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What is Diabetes?
Diabetes is a chronic health condition that is characterized by high blood glucose levels. Under normal conditions, the body uses sugar (glucose) to produce energy that is required to perform essential and daily functions.
Sugar is mainly obtained from a variety of food sources such as bread, fruits, starchy vegetables, and milk. To convert sugar into energy, it is the responsibility of a hormone known as insulin that acts as a key by helping sugar particles pass from the blood into the cell. Insulin is produced by the pancreas, a gland that is located underneath the liver and behind the stomach. When the pancreas is unable to produce insulin, produces it in smaller amounts (not enough for the body’s needs), or the body is not responding well to the insulin’s action (a phenomenon known as insulin resistance), this leads to diabetes.
As a result, the sugar cannot be used by the body and remains in the blood in high levels which is known as “hyperglycemia”.
Types of Diabetes
Type 1 Diabetes
This type is more common in children but can occur at any age; it is not caused by weight gain or eating large amounts of sugar. In this case, the insulin is completely deficient because the pancreas is not able to produce it. It is believed that the immune cells, particularly lymphocytes, attack the pancreas and destroy all cells that are responsible of secreting insulin. Consequently, the sugar accumulates in the blood and cannot reach cells to produce energy; this leads to high blood sugar levels and the appearance of diabetes symptoms.
Type 1 diabetes is mainly caused by genetic and immunologic factors that CANNOT be prevented. It accounts for 10% only of all diabetes cases.
Type 2 Diabetes
This type is more common in adults after the age of 40 years but, unfortunately, it has started to develop recently in children due to unhealthy eating habits and sedentary lifestyles. Type 2 diabetes is strongly influenced by being overweight, obese, and physically inactive. The pancreas in T2DM of diabetes is still able to produce insulin, but the amount is not enough for the body’s needs, or the body cells are not able to use it (insulin resistance) or both scenarios may result in impaired glucose regulation.
Gestational Diabetes
Usually occurs in women during the second trimester of pregnancy due to the hormonal changes and insulin resistance; it usually disappears after childbirth. However, it remains a risk factor that may lead to type 2 diabetes in the future.
Maturity Onset Diabetes of the Young (MODY)
Maturity Onset Diabetes of the Young (MODY) is not as common as the previously discussed types. It is caused due to an error in one gene that the affected person inherited from one or both parents. MODY is classified into many subtypes that can be managed by lifestyle interventions, sugar (glucose) lowering medications, or insulin injections. Because it can be transmitted to some of the offspring, medical investigation of children of affected parents is recommended to detect children who may carry this gene.
Symptoms of Diabetes
Diagnosing diabetes is commonly made by coincidence because many people cannot feel any of these symptoms. Regular medical checkups are essential for those who are at risk of developing diabetes to prevent any late detection of the condition.
Most common symptoms to look out for include:
- Frequent urination
- Frequent thirst
- Frequent hunger
- Impaired vision
- Unexplained weight loss (especially in children)
- Extreme tiredness
- Urinary and genital infections
- Wounds that won’t heal
Specific symptoms in type 1 diabetes
- Involuntary urination (bed wetting)
- Fast shallow breath with fruity odor which is an indication of critical condition known as diabetic ketoacidosis that needs immediate medical attention.
NOTE: Diagnosis is commonly made by coincidence because many people cannot feel any of these symptoms. Regular medical checkups are essential for those who are at risk of developing diabetes to prevent any late detection of the condition.
Causes of Diabetes
Type 1 Diabetes
This type is mainly caused by genetic and immunologic factors that CANNOT be prevented. It accounts for 10% only of all diabetes cases.
Type 2 Diabetes
The main cause of type 2 diabetes in not fully understood, but there are some risk factors that may lead to it such as overweight and lack of physical activity. Also, aging, family history, smoking, and some medications, such as corticosteroids, may lead to type 2 diabetes. There are specific risk factors in women such as previous history of diabetes during pregnancy (gestational diabetes) or polycystic ovarian syndrome. This type occurs in 90% of all diabetes cases.
Diabetes Complications
Diabetes complications can be divided into:
Acute complications
- Low blood glucose levels (hypoglycemia) in both type 1 and 2 diabetes,
- Diabetes ketoacidosis when blood sugar levels are extremely high
These complications can be prevented by regular monitoring of blood sugar and compliance to the treatment plan.
Long-term diabetes complications
- Heart and blood vessels disease
- Kidney disease
- Eye disorders which may cause vision loss
- Neuropathy
- Diabetic foot that may lead to amputation
Fortunately, it is possible to prevent or delay diabetes long-term complications and enjoy a normal active healthy life by following the treating doctor’s and diabetes-care team’s instructions. The diabetes-care team include a diabetes educator, dietitian, pharmacist, ophthalmologist, dentist, podiatrist, and fitness instructor.
It is important to be compliant with medical appointments, lab tests, and perform regular foot, eye, and teeth examinations. Adopting a healthy lifestyle is exceptionally important in addition to previously mentioned precautions.
Diagnosis
There are three lab test results that are required for a proper diagnosis by the physician:
| Lab Test | Normal | Pre-diabetes | Diabetes |
| Fasting glucose | Less than 5.6 mmol/L (< 100 mg/dL) | 5.6 – 6.9 mmol/L (100 – 125 mg/dL) | 7 mmol/L or greater (≥ 126 mg/dL) |
| 2 hours after meal | Less than 7.8 mmol/L (<140 mg/dL) | 7.8 – 11 mmol/L (140 – 199 mg/dL) | 11.1 mmol/L or greater (≥ 200 mg/dL) |
| HbA1c | Less that 5.7% | 5.7 – 6.4% | 6.5% or greater |
Treatment
Type 1 Diabetes
Until this day, this type cannot be cured or prevented. People with type 1 diabetes need injectable insulin therapy for survival. There are some medical centers that offer pancreatic transplant for those who have severe diabetes complications, such as kidney failure or recurrent low blood sugar (hypoglycemia).
Type 2 Diabetes
This type can be managed by lifestyle modification with or without the addition of glucose lowering medications, some of which can be taken by mouth and some can be injected, or by adding insulin therapy to the treatment regimen. In Dasman Diabetes Institute, there is a specialized remission clinic offering services for newly diagnosed people with type 2 diabetes by implementing lifestyle interventions that can lead to diabetes remission.
Glucose-Lowering Agents
It is highly recommended for people with type 2 diabetes to eat healthy and to exercise regularly (lifestyle modification approach). However, if blood sugar levels are not controlled by this approach, the treating doctor may consider diabetes medications that are commonly used to manage this condition. These medications are classified into different groups according to their unique action and how they work to help keep blood sugar levels under control. The medications also differ in the way they are administered; some can be taken orally in tablet form whilst others can be injected.
Selection of medication for treating type 2 diabetes
Depending on the patient’s medical history, the treating doctor may prescribe one glucose-lowering agent or more to help manage blood sugar levels appropriately. Usually, metformin (from the biguanide class of medications) is the first choice for people with type 2 diabetes, in addition to lifestyle modification. If metformin alone is not effective in controlling blood sugar levels, another medication can be given as an alternative or in addition to metformin. The type of medication the doctor selects depends on many factors, examples of which are:
- Risks and benefits of medication selected
- If the medication causes weight gain or weight reduction
- Other health conditions the patient has
- Other medications the patient takes (drug interactions)
- If patient accepts injections
- Cost of medication
Glucose-lowering agents do not cure diabetes; they may work together to keep the condition under control. People with type 2 diabetes may need to take multiple medications that work in different ways to reduce high glucose levels. For more information about the different medication groups, below is a summary of the agents belonging to each category:
Biguanides
Metformin is the only medication belonging to this group; the common brand name is Glucophage®. Please be aware that it is also available in other brand names based on the manufacturing company.
Indication
- Type 2 diabetes
Mechanism of Action
- Reduces the production of sugar (glucose) in the liver
- Reduces insulin resistance
Side Effects
- Most common side effects are related to the gastrointestinal tract such as nausea, vomiting, stomachache/discomfort, diarrhea or constipation, and metallic taste.
- Metformin does not directly affect kidney function. However, if kidney function is impaired, Metformin dose adjustment might be necessary by the treating doctor.
- As Metformin does not stimulate insulin production, the risk of low blood sugar (hypoglycemia) is less likely to occur.
Additional information related to medication use
- It is important to consult your doctor before and after having examinations that require contrast dye. The contrast dye may affect kidney function which warrants the discontinuation of the medicine.
- The medication may be temporarily stopped in case of gastroenteritis (stomach flu) which is accompanied by vomiting and diarrhea until you feel better.
- The product is available in immediate release formulation, the effect of which may last for 6-8 hours taken on regular intervals. Strengths available include: 500mg, 850 mg, and 1000mg.
- It is also available in extended release formulation (XR) that may last up to 24 hours. The dose can be taken once daily or in regular intervals.
Insulin Secretagogues
Two subgroup medications belong to this group including:
A: Sulfonylureas
Indication
- Type 2 diabetes
Mechanism of Action
- Stimulates the pancreas to produce insulin
Side Effects
- Hypoglycemia (low blood sugar)
- Weight gain
Examples of Medications in this Subgroup
Amaryl® (Glimepiride): Starting from 1-2mg with a maximum dose of 8mg. It is taken ONCE daily with the first meal.
Diamicron® (Gliclazide): Starting from 30mg with a maximum dose of 120mg. It is taken ONCE daily with the first meal; its effect lasts for 24 hours.
Daonil® (Glibenclamide): Starting from 2.5mg – 5mg with a maximum dose of 20mg. It is taken ONCE or TWICE daily with food.
Minidiab® (Glipizide): Starting from 2.5mg – 5mg with a maximum dose of 20mg. It is taken ONCE daily with the first meal.
Contraindications: Sulfa allergy
B. Meglitinides
Examples of Medications in this Subgroup
Novonorm® (Repaglinide): Starting from 1 mg – 2 mg before meals (can be taken 3-4 times daily according to meal consumption). The maximum daily dose is 16mg.
Additional Information related to medication use:
The medication should only be taken with food. If you are skipping a meal, the dose of that meal should not be taken.
Mechanism of action and side effects are similar to sulfonylureas. However, Hypoglycemia is less likely to occur compared to sulfonylurea.
DPP-4 Inhibitors
Indication
- Type 2 diabetes
Side Effects
- Flu-like symptoms
Examples of Medications in this Subgroup
Galvus® (Vildagliptin): ONE tablet to be taken ONCE or TWICE daily
Januvia® (Sitagliptin): ONE tablet to be taken ONCE daily before or after food
Onglyza® (Saxagliptin): ONE tablet to be taken ONCE daily before or after food
Trajenta® (Linagliptin): ONE tablet to be taken ONCE daily before or after food
All previously mentioned medications in this group may need adjustment by the treating doctor in case of kidney impairment, except for Trajenta® (Linagliptin). The maximum dose of Trajenta® (Linagliptin) can be taken in cases of kidney failure and dialysis.
Additional Information related to medication use:
The medications in this group can be taken before or after food, preferably the same time every day. They are less likely to directly cause hypoglycemia, but the risk of hypoglycemia increases if taking multiple glucose lowering medications or those that stimulate insulin production.
GLP-1 Analogues
All medications in this group are subcutaneous injections. These agents cannot substitute insulin.
Indication
- Type 2 diabetes
Side Effects
- Nausea and vomiting
- Stomachache
Mechanism of Action
- Reduces the production of sugar (glucose) in the liver
- Slows stomach motility
- Suppresses appetite
- Helps in weight loss
Examples of Medications in this Subgroup
Victoza® (Liraglutide): Subcutaneous injection to be administered starting from 0.6 mg. The dose shall be gradually increased according to the treating doctor’s instructions to a maximum daily dose of 1.8 mg ONCE daily.
Trulicity® (Dulaglutide): Subcutaneous injection to be administered ONCE WEEKLY. It is available in 0.75 mg and 1.5 mg.
Bydureon® (Exenatide): Subcutaneous injection to be administered ONCE WEEKLY. Available in 2 mg.
All previously mentioned medications in this group may need adjustment by the treating doctor in case of kidney impairment, except for Trajenta® (Linagliptin). The maximum dose of Trajenta® (Linagliptin) can be taken in cases of kidney failure and dialysis.
Contraindications
- Previous history of pancreatitis
- Family history of some forms of thyroid cancer
Additional Information related to medication use:
They are less likely to directly cause hypoglycemia, but the risk of hypoglycemia increases if taking multiple glucose lowering medications or those that stimulate insulin production.
SGLT2 Inhibitors
Side Effects
- Frequent urination
- May cause urinogenital infections
Mechanism of Action
- Prevents sugar (glucose) re-absorption by kidneys, which leads to excess sugar being excreted with urine
Examples of Medications in this Subgroup
Forxiga® (Dapagliflozin): Dose starts from 5 mg to 10 mg ONCE daily
Jardiance® (Empagliflozin): Dose starts from 10 mg to 25 mg ONCE daily
Invokana® (Canagliflozin): Dose starts from 100 mg to 300 mg ONCE daily
Additional Information related to medication use:
- It is preferred to take these medications in the daytime to avoid any sleep disturbance at night when there is a need to go to the toilet.
- The medications in this group can be taken before or after food, preferably at the same time every day.
- They may cause dehydration if water consumption is inadequate (according to the treating doctor recommendations).
- They are less likely to directly cause hypoglycaemia, but the risk of hypoglycaemia increases if taking multiple glucose lowering medications or those that stimulate insulin production.
- They may help to lose weight in case of overweight.
Prediabetes
Prediabetes is an intermediate silent stage between normal and type 2 diabetes. Blood sugar levels in this stage are above normal but not high enough to meet diabetes diagnostic standards. Statistics show that 84% of people who are not aware of their blood glucose are at higher risk to develop type 2 diabetes, heart disease, or stroke.
It is good to know that prediabetes is a reversible stage (preventable). Following a healthy lifestyle can bring high sugar values back to normal and thus prevent or delay the progression to type 2 diabetes and other complications.
Prediabetes Causes
Insulin is a hormone secreted from the pancreas to regulate high blood sugar levels. Think about insulin like a key that opens the cell’s gate for sugar molecules to enter the cell to produce energy. In prediabetes, the cells cannot respond well to the action of insulin (a phenomenon known as insulin resistance). Hence, the blood sugar levels start to rise. Consequently, the pancreas tries to compensate by producing more insulin and eventually becomes exhausted. Insulin production rate decreases and becomes insufficient to meet the body’s needs. The blood sugar levels in this case continue to rise. If high blood sugar levels are not controlled at this stage, the decline in insulin levels continues in its path to type 2 diabetes.
Risk Factors
Prediabetes is associated with some risk factors. These risk factors may include:
- Overweight and waist size: Being overweight with a larger waist size than normal is the main risk factor for prediabetes, especially if fat is accumulated around the abdomen (central obesity). The fat in this area causes pressure on vital internal organs such as the liver and pancreas, which worsens insulin resistance. The risk of insulin resistance increases in men with waist size of (102cm) or larger and in women with waist size of (88cm) or larger.
- Age: the risk of prediabetes increases after the age of 45, however, it may develop at any age.
- Unhealthy diet: A diet high in fat and carbohydrates (sugar) increases the risk of prediabetes.
- Physical inactivity: The more sedentary the lifestyle is, the higher the risk to develop prediabetes.
- Family history: The risk of prediabetes increases if first degree relative (parent or sibling) has type 2 diabetes.
- Ethnicity: Risk of prediabetes increases in some races than others for unclear reasons. African Americans and Asians are at higher risk to develop prediabetes.
- Obstructive sleep apnea: It is a condition that repeatedly disturbs sleep and increases the risk to develop prediabetes.
- Smoking: Tobacco smoke may lead to insulin resistance and central obesity and thus increases the risk of prediabetes.
Specific risk factors in women:
- Gestational diabetes: If a woman was previously diagnosed with gestational diabetes (diabetes while pregnant) or had a baby who weighed 4 kilos or more at birth, both the mother and the child at higher risk to develop type 2 diabetes after an associated stage of prediabetes.
- Polycystic ovarian syndrome: Women with this condition usually complain of irregular menstrual cycles, excess facial and body hair growth, and obesity. They are usually at higher risk to develop prediabetes.
Other health conditions (known as metabolic syndrome), especially if accompanied by obesity, are also associated with prediabetes may include:
- High blood pressure (Hypertension)
- Abnormal blood lipid levels (Low levels of the good cholesterol (HDL) and high levels of bad cholesterol (LDL) and triglycerides).
Signs and Symptoms
Prediabetes usually goes undetected for years because it is asymptomatic (with no clear symptoms) until type 2 diabetes symptoms start to appear. However, one possible sign can be observed and linked to prediabetes which is darkened patches of skin on some body parts such as the neck, joint (elbows, fingers’ joints, or knees), and armpits. This condition is known as acanthosis nigricans. If prediabetes is not treated at this stage, classic symptoms of diabetes may show up which include:
- Frequent hunger
- Excessive thirst
- Frequent urination
- Disturbed vision
Prediabetes and Diabetes Diagnostic Criteria
Three blood tests that are performed at medical laboratory are important to decide whether the person is normal or having prediabetes or diabetes. These tests are blood fasting glucose (sugar), oral glucose tolerance test (OGTT), and HbA1c.
Fasting plasma glucose test (FPG):
This test requires at least 8 hours fasting (fasting means no food/drink is taken during the past 8 hours, except water). The lab. technician will take a blood sample from your blood vessel.
Oral glucose tolerance test (OGTT):
Upon completing FPG test, a solution that contains 75g of sugar must be drunk. After two hours of ingesting the solution, another blood sample shall be taken.
Haemoglobin A1c (HbA1c):
This blood test gives an average level for blood sugar over the past three months.
Blood test results:
| FPG | OGTT | HbA1c | |
| Diabetes | 7mmol/L or more | 11.1mmol/L or more | 6.5% or higher |
| Prediabetes | 5.6 to 6.9mmol/L | 7.8 – 11mmol/L | 5.7 to 6.4% |
| Normal | Less than 5.6mmol/L | Less than 7.8mmol/L | 5.6% or less |
Type 2 diabetes Prevention: As mentioned earlier, prediabetes can be reversed and the progression to type 2 diabetes can be prevented or delayed by following a healthy lifestyle. Increasing physical activity and losing a small percentage (5% to 7%) of total weight reduce the risk of developing type 2 diabetes. In addition, brisk walking, or any other moderate activity for at least 30 minutes a day can help in lowering the risk of developing type 2 diabetes. Also, bear in mind that it is important to control blood pressure and cholesterol levels as well.
Our Advice
There are some basic actions that should be taken by all people with diabetes, whether type 1 or 2, to maintain good health and to prevent/delay diabetes-related complications. These actions may include:
- Follow a healthy and balanced diet
- Regular physical activity, preferably on daily basis for at least 30 minutes. Exercise improves insulin resistance which helps in maintaining normal blood glucose levels
- Quit smoking
- Regular blood sugar monitoring, especially for insulin users
- Medication and insulin compliance as directed by the treating doctor
- Regular follow up with the treating doctor and medical tests
Type 1 diabetes cannot be prevented but it is possible to prevent or delay type 2 diabetes by following a healthy lifestyle that includes:
- Increasing physical activity
- Eating healthy food
- Quitting smoking
- Maintaining healthy weight
Diabetes and Driving: All people treated with insulin injections or medications that stimulate the pancreas should closely monitor their blood sugar levels before driving their vehicles. This is extremely important, as it can prevent hypoglycemia while driving. Hypoglycemia can be life-threatening if it occurs on the road and may cause serious injuries for those travelling with you, in other vehicles, and to pedestrians.
