2 hours after consuming food, drink something with sugar in it or other carbohydrate.

Normal glucose level in blood tends to increase slightly and progressively in the age of 50, especially for those who physically inactive. Increasing glucose level in blood after eat or drink will stimulates pancreas to produce insulin. Insulin controls increasing blood sugar level by allowing the glucose move from bloodstream into the cells. When inside the cells it converted to energy, which used immediately or stored as fat or glycogen until it is needed.

This condition can also cause by poor response of muscle, fat and liver cells to insulin. Glucose biled up in blood stream and urin, cause excessive urination, thirst and hunger, and difficulties in fat and protein metabolism. Diabetes Mellitus is different to Diabetes Insipidus which cause by lack of vasopressin hormon, the hormone than control production of urine.

Diabetes is most common in adults over 45 years of age; in people who are overweight or physically inactive; in individuals who have an immediate family member with diabetes; and in people of African, Hispanic, and Native American descent. The highest rate of diabetes in the world occurs in Native Americans. More women than men have been diagnosed with the disease.

II. PANCREAS

Pancreas in an organ which has an important role in diabetes. In this disease, pancreas doesn’t produce enough insulin to process glucose in blood stream. Scientists believe that immune system abnormality that arise from childhood is the cause of the disease. This known by diabetes type 1. In diabetes type 2, pancreas still produces insulin but can not harmonize insulin production to the need for processing glucose in the blood.

 

Pancreas is a glandular organ that secretes digestive enzyme into the intestine and produce insulin and glucagon to the bloodstream. These two hormones have very important role in metabolism of carbohydrate. Pancreas is attached to duodenum, the upper portion of small intestine. A large main duct, the duct of wirsung, collects pancreatic juice and empties into the duodenum. Enzymes active in the digestion of carbohydrates, fat, and protein continuously flow from the pancreas through these ducts. Their flow is controlled by the vagus nerve and by the Hormones secretin and pancreozymin which are produced in the intestinal mucosa. When food enters the duodenum, secretin and pancreozymin are released into the bloodstream by secretory cells of the duodenum. When these hormones reach the pancreas, the pancreatic cells are stimulated to produce and release large amounts of water, bicarbonate, and digestive enzymes, which then flow into the intestine.

Insulin and glucagon are produced by one type of cells named Beta cells, which spread all over the pancreas, in the part called islet of Langerhans. Langerhans is the name of a Germany doctor, Paul Langerhans. He is the one who in 1869 explain the function and existence of this part. In adult normal human pancreas, exist 1.000.000 islet of Langerhans.

There are five kind different cells in the islet of Langerhans, three of these cells (alpha, beta and delta) produce three important hormones. Alpha cells produces glucagon, Beta cells produces insulin and Delta cells produces somatostatin. The role of fourth and fifth kind of cells, D1 cells and PP cell still uncertain. The demage of beta cells as insulin producer will cause type 1 diabetes.

Islet of Langerhans secretes insulin hormone and glucagon to control glucose level in blood. Insulin stimulate cells to absorb the glucose from blood, transform it to energy and use or store it. Insulin is a simple protein in which two polypeptide chains of amino acids are joined by disulfide linkage. insulin help transfer glucose into cells so that they can oxidize the glucose to produce energy for the body. Insulin is secreted when the level of blood glucose level rises-as after a meal.

In adipose (fat) tissue, insulin facilitates the storage of glucose and its conversion to fatty acids. Insulin also slow the breakdown of fatty acids. In muscle it promotes the uptake of amino acids for making proteins. In the liver it helps convert glucose into glycogen and it decreases gluconeogenesis (the formation of glucose from noncarbohydrate source).

Glucagon has opposite effect of insulin. This pancreatic hormone stimulates liver to release it’s stored sugar (glycogen) to bloodstream. Glucagon will be released when glucose level in blood is to low or too much insulin produced and cause significant decrease in glucose level. This mechanism control blood glucose level in the body. Islet of Langerhans is also secrete, in very small amount, somastostatin which inhibits the production of insulin and glucagon. Pancreas also produce pancreatic polypeptide hormone whose role is uncertain.

Inadeqate production of insulin is responsible for diabetes mellitus condition. Severe diabetics require periodic injection of insulin, which is extracted from the pancreas of pigs, sheep, and oxen. Insulin was first isolated as a pancreatic extract in 1921 by the Canadian scientists Sir Frederick G. Banting and Charles H. Best. By the early 1980s certain strains of bacteria had been genetically modified to produce human insulin.

II. THE CAUSE AND TYPE OF DIABETES

Person with diabetes produce not enough insulin to maintain normal glucose level in bloodstream or produce enough insulin but not correctly responsed by the body cells. In diabetes melitus, body cells can not absorb glucose in bloodstream because of low insulin amount. Glucose stay in blood and can not be processed to energy nor glycogen. When the glucose-laden blood passes through the kidneys, the organs that remove blood impurities, the kidneys cannot absorb all of the excess glucose. This excess glucose spills into urine, accompanied by water and electrolytes-ions required by cells to regulate the electric charge and flow of water molecules across the cell membrane. This cause frequent urination to get rid the additional water drawn into the urine; excessive thirst to trigger replacement of lost water; and hunger to replace the glucose lost in urination. Additional symptoms may include blurred vision, dramatic weight loss, irritability, weakness and fatique, and nausea and vomiting.

Insulin helps control glucose level which needed for many chemical process in the body. In a healthy person, when food being digested (1), glucose blood level increase (2). Pancreas secretes insulin (3) to allow body cells to absorb glucose. Insulin also facilitates the transformed of glucose to glycogen and stored it in the liver(4)and in the muscle that will be burned when needed. Several hormones control secretion of insulin which lead to decreasing blood glucose level.(5) These hormones stimulate pancreas to stop insulin secretion.(6)

In person with diabetes mellitus, pancreas produces not enough insulin or the body cannot response and use insulin. After eat or drink (A), pancreas produce too little insulin (B), to provide energy, the body had to burn fat instead of glucose as source of energy. This process produce poisonous chemical compound named ketone which most of it spill into the urine (D) and the rest still remain in the bloodstream (E), cause the life-threatening condition named ketoacidocis. If the body can not use insulin properly unabsorbed glucose will remain in bloodstream and will impair several important chemical function of the body, included fend of infection and fight deseases.

1. DIABETES TIPE I

Diabetes is classified into two types. In Type 1 diabetes, formerly called insulin-dependent diabetes mellitus (IDDM) and juvenile-onset diabetes, the body does not produce insulin or produces it only in very small quantities. Symptoms usually appear suddenly, typically in individuals under 20 years of age. Most cases occur around puberty—around age 10 to 12 in girls and age 12 to 14 in boys.

Type 1 diabetes is an autoimmune disease, that is, a condition in which the body’s disease-fighting immune system goes awry and attacks healthy tissues. In the case of Type 1 diabetes, the immune system mistakenly attacks and destroys insulin-producing cells, known as beta cells, in the pancreas. Scientists believe that a combination of genetic and environmental factors somehow triggers the immune system to destroy these cells. Scientists have so far identified 20 genes that play a role in Type 1 diabetes, although the exact function of these genes is still under investigation. Environmental factors, such as certain viruses, may also contribute to the development of the disease, particularly in people who already have a genetic predisposition for the disease. Type 1 diabetes also can result from surgical removal of the pancreas.

The body forms energy from several sources. Glucose from carbohydrate is the main resource that processed by the body become energy. If not available, the body take an alternative source of energy and process fat and protein in the muscle. Processing fat become energy will form an acidic substance called ketone. This substance billed up in blood stream and this will make blood become acidic. This condition is called Diabetic Ketoacidosis.

Early simptomps of diabetic ketoacidosis are excessive thirst and frequent urination, nause, vomitting, fatique dan stomachache (especially in children). Shortness and deeper breath usually occur because the body try to fix the acid level of the blood. Breath odor become aceton like smell. Without proper treatment, diabetic ketoacidosis can cause coma, sometimes for a few hours. Person with type 1 diabetes may develop ketoacidosis if pass one insulin injection, or experiencing stress cause by infection, accident or serious illness.

 

2. TYPE 2 DIABETES

In Type 2 diabetes, formerly known as non-insulin-dependent diabetes mellitus (NIDDM) and adult-onset diabetes, the body’s delicate balance between insulin production and the ability of cells to use insulin goes awry. Symptoms characteristic of Type 2 diabetes include those found in Type 1 diabetes, as well as repeated infections or skin sores that heal slowly or not at all, generalized tiredness, and tingling or numbness in the hands or feet.

The onset of Type 2 diabetes usually occurs after the age of 45, although the incidence of the disease in younger people is growing rapidly. Because symptoms develop slowly, individuals with the disease may not immediately recognize that they are sick. A number of genes are involved in Type 2 diabetes. In addition, there is a strong relationship between obesity and Type 2 diabetes. About 80 percent of diabetics with this form of the disease are significantly overweight. The cause of diabetes are also:

• High level of corticosteroid,
• Pregnancy (diabetes gestasional), will curred after birth
• drugs, demage the pancreas or inhabit formation or efect of insulin

IV. COMPLICATION

If left untreated, diabetes mellitus may cause life-threatening complications. Type 1 diabetes can result in diabetic coma (a state of unconsciousness caused by extremely high levels of glucose in the blood) or death. In both Type 1 and Type 2 diabetes, complications may include blindness, kidney failure, and heart disease. Diabetes can cause tiny blood vessels to become blocked; when this occurs in blood vessels of the eye, it can result in retinopathy (the breakdown of the lining at the back of the eye), causing blindness. Diabetes mellitus is the leading cause of new cases of blindness in people aged 20 to 74.

In the kidneys, diabetes can lead to nephropathy (the inability of the kidney to properly filter toxins from the blood). About 40 percent of new cases of end-stage renal disease (kidney failure) are caused by diabetes mellitus. High level of glucose in blood cause the tendency of increasing fat substance in bloodstream. This condition will lead to arteriosclerosis; blockages of large blood vessels.  This can lead to many cardiovascular problems, including high blood pressure, heart attack, and stroke. Although these conditions also occur in nondiabetic individuals, people with diabetes are two to four times more likely to develop cardiovascular disorders.

Complex substance formed by glucose on the inner lining of blood vessels will make the walls of arteries become thicken and easy to leak. Thickening blood vessel will reduce blood flows especially for the blood which flows to skin and nerve. Bad blood circulation cause by thickening macro blood vessel can cause brain injuries, heart, and leg blood vessel (makroangiopati), whereas thickening in micro blood vessel will cause eye, kidney, nerve and skin injury and lead to difficulty to heal wound.

Diabetes mellitus, without proper treatment,  can cause long period process of complication. The most dangerous complication in diabetes is heart attack and stroke. High level  of glucose in bloodstream will slowly demage the blood vessels of the body.  Person with diabetes has to aware if experiencing heavy cough without any particular cause (influenza or asthma). That kind of cough can be cause by demage of the blood vessel around the heart or demage of the heart itself. Person with diabetes can experiencing heart attack without feeling any pain in the chest because nerves around the heart have been demaged.

In the kidneys, diabetes can lead to nephropathy (the inability of the kidney to properly filter toxin from the blood). About 40 percent of new cases of end-stage renal disease (kidney failure) are cause by diabetes. Blockage of the macro blood vessel in diabetics cal lead to many cardiovascular problems, including high blood pressure, heart attack, and stroke. Although these condition also occur in nondiabetic individuals, people with diabetes are two to four times more likely to develop cardiovascular disorders.

Diabetes mellitus may also cause loss of feeling, particularly in the lower legs. This numbness may prevent a person from feeling the pain or irritation of a break in the skin or of foot infection until after complication have developed, possibly necessitating amputa of the foot or leg. Burning pain, sensitivity to touch, and coldness of the foot, condition collectively known as neuropathy, can also occur. Other complication include higher-risk pregnancies in diabetic women and a greater occurrence of dental disease.

V. TREATMENT AND DIAGNOSE

Diabetes is detected by measuring the amount of glucose in the blood after an individual has fasted (abstained from food) for about eight hours. In some cases, physicians diagnose diabetes by administering an oral glucose tolerance test, which measures glucose levels before and after a specific amount of sugar has been ingested. Other tests have been developed to search specific antibody (protein in imune system which attacks outside substance) which only exist in person with diabetic. This test can detect type 1 diabetes in earlier stage and reduce the risk of complication.

Once diabetes is diagnosed, treatment consists of controlling the amount of glucose in the blood and preventing complications. Depending on the type of diabetes, this can be accomplished through regular physical exercise, a carefully controlled diet, and medication.

Individuals with Type 1 diabetes must receive insulin, often two to four times a day, to provide the body with the hormone it does not produce. Insulin cannot be taken orally, because it is destroyed in the digestive system. The amount of insulin given is different for each individual, depend on several factor like level individual physical activities, diet, and the presence of health disorders. Typically, individuals with Type 1 diabetes use a meter several times a day to measure the level of glucose in a drop of their blood obtained by pricking a fingertip. They can then adjust the dosage of insulin, physical exercise, or food intake to maintain the blood sugar at a normal level. People with Type 1 diabetes must carefully control their diets by distributing meals and snacks throughout the day so as not to overwhelm the ability of the insulin supply to help cells absorb glucose. They also need to eat foods that contain complex sugars, which break down slowly and cause a slower rise in blood sugar levels

Although most persons with Type 1 diabetes strive to lower the amount of glucose in their blood, levels that are too low can also cause health problems. For example, if a person with Type 1 diabetes takes too much insulin, it can produce low blood sugar levels. This may result in hypoglycemia.

Faint, shakiness, confusion, nause, vomiting and anxiety are symptoms of hipoglicemia. The first organ influenced by this condition is brain. Person with hipoglicemia can experiencing psychological disorder like change of personality or in some case seems like he/she was drunk. Hipoglicemia is cause by hyperinsulin, either because overdose or too much insulin produce by the body. In hyperinsulin, glucose level in blood decrease sharply and the body can not adjust this fall. This condition will cause suply of glucose to the body cells, and especially to the brain become inadequate. Severe hypoglycemia can cause permanent brain demage, coma and death.

Reactive hipoglicemia occurs in the persons in stress or depression. Immediately treatment need to be done when symptoms of hypoglycemia happens. Consume simple sugar like candy, honey, fruit juice or syrup can reduce the risk of hypoglycemia.

In order to control insulin levels, people with Type 1 diabetes must monitor their glucose levels several times a day. In 1983 a group of 1,441 Type 1 diabetics aged 13 to 39 began participating in the Diabetes Control and Complications Trial (DCCT), the largest scientific study of diabetes treatment ever undertaken. The DCCT studied the potential for reducing diabetes-related complications, such as nerve or kidney disease or eye disorders, by having patients closely monitor their blood sugar levels four to six times a day, maintaining the levels as close to normal as possible. The results of the study, reported in 1993, showed a 50 to 75 percent reduction of diabetic complications in people who aggressively monitored and controlled their glucose levels. Although the study was performed on people with Type 1 diabetes, researchers believe that close monitoring of blood sugar levels would also benefit people with Type 2 diabetes

Injected insulin, not exactly the same with natural insulin produce by the body. Thin situation, in several patients, can lead of the formation of antibody that destroy the replacement insulin. This antibody reduce effectiveness of injected insulin and the patient force to increase the dosis. Insulin injection can cause alergic reaction in the skin.

For persons with Type 2 diabetes, treatment begins with diet control, exercise, and weight reduction, although over time this treatment may not be adequate. People with Type 2 diabetes typically work with nutritionists to formulate a diet plan that regulates blood sugar levels so that they do not rise too swiftly after a meal. A recommended meal is usually low in fat (30 percent or less of total calories), provides moderate protein (10 to 20 percent of total calories), and contains a variety of carbohydrates, such as beans, vegetables, and grains. Regular exercise helps body cells absorb glucose—even ten minutes of exercise a day can be effective. Diet control and exercise may also play a role in weight reduction, which appears to partially reverse the body’s inability to use insulin.

Overweight and fat will cause insulin resistence. This fact explain why diet and excercise are the best way to manage type 2 diabetes. Decrease body weight and increase muscle mass will reduce the fat and help body to use insulin better. Recent research conclude that there is a close relationship between diabetes and the point where fat piled up in the body. If fat accumulate in the hip and part of stomache, the risk of diabetes is higher. Several ways to prevent fat to be piled up:

1. Healthy way of live, orderly and dicipline
2. Regular and measured excercise
3. Do not watch TV or work in front of computer too long
4. Reduce candy, chocholate or snack with high salt
5. Reduce junk food, with high level of calories, carbohydrate and fat
6. Consume a lot of fruit and vegetables

For some people with Type 2 diabetes, diet, exercise, and weight reduction alone may work initially, but eventually this regimen does not help control high blood sugar levels. In these cases, oral medication may be prescribed. If oral medications are ineffective, a person with Type 2 diabetes may need insulin doses or a combination of oral medication and insulin. About 50 percent of individuals with Type 2 diabetes require oral medications, 40 percent require insulin or a combination of insulin and oral medications, and 10 percent use diet and exercise alone.

VI. LONG TERM AND CONTINOUS OBSERVATION

Person with diabetes have to check the glucose blood level regularly, in the morning before breakfast, two hours after meal and night before sleep. Beside these regular tests, the person should do this test in a particular condition like hipoglicemia, pregnancy etc. This test is an effective means to decide the daily amount of insulin needed.

Haemoglobin is a part of red blood cells which transport oxygen. One type of haemoglobin is HbA. HbA1c is specific subtype of HbA. Glucose sticks to haemoglobin to form Glycosylated Haemoglobin which called A1c or HbA1c. The more glucose in the blood the more faster HbA1c formed in the blood. This situation cause high level of HbA1c1 in the bloodstream. HbA1c is the best single measurement to know the risk of tissue demage cause by high level of glucose in the bloodstream especially in nerve and minor blood vessel in eyes and kidney.