Diabetes mellitus

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Diabetes mellitus
Classification and external resources
Blue circle for diabetes.svg
Universal blue circle symbol for diabetes.[1]
ICD-10 E10E14
ICD-9 250
MedlinePlus 001214
eMedicine med/546 emerg/134
NCI Diabetes mellitus
Patient UK Diabetes mellitus
MeSH C18.452.394.750



  • Gestational diabetes, is the third main form and occurs when pregnant women without a previous history of diabetes develop a high blood glucose level.[3]

Prevention and treatment involves a healthy diet, physical exercise, not using tobacco and being a normal body weight. Blood pressure control and proper foot care are also important for people with the disease. Type 1 diabetes must be managed with insulin injections.[3] Type 2 diabetes may be treated with medications with or without insulin.[7] Insulin and some oral medications can cause low blood sugar.[8] Weight loss surgery in those with obesity is an effective measure in those with type 2 DM.[9] Gestational diabetes usually resolves after the birth of the baby.[10]

As of 2014, an estimated 387 million people have diabetes worldwide, [11] with type 2 diabetes making up about 90% of the cases.[12][13] This is equal to 8.3% of the adult population,[13] with equal rates in both women and men.[14] In the years 2012 to 2014, diabetes is estimated to have resulted in 1.5 to 4.9 million deaths per year.[7][11] Diabetes at least doubles the risk of death.[3] The number of people with diabetes is expected to rise to 592 million by 2035.[11] The global economic cost of diabetes in 2014 was estimated to be $612 billion USD.[15] In the United States, diabetes cost $245 billion in 2012.[16]

Signs and symptoms

Overview of the most significant symptoms of diabetes

The classic symptoms of untreated diabetes are weight loss, polyuria (frequent urination), polydipsia (increased thirst), and polyphagia (increased hunger).[17] Symptoms may develop rapidly (weeks or months) in type 1 diabetes, while they usually develop much more slowly and may be subtle or absent in type 2 diabetes.


Diabetic emergencies

People (usually with type 1 diabetes) may also experience episodes of diabetic ketoacidosis, a type of metabolic problems characterized by nausea, vomiting and abdominal pain, the smell of acetone on the breath, deep breathing known as Kussmaul breathing, and in severe cases a decreased level of consciousness.[18]




The major long-term complications relate to damage to blood vessels. Diabetes doubles the risk of cardiovascular disease[19] and about 75% of deaths in diabetics are due to coronary artery disease.[20] Other "macrovascular" diseases are stroke, and peripheral vascular disease.

The primary microvascular complications of diabetes include damage to the eyes, kidneys, and nerves.[21] Damage to the eyes, known as diabetic retinopathy, is caused by damage to the blood vessels in the retina of the eye, and can result in gradual vision loss and potentially blindness.[21] Damage to the kidneys, known as diabetic nephropathy, can lead to tissue scarring, urine protein loss, and eventually chronic kidney disease, sometimes requiring dialysis or kidney transplant.[21] Damage to the nerves of the body, known as diabetic neuropathy, is the most common complication of diabetes.[21] The symptoms can include numbness, tingling, pain, and altered pain sensation, which can lead to damage to the skin. Diabetes-related foot problems (such as diabetic foot ulcers) may occur, and can be difficult to treat, occasionally requiring amputation. Additionally, proximal diabetic neuropathy causes painful muscle wasting and weakness.



Comparison of type 1 and 2 diabetes[12]
Feature Type 1 diabetes Type 2 diabetes
Onset Sudden Gradual
Age at onset Mostly in children Mostly in adults
Body size Thin or normal[23] Often obese
Ketoacidosis Common Rare
Autoantibodies Usually present Absent
Endogenous insulin Low or absent Normal, decreased
or increased
in identical twins
50% 90%
Prevalence ~10% ~90%

Diabetes mellitus is classified into four broad categories: type 1, type 2, gestational diabetes, and "other specific types".[5] The "other specific types" are a collection of a few dozen individual causes.[5] The term "diabetes", without qualification, usually refers to diabetes mellitus.

Type 1


"Brittle" diabetes, also known as unstable diabetes or labile diabetes, is a term that was traditionally used to describe the dramatic and recurrent swings in glucose levels, often occurring for no apparent reason in insulin-dependent diabetes. This term, however, has no biologic basis and should not be used.[25] Still, type 1 diabetes can be accompanied by irregular and unpredictable hyperglycemia, frequently with ketosis, and sometimes with serious hypoglycemia. Other complications include an impaired counterregulatory response to hypoglycemia, infection, gastroparesis (which leads to erratic absorption of dietary carbohydrates), and endocrinopathies (e.g., Addison's disease).[25] These phenomena are believed to occur no more frequently than in 1% to 2% of persons with type 1 diabetes.[26]

Type 1 diabetes is partly inherited, with multiple genes, including certain HLA genotypes, known to influence the risk of diabetes. In genetically susceptible people, the onset of diabetes can be triggered by one or more environmental factors, such as a viral infection or diet. There is some evidence that suggests an association between type 1 diabetes and Coxsackie B4 virus. Unlike type 2 diabetes, the onset of type 1 diabetes is unrelated to lifestyle.

Type 2



Type 2 diabetes is due primarily to lifestyle factors and genetics.[27] A number of lifestyle factors are known to be important to the development of type 2 diabetes, including obesity (defined by a body mass index of greater than thirty), lack of physical activity, poor diet, stress, and urbanization.[12] Excess body fat is associated with 30% of cases in those of Chinese and Japanese descent, 60–80% of cases in those of European and African descent, and 100% of Pima Indians and Pacific Islanders.[5] Those who are not obese often have a high waist–hip ratio.[5]

Dietary factors also influence the risk of developing type 2 diabetes. Consumption of sugar-sweetened drinks in excess is associated with an increased risk.[28][29] The type of fats in the diet is also important, with saturated fats and trans fatty acids increasing the risk and polyunsaturated and monounsaturated fat decreasing the risk.[27] Eating lots of white rice appears to also play a role in increasing risk.[30] A lack of exercise is believed to cause 7% of cases.[31]

Gestational diabetes

Main article: Gestational diabetes

Gestational diabetes mellitus (GDM) resembles type 2 diabetes in several respects, involving a combination of relatively inadequate insulin secretion and responsiveness. It occurs in about 2–10% of all pregnancies and may improve or disappear after delivery.[32] However, after pregnancy approximately 5–10% of women with gestational diabetes are found to have diabetes mellitus, most commonly type 2.[32] Gestational diabetes is fully treatable, but requires careful medical supervision throughout the pregnancy. Management may include dietary changes, blood glucose monitoring, and in some cases insulin may be required.


Other types





The following is a comprehensive list of other causes of diabetes:[34]









WHO diabetes diagnostic criteria[40][41]  edit
Condition 2 hour glucose Fasting glucose HbA1c


  • Glycated hemoglobin (HbA1C) ≥ 48 mmol/mol (≥ 6.5 DCCT %).[42]


Per the World Health Organization people with fasting glucose levels from 6.1 to 6.9 mmol/l (110 to 125 mg/dl) are considered to have impaired fasting glucose.[44] people with plasma glucose at or above 7.8 mmol/l (140 mg/dl), but not over 11.1 mmol/l (200 mg/dl), two hours after a 75 g oral glucose load are considered to have impaired glucose tolerance. Of these two prediabetic states, the latter in particular is a major risk factor for progression to full-blown diabetes mellitus, as well as cardiovascular disease.[45] The American Diabetes Association since 2003 uses a slightly different range for impaired fasting glucose of 5.6 to 6.9 mmol/l (100 to 125 mg/dl).[46]

Glycated hemoglobin is better than fasting glucose for determining risks of cardiovascular disease and death from any cause.[47]



There is no known preventive measure for type 1 diabetes.[3] Type 2 diabetes can often be prevented by a person being a normal body weight, physical exercise, and following a healthy diet.[3] Dietary changes known to be effective in helping to prevent diabetes include a diet rich in whole grains and fiber, and choosing good fats, such as polyunsaturated fats found in nuts, vegetable oils, and fish.[48] Limiting sugary beverages and eating less red meat and other sources of saturated fat can also help in the prevention of diabetes.[48] Active smoking is also associated with an increased risk of diabetes, so smoking cessation can be an important preventive measure as well.[49]


Main article: Diabetes management


Learning about the disease and actively participating in the treatment is vital for people with diabetes, since the complications of diabetes are far less common and less severe in people who have well-managed blood sugar levels.[50][51] The goal of treatment is an HbA1C level of 6.5%, but should not be lower than that, and may be set higher.[52] Attention is also paid to other health problems that may accelerate the deleterious effects of diabetes. These include smoking, elevated cholesterol levels, obesity, high blood pressure, and lack of regular exercise.[52] Specialised footwear is widely used to reduce the risk of ulceration, or re-ulceration, in at-risk diabetic feet. Evidence for the efficacy of this remains equivocal, however.[53]


See also: Diabetic diet

People with diabetes can benefit from education about the disease and treatment, good nutrition to achieve a normal body weight, and sensible exercise, with the goal of keeping both short-term and long-term blood glucose levels within acceptable bounds. In addition, given the associated higher risks of cardiovascular disease, lifestyle modifications are recommended to control blood pressure.[54]


Metformin is generally recommended as a first line treatment for type 2 diabetes, as there is good evidence that it decreases mortality.[55] Routine use of aspirin, however, has not been found to improve outcomes in uncomplicated diabetes.[56] Angiotensin converting enzyme inhibitors (ACEIs) improve outcomes in those with DM while the similar medications angiotensin receptor blockers (ARBs) do not.[57]

Type 1 diabetes is typically treated with a combinations of regular and NPH insulin, or synthetic insulin analogs. When insulin is used in type 2 diabetes, a long-acting formulation is usually added initially, while continuing oral medications.[55] Doses of insulin are then increased to effect.[55]

In those with diabetes some recommend blood pressure levels below 120/80 mmHg;[58][59] however, evidence only supports less than or equal to somewhere between 140/90 mmHg to 160/100 mmHg.[60][61]

Pancreatic transplantation

A pancreas transplant is occasionally considered for people with type 1 diabetes who have severe complications of their disease, including end stage renal disease requiring kidney transplantation.[62]




  no data
  ≤ 7.5
  ≥ 82.5
  No data


In 2014, the International Diabetes Federation (IDF) estimated that diabetes resulted in 4.9 million deaths.[11] The World Health Organization (WHO) estimated that diabetes resulted in 1.5 million deaths in 2012, making it the 8th leading cause of death.[7] The discrepancy between the two estimates is due to the fact that cardiovascular diseases are often the cause of death for individuals with diabetes; the IDF uses modelling to estimate the amount of deaths that could be attributed to diabetes.[15] More than 80% of diabetic deaths occur in low and middle-income countries.[64]



Main article: History of diabetes

Diabetes was one of the first diseases described,[66] with an Egyptian manuscript from c. 1500 BCE mentioning "too great emptying of the urine".[67] The first described cases are believed to be of type 1 diabetes.[67] Indian physicians around the same time identified the disease and classified it as madhumeha or "honey urine", noting the urine would attract ants.[67] The term "diabetes" or "to pass through" was first used in 230 BCE by the Greek Appollonius of Memphis.[67] The disease was considered rare during the time of the Roman empire, with Galen commenting he had only seen two cases during his career.[67] This is possibly due the diet and life-style of the ancient people, or because the clinical symptoms were observed during the advanced stage of the disease. Galen named the disease "diarrhea of the urine" (diarrhea urinosa). The earliest surviving work with a detailed reference to diabetes is that of Aretaeus of Cappadocia (2nd or early 3rd century CE). He described the symptoms and the course of the disease, which he attributed to the moisture and coldness, reflecting the beliefs of the "Pneumatic School". He hypothesized a correlation of diabetes with other diseases and he discussed differential diagnosis from the snakebite which also provokes excessive thirst. His work remained unknown in the West until the middle of the 16th century when, in 1552, the first Latin edition was published in Venice.[68]

Type 1 and type 2 diabetes were identified as separate conditions for the first time by the Indian physicians Sushruta and Charaka in 400-500 CE with type 1 associated with youth and type 2 with being overweight.[67] The term "mellitus" or "from honey" was added by the Briton John Rolle in the late 1700s to separate the condition from diabetes insipidus, which is also associated with frequent urination.[67] Effective treatment was not developed until the early part of the 20th century, when Canadians Frederick Banting and Charles Herbert Best isolated and purified insulin in 1921 and 1922.[67] This was followed by the development of the long-acting insulin NPH in the 1940s.[67]


The word diabetes (/ˌd.əˈbtz/ or /ˌd.əˈbtɨs/) comes from Latin diabētēs, which in turn comes from Ancient Greek διαβήτης (diabētēs) which literally means "a passer through; a siphon."[69] Ancient Greek physician Aretaeus of Cappadocia (fl. 1st century CE) used that word, with the intended meaning "excessive discharge of urine", as the name for the disease.[70][71][72] Ultimately, the word comes from Greek διαβαίνειν (diabainein), meaning "to pass through,"[69] which is composed of δια- (dia-), meaning "through" and βαίνειν (bainein), meaning "to go".[70] The word "diabetes" is first recorded in English, in the form diabete, in a medical text written around 1425.

The word mellitus (/mɨˈltəs/ or /ˈmɛlɨtəs/) comes from the classical Latin word mellītus, meaning "mellite"[73] (i.e. sweetened with honey;[73] honey-sweet[74]). The Latin word comes from mell-, which comes from mel, meaning "honey";[73][74] sweetness;[74] pleasant thing,[74] and the suffix -ītus,[73] whose meaning is the same as that of the English suffix "-ite".[75] It was Thomas Willis who in 1675 added "mellitus" to the word "diabetes" as a designation for the disease, when he noticed the urine of a diabetic had a sweet taste (glycosuria).[71] This sweet taste had been noticed in urine by the ancient Greeks, Chinese, Egyptians, Indians, and Persians.

Society and culture

The 1989 "St. Vincent Declaration"[76][77] was the result of international efforts to improve the care accorded to those with diabetes. Doing so is important not only in terms of quality of life and life expectancy, but also economically—expenses due to diabetes have been shown to be a major drain on health—and productivity-related resources for healthcare systems and governments.

Several countries established more and less successful national diabetes programmes to improve treatment of the disease.[78]


In 2010, diabetes-related emergency department (ED) visit rates in the United States were higher among people from the lowest income communities (526 per 10,000 population) than from the highest income communities (236 per 10,000 population). Approximately 9.4% of diabetes-related ED visits were for the uninsured.[80]



Other animals



Inhaled insulin has been developed.[82] The original products were withdrawn due to side effects.[82] Afrezza, under development by pharmaceuticals company MannKind Corporation, was approved by the FDA for general sale in June, 2014 [83] There are several advantages of inhaled insulin: they are convenient and easy to use and provide a useful alternative therapy for patients who cannot use intravenous insulin.[84]


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  11. ^ a b c d "Update 2014". IDF. International Diabetes Federation. Retrieved 29 November 2014. 
  13. ^ a b c d Shi, Yuankai; Hu, Frank B. "The global implications of diabetes and cancer". The Lancet 383 (9933): 1947–8. doi:10.1016/S0140-6736(14)60886-2. PMID 24910221. 
  15. ^ a b IDF DIABETES ATLAS (6th ed.). International Diabetes Federation. 2013. p. 7. ISBN 2930229853. 
  16. ^ American Diabetes, Association (Apr 2013). "Economic costs of diabetes in the U.S. in 2012.". Diabetes Care 36 (4): 1033–46. doi:10.2337/dc12-2625. PMC 3609540. PMID 23468086. 
  18. ^ a b Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN (July 2009). "Hyperglycemic crises in adult patients with diabetes". Diabetes Care 32 (7): 1335–43. doi:10.2337/dc09-9032. PMC 2699725. PMID 19564476. 
  23. ^ Lambert P, Bingley PJ (2002). "What is Type 1 Diabetes?". Medicine 30: 1–5. doi:10.1383/medc. 
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  62. ^ "Pancreas Transplantation". American Diabetes Association. Retrieved 9 April 2014. 
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  75. ^ Oxford English Dictionary. -ite. Retrieved 2011-06-10.
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  80. ^ Washington R.E., Andrews R.M., Mutter R.L. (November 2013). "Emergency Department Visits for Adults with Diabetes, 2010". HCUP Statistical Brief #167. Rockville MD: Agency for Healthcare Research and Quality. 
  82. ^ a b Maria Rotella C, Pala L, Mannucci E (Summer 2013). "Role of Insulin in the Type 2 Diabetes Therapy: Past, Present and Future.". International journal of endocrinology and metabolism 11 (3): 137–144. doi:10.5812/ijem.7551. PMC 3860110. PMID 24348585. 

Further reading

External links