Mark James P. Jimenez BSCP 3-3S Questions: 1.

Research on Diabetes Type 1&2 Epidemiology Ethology Anatomy and Physiology Pathophysiology 2. Research on the effects of blood glucose of type 2 DM with regard to depression 3. Find BECKS Depression Index (scoring and interpretation) 4. Reference : Minimum of 5 international books on Ana&Phy; 10 scientific journals; 10 research papers (local and abroad) Answers: 1. Type 1 Diabetes Diabetes means your blood glucose, or blood sugar, levels are too high. With type 1 diabetes, your pancreas does not make insulin. Insulin is a hormone that helps glucose get into your cells to give them energy. Without insulin, too much glucose stays in your blood. Over time, high blood glucose can lead to serious problems with your heart, eyes, kidneys, nerves, and gums and teeth. Type 1 diabetes happens most often in children and young adults but can appear at any age. Symptoms may include

Being very thirsty Urinating often Feeling very hungry or tired Losing weight without trying Having sores that heal slowly Having dry, itchy skin Losing the feeling in your feet or having tingling in your feet Having blurry eyesight

A blood test can show if you have diabetes. If you do, you will need to take insulin for the rest of your life. 2. Type 2 Diabetes Diabetes means your blood glucose, or blood sugar, levels are too high. With type 2 diabetes, the more common type, your body does not make or use insulin well. Insulin is a hormone that helps glucose get into your cells to give them energy. Without insulin, too much glucose stays in your blood. Over time, high blood glucose can lead to serious problems with your heart, eyes, kidneys, nerves, and gums and teeth. You have a higher risk of type 2 diabetes if you are older, obese, have a family history of diabetes, or do not exercise.

The symptoms of type 2 diabetes appear slowly. Some people do not notice symptoms at all. The symptoms can include

Being very thirsty Urinating often Feeling very hungry or tired Losing weight without trying Having sores that heal slowly Having blurry eyesight

A blood test can show if you have diabetes. Many people can manage their diabetes through healthy eating, physical activity, and blood glucose testing. Some people also need to take diabetes medicines. Etiology of Diabetes Type I Diabetes Type I (also often referred to as juvenile onset or insulin-dependent diabetes) is most common to present in childhood, although it can occur at any age. It is the less common form of diabetes. What is known about the etiology of Type I diabetes is that it appears to be due to an autoimmune disease. An autoimmune disease occurs when the immune system (which normally fights disease) goes haywire, attacking and damaging cells and tissues of the body. There are many types of autoimmune diseases (from multiple sclerosis to Graves' disease) and the factor that sets them off in the first place is generally poorly understood. However, once the autoimmune attack starts in diabetics, the cells of the pancreas that normally produce insulin are damaged. The body is no longer able to produce insulin in adequate levels and high blood sugar and all the symptoms and effects of diabetes follow. Although this is fairly well agreed upon as the etiology of Type I diabetes, the initial inciting factor or factors that determines if someone is going to develop the disease is not understood. Type II Diabetes

Type II diabetes appears to be an even more complicated picture. The etiology of diabetes of this type is unclear and may vary from patient to patient. On the one hand, some patients appear to have decreased levels of insulin secretion, similar to Type I. Others have relatively normal insulin levels but the body's peripheral response to insulin is lower than normal (termedinsulin resistance). These both appear to be important etiologies in the development of Type II diabetes, either alone or in concert. It is unclear what causes these problems in the first place but, because family history and ethnicity are strong risk factors of diabetes, there may be a strong genetic component. Also, obesity is though to alter the way that fat cells responde to insulin and this may play an important role in the development of insulin resistance. While the exact cause of diabetes is not known in all cases, the risk factors (such as family history, obesity, advanced age, ethnicity, etc.) are well recognized and people at high risk for Type II Diabetes are often counseled to be on the look out for signs and symptoms of early diabetes and to take steps to reverse those risk factors which can be controlled (such as weight loss, exercise, dietary changes, etc.). Anatomy and Physiology of Diabetes Diabetes mellitus is the full name of the type of diseases commonly referred to as diabetes. All of the diseases under this umbrella term affect the ability of the body to metabolize sugar properly. In

all three forms, which include type 1 (Insulin Dependent), type II (non insulin dependent) and gestational (Effects pregnant women), the subject's pancreas fails to make proper amounts of insulin. Insulin is a hormone that aids the cells of the body to effectively use the sugar taken from the plasma to the cells. This condition results in elevated blood glucose levels, and if it is left untreated it can cause damage to many of the organs in the body including the liver, heart and eyes.Type 1 diabetes is characterized by a loss of beta cells in the subject's pancreas, which leads to a deficiency of insulin in the subject's body. Most cases are due to the body's own t-cell mediating an autoimmune attack against the cells, resulting in their destruction. This form of diabetes accounts for 10 percent of all diabetes cases in Europe and North America. Commonly, this form of the disease is referred to as juvenile diabetes because it often develops in children, but it is possible for adults to develop this form of diabetes.Type 2 diabetes is characterized by the inefficiency of cells to process insulin, though it may be combined with a loss of insulin producing beta cells. This is often the result of the destruction of insulin receptors in the body's tissues responsible for processing the intake of insulin.Gestational diabetes often occurs similarly in form to type 2 diabetes, but its cause is due to pregnancy. In this form of the disease, the body's tissues become resistant to insulin following pregnancy. Women with gestational diabetes are often advised to have induced labor or a cesarean section in order to prevent certain complications Pathophysiology of Diabetes Milletus Type 1 Diabetes mellitus is the full name of the type of diseases commonly referred to as diabetes. All of the diseases under this umbrella term affect the ability of the body to metabolize sugar properly. In all three forms, which include type 1 (Insulin Dependent), type II (non insulin dependent) and gestational (Effects pregnant women), the subject's pancreas fails to make proper amounts of insulin. Insulin is a hormone that aids the cells of the body to effectively use the sugar taken from the plasma to the cells. This condition results in elevated blood glucose levels, and if it is left untreated it can cause damage to many of the organs in the body including the liver, heart and eyes.Type 1 diabetes is characterized by a loss of beta cells in the subject's pancreas, which leads to a deficiency of insulin in the subject's body. Most cases are due to the body's own t-cell mediating an autoimmune attack against the cells, resulting in their destruction. This form of diabetes accounts for 10 percent of all diabetes cases in Europe and North America. Commonly, this form of the disease is referred to as juvenile diabetes because it often develops in children, but it is possible for adults to develop this form of diabetes.Type 2 diabetes is characterized by the inefficiency of cells to process insulin, though it may be combined with a loss of insulin producing beta cells. This is often the result of the destruction of insulin receptors in the body's tissues responsible for processing the intake of insulin.Gestational diabetes often occurs similarly in form to type 2 diabetes, but its cause is due to pregnancy. In this form of the disease, the body's tissues become resistant to insulin following pregnancy. Women with gestational diabetes are often advised to have induced labor or a cesarean section in order to prevent certain complications Pathophysiology of Diabetes type 2 Type 2 diabetes is caused by either inadequate production of the hormone insulin or a lack of response to insulin by various cells of the body. Normal regulation of blood sugar

Glucose is an important source of energy in the body. It is mainly obtained fromcarbohydrates in the diet which are broken down into glucose for the various cells of the body to utilize. The liver is also able to manufacture glucose from its glycogen stores. In a healthy person, a rise in blood sugar after a meal triggers the pancreatic beta cells to release the hormone insulin. Insulin, in turn, stimulates cells to take up the glucose from the blood. When blood glucose levels fall, during exercise for example, insulin levels also decline. As well as insulin stimulating the uptake of glucose from the blood by body cells, it also induces the:

Stimulates the conversion of glucose to pyruvate (glycolysis) to release free energy Conversion of excess glucose to glycogen for storage in the liver (glycogenesis) Uptake and synthesis of amino acids, proteins, and fat

Pathology of type 2 diabetes In type 2 diabetes, the body either produces inadequate amounts of insulin to meet the demands of the body or insulin resistance has developed. Insulin resistance refers to when cells of the body such as the muscle, liver and fat cells fail to respond to insulin, even when levels are high. In fat cells, triglycerides are instead broken down to produce free fatty acids for energy; muscle cells are deprived of an energy source and liver cells fail to build up glycogen stores. This also leads to an overall rise in the level of glucose in the blood. Glycogen stores become markedly reduced and there is less glucose available for release when it may be needed. Obesity and lack of physical activity are thought to be major causes of insulin resistance.

2. Effects of of blood glucose of type 2 DM with regard to depression Diabetes and depression Symptoms of depression are common in people with diabetes compared with the general population, and major depression is present in approximately 15% of people with diabetes. Depression is associated with poorer self-care behaviour, poorer blood glucose management, health complications, decreased quality of life and psychological well-being, increased family problems, and higher healthcare costs. The association between depression and diabetes is unclear. Depression may develop because of stress but also may result from the metabolic effects of diabetes on the brain. Studies suggest that people with diabetes who have a history of depression are more likely to develop diabetic complications than those without depression. Despite the enormous advances in brain research in the past 20 years, depression often goes undiagnosed and untreated. It often takes a mental health professional to recognize these symptoms, inquire about their duration and severity, diagnose the disorder and suggest appropriate treatment.

Research shows that depression leads to poorer physical and mental functioning, so a person is less likely to follow a required meal or medication plan. Treating depression with psychotherapy (talk therapy), medication or a combination of these treatments can improve a patients well-being and ability to manage diabetes. In people who have diabetes and depression, scientists report that psychotherapy and antidepressant medications have positive effects on both mood and blood glucose management. Prescription antidepressant medications are generally well tolerated and safe for people with diabetes. Specific types of psychotherapy can also relieve depression. However, recovery from depression takes time. Antidepressant medications can take several weeks to work and may need to be combined with ongoing psychotherapy. Not everyone responds to treatment in the same way. Prescriptions and dosing may need to be adjusted. Therefore, treatment for depression in the context of diabetes should be managed by a mental health professional, such as a psychiatrist, psychologist or clinical social worker who is in close communication with the physician providing diabetes care. This is especially important when antidepressant medication is needed or prescribed, so that potentially harmful drug interactions can be avoided. In some cases, a mental health professional who specializes in treating individuals with depression and co-occurring physical illnesses, such as diabetes, may be available. People with diabetes who develop depression, as well as people in treatment for depression who subsequently develop diabetes, should make sure to tell any physician they visit about the full range of medications they are taking. Use of herbal supplements of any kind should be discussed with a physician before they are tried. Recently, scientists have discovered that St. Johns wort, an over-the-counter herbal remedy promoted as a treatment for mild depression, can have harmful interactions with some other medications. It is important to remember that depression is a disorder of the brain that can be treated in addition to whatever other illnesses a person might have, including diabetes. If you think you may be depressed or know someone who is, dont lose hope. Seek help for depression. Anxiety Its normal to feel anxious or worried at times. Everyone does. In fact, a moderate amount of anxiety can be good. It helps you respond appropriately to real danger, and it can help motivate you to excel at work and at home. But if you often feel anxious without reason and your worries disrupt your daily life, you may have an anxiety disorder. Anxiety disorders cause excessive or unrealistic anxiety and worry about life circumstances, usually without a readily identifiable cause. Little is known about the relationship between diabetes and anxiety. Recent evidence suggests that the rate of anxiety disorders is elevated in people with type 1 diabetes. Anxiety disorders appear to be increased in individuals with diabetes compared with the general population (14 vs. 3 to 4%, respectively). As many as 40% of people have at least some anxiety symptoms, and fear of hypoglycemia is not uncommon in those with diabetes. Recent studies suggest that anxiety disorders in people with type 1 and 2 diabetes is associated with poor blood sugar control.

Beck Depression Inventory

Choose the one statement, from among the group of four statements in each question that best describes how you have been feeling during the past few days. Circle the number beside your choice.

0 1 2 3

I do not feel bad. I feel sad. I am sad all the time and I cant snap out of it. I am so sad or unhappy that I cannot stand it. I am not particularly discouraged about the future. I feel discouraged about the future. I feel I have nothing to look forward to. I feel that the future is hopeless and that things cannot improve. I do not feel like a failure. I feel I have failed more than the average person. As I look back on my life, all I can see is a lot of failure. I feel I am a complete failure as a person. I get as much satisfaction out of things as I used to. I dont enjoy things the way I used to. I dont get any real satisfaction out of anything anymore. I am dissatisfied or bored with everything. I dont feel particularly guilty. I feel guilty a good part of the time. I feel guilty most of the time. I feel guilty all of the time. I dont feel that I am being punished. I feel I may be punished. I expect to be punished. I feel I am being punished.

0 1 2 3

0 1 2 3

0 1 2 3 0 1 2 3 0 1 2 3

10

11

0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3

I dont feel disappointed in myself. I am disappointed in myself. I am disgusted with myself. I hate myself. I dont feel I am worse than anybody else. I am critical of myself for my weaknesses or mistakes. I blame myself all the time for faults. I blame myself for everything bad that happens. I dont have any thoughts of killing myself. I have thoughts of killing myself but I would not carry them out. I would like to kill myself. I would kill myself if I had the chance. I dont cry anymore than usual. I cry more now than I used to. I cry all the time now. I would kill myself if I had the chance. I am not more irritated by things than I ever am. I am slightly more irritated now than usual. I am quite annoyed or irritated a good deal of the time. I feel irritated all the time now.

12

13

14

0 1 2 3 0 1 2 3 0 1 2 3

I have not lost interest in other people. I am less interested in other people than I used to be. I have lost most of my interest in other people. I have lost all my interest in other people. I make decisions about as well as I ever could. I put off making decisions more than I used to. I have a greater difficulty in making decisions than before. I cant make decisions at all anymore. I dont feel I look any worse than I used to. I am worried that I am looking old or unattractive. I feel that there are permanent changes in my appearance that make me look unattractive. I believe that I look ugly. I can work about as well as before. It takes an extra effort to get started at doing something. I have to push myself very hard to do anything. I cant do any work at all. I can sleep as well as usual. I dont sleep as well as I used to. I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. I wake up several hours earlier than I used to and cannot get back to sleep. I dont get more tired than usual. I get tired more easily than I used to. I get tired from doing almost anything. I am too tired to do anything. My appetite is no worse than usual. My appetite is not as good as it used to be. My appetite is much worse now. I have no appetite at all anymore. I havent lost much weight, if any, lately. I have lost more than five pounds. I have lost more than ten pounds. I have lost more than fifteen pounds trying to lose weight. Score 0 if you have been purposely trying to lose weight.

15

0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3

16

17

18

19

0 1 2 3

20

0 1 2

I am no more worried about my health than usual. I am worried about my physical problems such as aches and pains or upset stomach. I am very worried about physical problems and its hard to think of much else.

3 21 0 1 2 3

I am so worried about my physical problems that I cannot think about anything else. I have not noticed any recent change in my interest in sex. I am less interested in sex. I am much less interested in sex. I have lost interest in sex completely.

Please indicate if you have felt any of the following, how often and for what period of time:

Depressed mood Loss of interest or pleasure in usual activities Significant change in weight and/or appetite Insomnia or hypersomnia Psychomotor agitation or retardation Increased fatigue and loss of energy Feelings of self-reproach, worthlessness or inappropriate guilt Slowed thinking or impaired concentration Suicide attempt or suicidal ideation

Scoring:

Beck Depression Scale: 1-10: These up and downs are considered normal 11-16: Mild mood disturbance 17-20: Borderline clinical depression 21-30: Moderate depression 31-40: Severe depression over 40: Extreme depression

DSM-IV: Need to have felt at least 5 of the 9 symptoms, usually everyday for 2-4 weeks.

References:
Alberti KG, Zimmet PZ: Definition, diagnosis and classification of diabetes mellitus and its complications. I. Diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med15 :539 553,1998 Zimmet P, Alberti KGMM, Shaw J: Global and societal implications of the diabetes epidemic. Nature404 :782 787,2001

Johansson C, Samuelsson U, Ludvigsson J: A high weight gain early in life is associated with an increased risk of childhood diabetes.Diabetologia37 :91 94,1994 Bruining GJ: Association between infant growth before onset of juvenile type 1 diabetes and autoantibodies to IA-1. Lancet356 :655656,2000 Hypponen E, Virtanen SM, Kenward MG, Knip M, Akerblom HK, Childhood Diabetes in Finland Study Group: Obesity, increased linear growth, and risk of type 1 diabetes in children. Diabetes Care23:1755 1760,2000

Libman IM, Pietropaolo M, Arslanian SA, LaPorte RE, Becker DJ: Changing prevalence of overweight children and adolescents at onset of insulin-treated diabetes. Diabetes Care26 :2871 2875,2003

Wilkin TJ: The accelerator hypothesis: weight gain as the missing link between type I and type II diabetes. Diabetologia44 :914 922,2001

Dahlquist G, Blom L, Tuvemo T, Nystrom L, Sandstrom A, Wall S: The Swedish childhood diabetes study: results from a nine year case register and a one year casereferent study indicating that type 1 (insulin-dependent) diabetes mellitus is associated with both type 2 (non-insulin-dependent) diabetes mellitus and autoimmune disorders.Diabetologia32 :2 6,1989 Pozzilli P, Visalli N, Signore A, Andreani D: Clinical remission in patients with IDDM and family history of NIDDM. Lancet337 :1165 ,1991 Ramachandran A, Snehalatha C, Premila L, Mohan V, Viswanathan M: Familial aggregation in type 1 (insulin-dependent) diabetes mellitus: a study from south India. Diabet Med7 :876 879,1990 Teupe B, Bergis K: Epidemiological evidence for double diabetes.Lancet337 :361 362,1991 Carel JC, Boitard C, Bougneres PF: Decreased insulin response to glucose in islet cell antibody-negative siblings of type 1 diabetic children. J Clin Invest92 :509 513,1993

Erbey JR, Kuller LH, Becker DJ, Orchard TJ: The association between a family history of type 2 diabetes and coronary artery disease in a type 1 diabetes population. Diabetes Care21 :610 614,1998

Chern MM, Anderson VE, Barbosa J: Empirical risk for insulin-dependent diabetes (IDD) in sibs: further definition of genetic heterogeneity. Diabetes31 :1115 1118,1982