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Diabetes mellitus is a chronic disease caused by inherited and/or acquired deficiency in production of insulin by the pancreas, or by the ineffectiveness of the insulin produced. Such a deficiency results in increased concentrations of glucose in the blood, which in turn damage many of the body's systems, in particular the blood vessels and nerves.

There are two principal forms of diabetes:

*Type 1 diabetes (formerly known as insulin-dependent) in which the pancreas fails to produce the insulin which is essential for survival. This form develops most frequently in children and adolescents, but is being increasingly noted later in life.

*Type 2 diabetes (formerly named non-insulin-dependent) which results from the body's inability to respond properly to the action of insulin produced by the pancreas. Type 2 diabetes is much more common and accounts for around 90% of all diabetes cases worldwide. It occurs most frequently in adults, but is being noted increasingly in adolescents as well. Certain genetic markers have been shown to increase the risk of developing Type 1 diabetes. Type 2 diabetes is strongly familial, but it is only recently that some genes have been consistently associated with increased risk for Type 2 diabetes in certain populations. Both types of diabetes are complex diseases caused by mutations in more than one gene, as well as by environmental factors.

Diabetes in pregnancy may give rise to several outcomes, including congenital malformations, increased birth weight and an elevated risk of perinatal mortality. Strict metabolic control may reduce these risks to the level of those of non-diabetic expectant mothers.

Impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG) refer to levels of blood glucose concentration above the normal range, but below those which are diagnostic for diabetes. Subjects with IGT and/or IFG are at substantially higher risk of developing diabetes and cardiovascular disease than those with normal glucose tolerance. The benefits of clinical intervention in subjects with moderate glucose intolerance is a topic of much current interest.

Symptoms:

The symptoms of diabetes may be pronounced, subdued, or even absent.

* In Type 1 diabetes, the classic symptoms are excessive secretion of urine (polyuria), thirst (polydipsia), weight loss and tiredness.

* These symptoms may be less marked in Type 2 diabetes. In this form, it can also happen that no early symptoms appear and the disease is only diagnosed several years after its onset, when complications are already present.

Prevalence:

* Recently compiled data show that approximately 150 million people have diabetes mellitus worldwide, and that this number may well double by the year 2025. Much of this increase will occur in developing countries and will be due to population growth, ageing, unhealthy diets, obesity and sedentary lifestyles.

* By 2025, while most people with diabetes in developed countries will be aged 65 years or more, in developing countries will be in the 45-64 year age bracket and affected in their most productive years. Diagnosis:

* WHO has published recommendations on diagnostic values for blood glucose concentration. The diagnostic level of fasting blood glucose concentration was last modified in 1999. Treatment:

* The mainstay of non-pharmacological diabetes treatment is diet and physical activity.

* About 40% of diabetes sufferers require oral agents for satisfactory blood glucose control, and some 40% need insulin injections. This hormone was isolated by Frederic Banting and Charles Best in 1921 in Canada. It revolutionized the treatment of diabetes and prevention of its complications, transforming Type 1 diabetes from a fatal disease to one in which long-term survival became achievable.

* People with Type 1 diabetes are usually totally dependent on insulin injections for survival. Such people require daily administration of insulin. The majority of people suffering from diabetes have the Type 2 form. Although they do not depend on insulin for survival, about one third of sufferers needs insulin for reducing their blood glucose levels.

* Insulin is unavailable and unaffordable in many poor countries, despite being listed by WHO as an essential drug. Access to insulin by those who require it is a subject of special concern to international health agencies and national health authorities. Complications associated with Diabetes Mellitus:

* Diabetic retinopathy is a leading cause of blindness and visual disability. Diabetes mellitus is associated with damage to the small blood vessels in the retina, resulting in loss of vision. Findings, consistent from study, make it possible to suggest that, after 15 years of diabetes, approximately 2% of people become blind, while about 10% develop severe visual handicap. Loss of vision due to certain types of glaucoma and cataract may also be more common in people with diabetes than in those without the disease.

Good metabolic control can delay the onset and progression of diabetic retinopathy. Loss of vision and blindness in persons with diabetes can be prevented by early detection and treatment of vision-threatening retinopathy: regular eye examinations and timely intervention with laser treatment, or through surgery in cases of advanced retinopathy. There is evidence that, even in developed countries, a large proportion of those in need is not receiving such due to lack of public and professional awareness, as well as an absence of treatment facilities. In developing countries, in many of which diabetes is now common, such care is inaccessible to the majority of the population.

* Diabetes is among the leading causes of kidney failure, but its frequency varies between populations and is also related to the severity and duration of the disease. Several measures to slow down the progress of renal damage have been identified. They include control of high blood glucose, control of high blood pressure, intervention with medication in the early stage of kidney damage, and restriction of dietary protein. Screening and early detection of diabetic kidney disease are an important means of prevention.

* Heart disease accounts for approximately 50% of all deaths among people with diabetes in industrialized countries.

Risk factors for heart disease in people with diabetes include smoking, high blood pressure, high serum cholesterol and obesity. Diabetes negates the protection from heart disease which pre-menopausal women without diabetes experience. Recognition and management of these conditions may delay or prevent heart disease in people with diabetes.

* Diabetic neuropathy is probably the most common complication of diabetes. Studies suggest that up to 50% of people with diabetes are affected to some degree. Major risk factors of this condition are the level and duration of elevated blood glucose. Neuropathy can lead to sensory loss and damage to the limbs. It is also a major cause of impotence in diabetic men.

* Diabetic foot disease, due to changes in blood vessels and nerves, often leads to ulceration and subsequent limb amputation. It is one of the most costly complications of diabetes, especially in communities with inadequate footwear. It results from both vascular and neurological disease processes. Diabetes is the most common cause of non-traumatic amputation of the lower limb, which may be prevented by regular inspection and good care of the foot.

Prevention:

Large, population-based studies in China, Finland and USA have recently demonstrated the feasibility of preventing, or delaying, the onset of diabetes in overweight subjects with mild glucose intolerance (IGT).

The studies suggest that even moderate reduction in weight and only half an hour of walking each day reduced the incidence of diabetes by more than one half. Diabetes is a serious and costly disease which is becoming increasingly common, especially in developing countries and disadvantaged minorities. However, there are ways or preventing it and/or controlling its progress. Public and professional awareness of the risk factors for ,and symptoms of diabetes are an important step forwards its prevention and control.

(WHO Release)

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