Diabetes Mellitus

    Diabetes mellitus (diabetes) is a metabolic disorder characterized by abnormally high levels of a simple sugar (glucose) in the blood (hyperglycemia) as a result of defects in insulin secretion or defective action of insulin or both. The two most common types of diabetes are type 1 and type 2. Type 1 diabetes is a deficiency in insulin secretion resulting from destruction of insulin-producing cells in the pancreas (pancreatic islet ß cells); individuals with type 1 diabetes must receive exogenous insulin to prevent ketoacidosis, a life-threatening complication of insulin-dependent diabetes mellitus (IDDM). Type 2 diabetes (non-insulin dependent diabetes mellitus or NIDDM) is an endocrine abnormality caused by a combination of insulin resistance and insufficient secretion of insulin in response to resistance. Type 2 diabetes can be diagnosed in childhood or can begin in mid-life (adult onset diabetes). It is the predominant type of diabetes internationally. Insulin is a hormone produced in the pancreas, a digestive organ located behind the liver in the right upper abdomen. Insulin helps metabolize food, converting it into energy. In type 2 diabetes, resistance of the body to the action of insulin is accompanied by reduced production of insulin by the pancreas. The inability to secrete sufficient amounts of insulin varies considerably from person to person. Without sufficient insulin, glucose cannot be transported from the blood into the body’s cells; it accumulates in the blood, resulting in hyperglycemia. Genetic predisposition for diabetes is believed to be the main cause of type 1 and type 2 diabetes. Classic symptoms of diabetes such as frequent urination, excessive thirst and hunger, mood swings, light-headedness may not develop in all individuals, and diabetes can go unrecognized for years before it is diagnosed. Diabetes is associated with complications such as persistent infection, vision loss (retinopathy), kidney disease (diabetic nephropathy), gout, poor peripheral circulation sometimes leading to amputation, and an increased risk of heart disease (coronary artery disease) and stroke (cerebral vascular accident). Risk for developing diabetes can be significantly reduced in susceptible individuals by careful monitoring and control of blood glucose levels through weight control and regular exercise.Risk: Gender, age, family history of diabetes, and ethnic background are important risk factors for developing type 2 diabetes. Risk is greater among women than men and greater among inactive rather than active individuals of either sex. Individuals with a family history of type 2 diabetes in a parent or sibling, who are over the age of 45, or who are obese (body mass index [BMI] greater than 30) have a greater likelihood of developing the disease. Ninety percent of individuals with type 2 diabetes are obese (Votey). A previously identified abnormal fasting plasma glucose, high blood pressure, and high cholesterol (generally total cholesterol >200mg/dL) are considered to be major risk factors for type 2 diabetes. This disorder is more common among Hispanics, Native Americans, blacks, Asians and Pacific Islanders than non-Hispanic whites (Votey). Incidence and Prevalence: An estimated 8% of the population of the US or 23.6 million people diabetes and another 54 million have pre-diabetes (“National Diabetes Fact Sheet”). Pre-diabetes is a condition in which blood glucose levels are higher than normal but not high enough to diagnose diabetes. Each year, about 1.6 million people aged 20 years or older are newly diagnosed with diabetes (“National Diabetes Fact Sheet”). Approximately 90% of these individuals have type 2 diabetes (Lithgary). Incidence of type 2 diabetes mellitus is rising and is expected to increase worldwide in the coming decade. Incidence is also rapidly increasing in US children and adolescents due to the rise of childhood obesity; 2 million American adolescents have pre-diabetes (“National Diabetes Fact Sheet”). The incidence of type 2 diabetes now exceeds type 1 diabetes in the pediatric population. Increases among Hispanic and African-American children are greater than among other ethnic populations.

    Diagnosis

    History: Individuals often are asymptmoatic and only occasionally report the classic symptoms of diabetes mellitus, including increased urination (polyuria), excessive thirst (polydipsia), and excessive hunger (polyphagia). The individual may complain of frequent skin infections that are slow to heal, itching, blurred vision, tingling, numbness, and pain in the arms and legs. There may be a feeling of general fatigue and drowsiness. Women may experience chronic vaginal infections (vaginitis).

    Physical exam: High blood pressure is present in at least half the individuals with type 2 diabetes, and obesity is a very common finding. The feet and lower legs are examined carefully for signs of ulceration, persistent infection, or gout. Blood pressure in the leg may be lower than in the arm (ankle-brachial index) indicating poor circulation to the extremities. A decreased sensation of pain may be detected in the legs and feet consistent with peripheral nerve dysfunction (diabetic neuropathy). An eye exam may reveal changes in the blood vessels, bleeding, and yellow or white patches in the retina (diabetic retinopathy).

    Tests: Diagnosis depends primarily on plasma glucose levels, especially an elevated level of fasting plasma glucose (FPG) and the presence of impaired glucose tolerance (IGT). Glucose tolerance testing measures and compares fasting and non-fasting blood glucose levels to evaluate glucose metabolism. The oral glucose tolerance test measures blood glucose at half-hour intervals within 2 hours after drinking a set amount of a glucose solution. Individuals with diabetes show abnormal rises in blood glucose (hyperglycemia) within the 2-hour period.

    Urinalysis is performed to measure the amount of glucose excreted in the urine; elevated urine glucose (glycosuria) is a typical abnormal finding in diabetes. The absence of ketosis (abnormally elevated concentration of ketones in the blood) is a primary feature that distinguishes type 2 from type 1 diabetes. A blood chemistry profile is performed to evaluate lipid levels, fluid and electrolyte balance, and to measure serum creatinine, an indicator of kidney function. Periodic testing of the amount of glucose bound to a protein (hemoglobin) in red blood cells (glycosylated hemoglobin or HbA1c) may be used to estimate plasma glucose levels over the preceding 1 to 3 months, and may help the physician recommend changes in diet, exercise, and insulin therapy. However, lack of standardization of assays for HbA1c has discouraged physicians from using it for diagnosis even though it may be used to monitor effectiveness of treatment (Kronenberg).

    Treatment

    According to the American Diabetes Association, eating well-balanced, healthy meals, and engaging in regular aerobic exercise are the best treatment and preventive measures for those with type 2 diabetes or a family history of type 2 diabetes. Both can significantly improve glucose tolerance and decrease medication requirements. Individual education in weight control through diet and exercise can be an effective combination to control type 2 diabetes. Stress reduction techniques also assist in controlling type 2 diabetes. Self-care education aimed at providing early intervention for any injuries to the lower legs and feet, including small scratches, should include daily inspection of feet and lower extremities, daily foot cleansing, moisturizing, and nail trimming. Wearing protective footwear can additionally guard against injury. If diet, exercise, and stress reduction are not effective in controlling blood glucose levels, the physician may need to prescribe medication (oral hypoglycemics) to lower blood glucose. Diabetes mellitus type 2 is a progressive, chronic disease, so over time individuals with this disease are likely to need medications to control it.

    In some cases oral medications may not be enough to effectively control glucose levels and insulin therapy is needed. These individuals lose all insulin secretory ability and, in effect, become a type 1 diabetic. As in diabetes type 1, pancreatic beta cell failure occurs, requiring insulin therapy since oral medication will have little or no effect. Insulin may be administered alone or in combination with an oral medication. Insulin can be self-injected; a health care provider will train the individual in the proper method of injection. Insulin therapy also might be required if exercise and diet are particularly difficult for an individual with physical disabilities, obesity, or comorbid conditions that reduce the ability to exercise.

    Treatment also includes monitoring blood glucose levels at regular intervals by the physician and daily by the individual with a home-monitoring glucometer. Periodic testing of glycosylated hemoglobin (HbA1c) provides an indication of glucose levels over the preceding 60 to 90 days. The individual should be educated about the symptoms of, and early response to, hyperglycemia and abnormally low glucose levels (hypoglycemia). The individual should also have regular physical and eye exams.

    Prognosis

    Exercise and weight loss make the body more sensitive to the action of insulin and thereby help to control blood glucose levels. Outcomes are favorable with good regulation of blood glucose levels and compliance with the recommended self-care regimen. The development of complications will adversely affect outcome. Diabetes-related blindness, kidney disease, and amputation can result in permanent disability. Although type 2 diabetes is a chronic, progressive condition with no known cure, the condition can be effectively managed with patient education and regular, appropriate medical care.

    Complications

    Complications of type 2 diabetes mellitus, some of which can be fatal, include low blood glucose (hypoglycemia), infection, poor healing, gout, poor blood circulation in the extremities, gangrene, amputation of a lower extremity, skin ulceration, eye disease (diabetic retinopathy, glaucoma, cataracts), erectile dysfunction, joint disease (Charcot joints), nerve damage (diabetic neuropathy), heart disease (cardiovascular disease, atherosclerosis), heart attack (myocardial infarction), stroke (cerebral vascular accident), and kidney failure (end stage renal disease). The presence of retinopathy is predictive of the relationship between elevated glucose levels and development of diabetic complications. Diabetic coma and ketoacidosis seen in type 1 diabetes are rare in type 2 diabetes. Hyperosmolar, nonketonic coma, however, is seen in newly diagnosed individuals and the elderly and is associated with high mortality. Type 2 diabetes contributes to metabolic syndrome, a condition characterized by obesity, glucose intolerance, hypertension, high triglycerides, and low HDL cholesterol (“good” cholesterol).

    Return to Work (Restrictions / Accommodations)

    Frequent breaks and a private place with facilities for hand washing and disposal of glucose testing strips, may be needed to allow for monitoring glucose levels. Limitations may be placed on continuous physical exertion, working in extreme temperature or moist areas, working at unprotected heights, and working in isolated areas alone. If the disease progresses and is associated with visual or sensory impairment, work requiring visual acuity, fine dexterity, prolonged walking, or heavy labor may need to be limited.

    Failure to Recover

    If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual’s medical case.Regarding diagnosis:

    • Does individual have a family history of diabetes?
    • Is individual over 45?
    • Is individual obese?
    • Is individual sedentary rather than physically active?
    • Does individual have polydipsia, polyuria, and polyphagia?
    • Does individual complain of frequent skin infections that are slow to heal, itching, blurred vision, tingling, numbness, pain in the arms and legs, general fatigue and drowsiness? If female, does individual have chronic vaginitis?
    • On exam, did individual have hypertension, obesity, leg ulcers, or changes in the eye?
    • Were a urinalysis, fasting plasma glucose, glucose tolerance test, and blood chemistry profile done? Were HDL cholesterol and/or total cholesterol elevated?
    • Were conditions with similar symptoms ruled out?

    Regarding treatment:

    • Does individual eat well-balanced, healthy meals and participate in regular aerobic exercise?
    • Was individual trained in daily inspection and early intervention of injuries to the lower legs? Daily foot care?
    • Were oral hypoglycemics given?
    • Does individual monitor blood sugar regularly?
    • Are plasma glucose levels stable?
    • Has it become necessary for individual to take insulin?
    • Has individual been compliant with self-care recommendations and treatment regimen?

    Regarding prognosis:

    • Can individual’s employer accommodate any necessary restrictions?
    • Are blood pressure and cholesterol being controlled?
    • Was smoking cessation advised?
    • Does individual have any conditions that may affect ability to recover?
    • Have any complications developed that would slow or prevent recovery such as hypoglycemia, infection, gangrene, amputation of a lower extremity, skin ulceration, diabetic retinopathy, glaucoma, cataracts, erectile dysfunction, joint disease, diabetic neuropathy, cardiovascular disease, atherosclerosis, heart attack, stroke, or kidney failure?

    References

    Cited

    Votey, Scott R., and Anne L. Peters. “Diabetes Mellitus, Type II- A Review.” eMedicine. Eds. William Lober, et al. 2 Feb. 2009. Medscape. 25 Mar. 2006 <http://emedicine.medscape.com/article/766143-overview>.”National Diabetes Fact Sheet.” American Diabetes Association. 2002. 25 Mar. 2009 <http://www.diabetes.org/diabetes-statistics.jsp>.

    Williams, R. H., and Reed P. Larsen, eds. Williams Textbook of Endocrinology. 10th ed. Philadelphia: Elsevier, Inc., 2003.

    Ligaray, Kenneth P., and William L. Isley. “Diabetes Mellitus, Type 2.” eMedicine. Eds. David S. Schade, et al. 6 Aug. 2008. Medscape. 25 Mar. 2009 <http://emedicine.medscape.com/article/117853-overview>.

    Source: Medical Disability Advisor

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