Diagnosis of  Diabetes

  Recognizing Symptoms: David M. Huffman, MD, FACE

David M. Huffman, MD,FACEForty years ago in small towns across this country, children who developed diabetes were often near death by the time their doctors recognized their symptoms.  David Huffman was one such, who set out to change the treatment of diabetes, and the doctors who attempt it, by any means necessary…

Type 1 Diabetes Mellitus: Diabetes was first named by Aretaeus of Cappadocia in approximately 30 AD, as a reference to a disorder with no treatment which produced "a wonderful wasting of the body into urine". The term "mellitus", meaning sweet, was added after the urine was noted to be sticky or sweet to taste. The original description primarily referred to a disorder which killed young people, usually rapidly, which we now call type 1 diabetes. Many physicians wrote about this form of diabetes, which occurred without warning in previously healthy persons, caused extreme thirst and polyuria, followed by weight loss and death accompanied by a fruity odor during the final days. Many treatments were offered for type 1diabetes in the 18th and 19th centuries, and by the turn of the 20th century most patients with symptoms of type 1 diabetes were treated in asylums with starvation diets, which could prolong life only briefly while producing human skeletons. The surviving photographs of such patients are painful to view.

We know now that type 1 diabetes is an autoimmune disorder, in which the immune system recognizes the beta cells (the cells in the pancreas which make insulin) as foreign, and destroys most or all of these cells. About 0.5-1 percent of the population in North America develops type 1 diabetes. Some genes predispose people to type 1 diabetes, but another stimulus, such as a viral infection, may be necessary to cause beta cell destruction. In most people with type 1 diabetes, we can measure antibody proteins in the blood which bind to the beta cells. Because they have little or no insulin, people with Type 1 diabetes require insulin treatment. Oral agents do not work in most people with type 1 diabetes, and are rarely used.

How do you tell a person with type 1 diabetes? These people are typically thinner, and do not have a family history of diabetes. Most are young at diagnosis; peak incidence occurs at ages 8 and 15 years, but it can occur at any age.

Type 2 Diabetes Mellitus: In the early 1600s, English surgeon Thomas Willis wrote of a diabetes which occurred in people who were obese and ate and drank heavily. This form of diabetes was associated with infections, particularly of the feet, and with heart attack and stroke. This was a disorder which was associated with affluence. Throughout the years thereafter, reports of type 2 diabetes described a milder, more chronic, progression of symptoms leading to more deaths from complications than from wasting away. During war, depressions, and famine, type 2 diabetes was relatively rare. But in richer societies, it became increasingly common in the older population.

Now we know that type 2 diabetes occurs when the body becomes resistant to the effects of insulin, either because of weight gain, illness, or other stressors. People with type 2 diabetes initially have more insulin, but overwork eventually causes beta cell exhaustion and death, and insulin levels decline as years pass, leading to progression of diabetes. Type 2 diabetes is commonplace; about 20-25 percent of adults have genes which predispose them to diabetes if they become obese. About 7 to 9 percent of the North American population has type 2 diabetes.

Type 2 diabetes can be treated with diet and weight loss through exercise. Because many people have little inclination to exercise or diet, there are many oral agents which decrease insulin resistance or increase insulin production by the beta cells. Eventually, most people with type 2 diabetes will require insulin treatment.

Gestational Diabetes Mellitus: Pregnant women are very susceptible to diabetes. Today, about 1 of every 8 pregnancies in North America is complicated by diabetes. Pregnancy causes insulin resistance, and the diabetes produced is similar to type 2 diabetes. Untreated pregnant women with diabetes deliver very large, premature infants with a high rate of stillbirth and congenital anomalies. Controlling the blood sugar very well during pregnancy eliminates this risk. Most women with gestational diabetes are treated with diet or insulin. Women with a history of gestational diabetes have a high risk of developing type 2 diabetes later in life.

Latent Type 1 Diabetes Mellitus in Adults:  Since the discovery of autoantibodies it has been recognized that some adults, who were previously considered to have Type 2 diabetes, actually have Type 1 diabetes. According to the most recent classification of diabetes mellitus, latent autoimmune diabetes that is seen in adults, is actually a slow progressive form of Type 1 autoimmune diabetes mellitus. The terms Latent Autoimmune Diabetes in Adults or LADA, and Type 1.5 are sometimes used to describe this condition. Testing for the presence of circulating islet-cell antibodies (ICA), antibodies to glutamic acid decarboxylase (GAD), and careful clinical evaluation can help identify these individuals.

Characteristics Include:

Adult at time of diagnosis (usually over 25 years of age)

Initial presentation masquerades as non-obese type 2 diabetes

Does not present as diabetic ketoacidosis

Can initially be controlled with meal planning with or without diabetes pills

Insulin dependency gradually develops, frequently within months

Positive islet-cell antibodies (ICA), and antibodies to glutamic acid decarboxylase (GAD)

Low C-peptide levels

Often do not have a family history of type 2 diabetes

 

Dr Huffman is an Endocrinologist who enjoys woodworking, cabinet making, computer gadegtry, and maintaining his own computer networks . . . in his "spare time." He also enjoys cooking, biking, growing sprouts, and the occasional fine wine. . . In moderation of course! As a child he won the annual science fair by applying the thoughts of his curious mind, and has always been an avid reader, and researcher at heart.

 

Classification of Diabetes

Some people cannot be clearly classified as having Type 1 or Type 2 Diabetes Mellitus, as their clinical symptoms and the progression of their diabetes varies. There are times when people who would otherwise have Type 2 diabetes present with ketoacidosis, as would be expected with Type 1 diabetes. And there are times when people with Type 1 diabetes show early evidence of autoimmune disease, but have a late onset and slow progression of symptoms, as would be expected with Type 2 diabetes. Difficulty in diagnosis may occur in these children, adolescents, and adults and the true diagnosis may become more obvious over time.

In addition, there are other types of diabetes caused by conditions such as genetic defects in ß-cell function; genetic defects in insulin action; diseases such as cystic fibrosis; pancreatic or hormonal causes; drug and chemical induced diabetes; or following organ transplantation or treatment for AIDS.

Reference: ADA Clinical Practice Recommendations, Diabetes Care 2010

 

 

       Finding My Diagnosis: Nancy Hora

Nancy HoraI am a 53 year old married mother of three. During my second pregnancy in 1989 I was diagnosed with gestational diabetes when my glucose tolerance test resulted in blood glucose over 130. After the pregnancy I did not have any further problems. Then during the spring of 1996 I had a severe case of the flu. After recovering from the flu I began to loose weight. I was always thirsty, had to urinate constantly, and developed a urinary tract infection. My physician husband thought maybe I had diabetes. Lab results confirmed that my blood glucose was over 300. My internal medicine doctor started me on Metformin (glucophage). 

After a short period of time I began seeing an endocrinologist who determined I had Type I diabetes, and he started me on insulin.  The thought was to try to preserve what little amount of insulin my pancreas was still producing.  After 3 years of 5 shots of insulin a day, including every night at 2am, my endocrinologist started me on an insulin pump. 

From the beginning I have preferred being on an insulin pump. I could now sleep though the night again.  Also, I found it was easier to control my diabetes when I play golf by decreasing by basal level 30%.  I still have to watch what I eat and bolus the correct amount of insulin from my pump every time I eat.  Although controlling my diabetes is not always easy I find if I keep a journal and write down everything I eat, my blood glucose levels, and the amount of insulin I am bolusing, it is easier to talk to my Diabetes Care Team and my Doctor so they can help me take care of myself.

Nancy attended the University of Vermont in Burlington, and received her AS in Medical Technologies in 1978, and her BS in Biological Science in 1980. She has worked as a Research Technician at Duke University Medical Center, Stritch School of Medicine, Mayo Clinic, the University of Vermont School of Medicine, and Yale School of Medicine. Nancy has two daughters and a son, and enjoys spending quality time with her husband and family. She is active in her church, and especially enjoys the fellowship of their ladies "Bunco" group. But, her all time favorite activity is playing golf.  

 

 

 

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