Clinical

Causes and consequences of diabetes

Linda Nazarko, Consultant Nurse, Ealing and Harrow Community Services, Visiting Fellow London South Bank University, Visiting Lecturer, Kings College, London and BJHCA Board Member

Abstract
The incidence of diabetes in the UK has reached epidemic proportions. Healthcare assistants (HCAs) and assistant practitioners (APs) will regularly encounter people who have been diagnosed with diabetes, and those who have the symptoms of diabetes but who have not been formally diagnosed. This series aims to enable HCAs and APs to improve their knowledge and understanding of diabetes. Key words n Diabetes type 1 and 2 n Insulin n Hyperglycaemia

What is diabetes?
Diabetes mellitus literally means sweet diabetes. Many years ago, before it was possible to test urine for sugar, physicians diagnosed by tasting the urine. The high sugar content of diabetic urine gave it a sweet taste. Diabetes mellitus is a chronic disease caused by inherited and/or acquired deficiency in the production of insulin by the pancreas, or by the ineffectiveness of the insulin produced. Such a deficiency results in increased concentrations of glucose in the blood, which in turn damage many of the bodys systems, in particular the blood vessels and nerves (WHO, 2009b). Below is a classification of diabetes (based on WHO, 2009c): Diabetes mellitus n Type 1 diabetes (T1D) formerly known as insulindependent diabetes (IDDM) n Type 2 (T2D) formerly known as non-insulin dependent diabetes (NIDDM) n Other types of diabetes n Diabetes that occurs during pregnancy (gestational) Pre-diabetes n People who have abnormal blood sugars who have not developed diabetes but are at risk of becoming diabetic High diabetic risk n Previous abnormality of glucose tolerance, e.g. past history of gestational or steroid induced diabetes n People at risk of diabetes such as those people with an identical twin who has type 1 diabetes.

t the beginning of the 21st century, 5% of the world population had diabetes. The growth rate of the disease, which was doubling with each generation, indicated that it could become one of the major health issues of the century (Stout, 1997). In 1935, 15 million people worldwide had diabetes; in 2004, 150 million had developed the disease (Patel, 2003). This is predicted to rise to 366 million by 2030 (World Health Organization (WHO), 2009). In the UK, the number of people diagnosed with diabetes has risen from 1.4 to 2.5 million since 1996, and it is estimated that there will be 4 million people with diabetes in the UK by 2025 (Diabetes UK, 2009). The WHO have described this as an epidemic of diabetes (WHO, 2009a). Diabetes reduces life expectancy by 1015 years, but actual deaths from the illness are underestimated because diabetes can lead to other diseases, which may be recorded as the cause of death (Department of Health (DH), 2009). People from certain groups, such as older people, black people and Asian people, have a higher risk of diabetes (Perry, 2002; Diabetes UK, 2009).

How insulin acts

Insulin is a hormone produced in the pancreas (specifically within clusters of pancreatic cells called islets of Langerhans), and is the bodys mechanism for regulating blood glucose levels. The pancreas is part of the endocrine system, which is a system of glands that release hormones directly into the blood stream as a chemical signal to help control cell functioning. When we digest carbohydrate, the body breaks it down into simple sugars (glucose). Glucose is then absorbed by the intestine into the blood supply, causing blood glucose levels to rise. The pancreas responds to this by producing insulin, which is released directly into the blood stream and acts quickly. Insulin allows the body to use the glucose for energy, and convert the surplus into glycogen and fat, thus

Aims
This article is one of a series aiming to enable the healthcare assistant (HCA) and assistant practitioner (AP) to understand diabetes not simply as a disorder of carbohydrate metabolism, but also as a chronic disease that affects every aspect of a persons body. In this article an overview of diabetes, its causes and effects will be provided as follows: n Review the anatomy and physiology of diabetes n Discuss type 1 insulin-dependent diabetes n Discuss type 2 non-insulin-dependent diabetes

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Figure 1. Illustration of the frequency of diabetes diagnosis form of type 1 diabetes is most common in children but can also occur in adults. More common in adults is the slowly-progressive form of diabetes, sometimes referred to as latent autoimmune diabetes adult (LADA). People with slowly-progressive type 1 diabetes may have sufficient beta cells to prevent significant problems for many years, but their diabetic control can rapidly deteriorate when the body is stressed by infection, trauma or surgery. People with slowlyprogressive type 1 diabetes will eventually become insulin dependent. The causes of type 1 diabetes are not yet fully understood, although there appear to be several factors of importance. Type 1 diabetes is primarily an autoimmune disease, and people with autoimmune diseases such as Graves disease, Hashimotos thyroiditis and Addisons disease have an increased risk of developing diabetes. Some are more genetically predisposed to developing the antibodies that lead to the destruction of the beta cells than others; viral infections such as congenital rubella, mumps, Coxsackies B3 or B4 can trigger diabetes in people who are genetically susceptible to it (Leslie et al, 2006). Environmental factors are also thought to play a part in the development of type 1 diabetes, but the relationship between the environment and diabetes is not completely understood. In some cases diabetes can develop in people with no evidence of autoimmune disease, and where the cause is not yet understood. This is described as idiopathic diabetes.

preventing the amount of glucose in the blood from becoming too high. In healthy non-diabetics, this process maintains a stable blood glucose level in the region of 38 mmol/L. Glycogen is stored in the liver and muscles. When blood glucose levels fall, the glycogen in the liver is broken down and converted back into glucose. This process is called glycogenolysis. When glycogen stores have been exhausted, the body begins to break down fat to produce glucose. When fat stores have been exhausted, the body then begins to break down muscle in a process known as gluconogenesis.

Type 1 diabetes
Type 1 diabetes is most commonly diagnosed before the age of 40 (Williams and Pickup, 2005). Less than 10% of adults have type 1 diabetes (DH, 2009). Type 1 is a disease that leads to the destruction of the beta cells of the pancreas. In type 1 diabetes no insulin is produced, and often the rate of pancreatic beta cell destruction is rapid (Williams and Pickup, 2005). This rapidly progressive

Type 2 diabetes
Over 90% of people with diabetes have type 2 diabetes (DH, 2009). One person in 20 is now diabetic, and 145 000 new cases were diagnosed in UK alone in 20082009. Figure 1 (based on Diabetes UK, 2009) illustrates the frequency of diabetes diagnosis. Different ethnic groups have different incidences of diabetes, as described in Figure 2. In general, men are more likely to develop type 2 diabetes than women. The risk of diabetes increases with age, and approximately 20% of elderly Caucasians are diabetic (Meneilly and Tessier, 1995). One research study found that 25% of care home residents were diabetic (Sinclair et al, 2001). Type 2 diabetes is more common in overweight people; the incidence of the disease in the US is twice that of the UK. It has been described as A collision between thrifty genes and an affluent society (Group and Tuomi, 1997) In the past, the food supply for humans was not guaranteed. Harvests failed and food could be in short supply. People who could survive on smaller amounts of food could survive when food was in short supply. Now in affluent societies food is plentiful and people eat more and exercise less. this has led to an explosion in obesity. As the population becomes more obese the incidence of type 2 diabetes increases. At the onset of type 2 diabetes,

General population Pakistani Irish Indian Cahines Black Caribbean Black African Bangladeshi 0% 2% 4% 6%

Men Women

8%

10%

Figure 2. Incidence of diabetes (types 1 and 2) by ethnic group and gender (Based on Diabetes UK, 2009)

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the pancreatic beta cells produce insulin normally, but the body is unable to use the insulin released into the bloodstream effectively. Normally, circulating insulin is taken up by glucose receptors found in muscle, fat and the liver. The bodys reduced ability to use insulin effectively is known as insulin resistance (Donnelly and Garber, 1999). Insulin resistance leads to high blood glucose levels. The beta cells respond to high blood glucose levels by producing more insulin in an effort to reduce blood glucose levels. This excessive glucose production fails to maintain normal blood glucose levels, and the pancreas works increasingly hard. Eventually, the beta cells are exhausted by the overproduction of insulin and begin to fail. The blood sugar rises. Figure 3: Example of central obesity

Insulin resistance syndrome

Insulin resistance is worse in overweight people. It is also linked to a number of other abnormalities such as high levels of insulin (hyperinsulaemia) central obesity (Figure 3), high cholesterol, hgh blood pressure, and changes to blood clotting. These abnormalities are known as insulin resistant syndrome (IRS) (Took, 1999), and increase the risk of strokes and heart attacks.
iStockphoto/PaulCowan

Hyperglycaemia
An excess of sugar in the blood, which is symptomatic of diabetes, is called hyperglycaemia. Hyperglycaemia causes: n Lack of energy. This is because glycolysis, the process that enables sugar to be broken down into adenosine triphosphate (ATP), is affected. ATP enables cells and tissues to obtain energy n Lack of reserves. This is because glycogen, which is normally stored in the liver, is broken down. High blood glucose prevents the body from drawing on emergency reserves of glycogen n Increased risk of tissue damage. This is because hyperglycaemia leads to high levels of circulating amino acids and urea. n Diabetic coma.

n A quarter of all people with type 2 diabetes suffer nephropathy (damage or disease to the kidneys) though they usually die of cardiac problems before they reach end stage renal failure n Increases the risk of blindness. Almost everyone who has been diabetic for 20 years has retinopathy.

Diabetic risk factors

The risk of developing diabetes varies according to ethnic group, weight and genetic factors. Diabetic risk factors include: n Obesity body mass index (BMI) more than 30kg/m2 n Parent, sibling or child with type 2 diabetes n Hyperlipidaemia (high cholesterol) n Hypertension n Coronary artery disease n Cerebrovascular disease n Peripheral neuropathy n Peripheral vascular disease n History of developing diabetes during pregnancy n History of having a baby weighing more than 4kg/8lb 8oz n History of skin infections.

Consequences of diabetes
Undiagnosed or poorly-treated diabetes can lead to premature death. More than 20 000 people in the UK die prematurely each year because of diabetes. According to Diabetes UK (2009), the disease cuts life expectancy by 1015 years. Undiagnosed or poorly controlled diabetes has the following effects: n Increases the risk of cerebrovascular disease and stroke by twelve times n Increases the risk of coronary heart disease by twelve times n Increases the risk of peripheral neuropathy (damage to the peripheral nerves) by 16 times

Clinical features
People who have diabetes may display certain clinical features: n Thirst n Weight loss n Tiredness and irritability n Rapid deterioration of vision

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The rate at which diabetes deteriorates can be related to ethnicity. Twenty years after diagnosis of type 2 diabetes most Caucasians require insulin therapy. The disease progresses more rapidly in other ethnic groups. Ten years after diagnosis most Asian diabetics will require insulin therapy (Burden, 1996).

Key Points
n The number of people with diabetes is rising. n The incidence of diabetes rises with age. n Around 10% of adult diabetics have type 1 diabetes and 90% have type 2 diabetes. n Diabetes reduces life expectancy by 10-15 years. n Older people and people from certain ethnic backgrounds have a higher risk of diabetes. n Diabetes increases the risk of blindness, renal failure, stroke and circulatory problems.

Conclusion
Diabetes is one of the major health issues of the 21st century. The number of people with diabetes is growing, but the growth of diabetes is not inevitable. There is much that can be done to reduce the risk of diabetes and to manage diabetes well. The next article of this series will discuss ways in which HCAs and APs can help people to manage diabetes and reduce diabetic risk factors. BJHCA
Burden AC (1996) Quality of care, past present and future. Indo Asian Diabetics practical ways of improving care. Practical Diabetes International Supplement: 13(3): 523 Department of Health (2009) Diabetes. Department of Health, London. http://tinyurl.com/yjvg2xv (Accessed 10 October 2009) Diabetes UK (2009) Diabetes in the UK 2009: Key statistics on diabetes. Diabetes UK, London. http://tinyurl.com/yzemvsz (Accessed 26 October 2009) Donnelly R, Garber A (1999) Proceedings of worldwide insulin resistance editorial board meeting. Diabetes, obesity and metabolism: 1 (supplement 1): SVS16 Group C, Tuomi T (1997) Non insulin dependent diabetes a collision between thrifty genes and an affluent society. Annals of Medicine 29(1): 3753 Leslie RD, Williams R, Pozzilli P (2006) Clinical review: Type 1 diabetes and latent autoimmune diabetes in adults: one end of the rainbow.Journal of Clinical Endocrinology & Metabolism (Journal titles in full) 91(5): 165459 Meneilly GS, Tessier D (1995) Diabetes in the elderly Diabetic Medicine: 12: 94960 Patel A (2003) Diabetes in Focus Pharmaceutical Press, London Perry, M (2002)Type 2 diabetes in the elderly APS Publishing, Salisbury Sinclair AJ, Gadsby R, Penfold S, Croxson SC, Bayer AJ (2001) Prevalence of diabetes in care home residents. Diabetes Care 24(6): 106668 Stout RW (1997) Old age and diabetes mellitus: 741-74-11. In: Pickup J, Williams G (eds) Textbook of diabetes. Blackwell Science, Oxford Took J (1999) The association between insulin resistance and endiotheliopathy. Diabetes, Obesity and metabolism: 1(supplement 1): S17S22 Watkins, PJ (2003) Diabetes and its management Blackwell Science, Oxford Williams G, Pickup J (2005) Handbook of Diabetes. Blackwell Science, Oxford World Health Organization (2009a) Diabetes. WHO, Geneva. http:// tinyurl.com/yfccasm (Accessed 26 October, 2009) World Health Organization (2009b) Defining Diabetes WHO, Geneva, http://tinyurl.com/ygprz67 (Accessed 10th October 2009) World Health Organization (2009c). Types of diabetes. WHO, Geneva. http://tinyurl.com/ygtjze3 (Accessed 26 October 2009)

n Urinary problems n Fungal infection n Cellulitis, poor wound healing and boils. Older people, and those from ethnic minorities, have a greater risk of diabetes than the rest of the population. Ageing affects the presentation of diabetes, and older people may have fewer symptoms than the young. Diabetes is insidious and many of the changes associated with the disease are less marked in older people. The thirst mechanism is less efficient in old age, so the older diabetic may be less aware of a thirst. The older person, their family and professional carers may attribute unusual tiredness to old age. Rapid deterioration in vision might also be considered a part of the ageing process. Urinary continence problems may go uninvestigated, and the older person is arguably more likely to receive pads than a continence assessment. If the older person develops a fungal infection staff may be inclined to blame the last course of antibiotics rather than suspect diabetes. When an older person develops cellulitis (a diffuse, acute infection of the skin and subcutaneous tissue, commonly characterized by local heat, redness, pain, swelling, and occasionally fever and malaise), medical and nursing staff may not always consider a blood glucose test. At least half of all cases of diabetes in older people are undiagnosed, and many wiill have had undetected diabetes for years before their diagnosis (Watkins, 2003) Delayed diagnosis is dangerous and increases the risk of complications.

Disease progression
Type 2 diabetes is often thought of as mild, but many people with type 2 diabetes progress to insulin therapy.

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