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Diabetes mellitus is a syndrome with disordered metabolism and inappropriate hyperglycemia due to either a deficiency of insulin secretion or to a combination of insulin resistance and inadequate insulin secretion to compensate Type 1 diabetes is due to pancreatic islet B cell destruction predominantly by an autoimmune process, and these patients are prone to ketoacidosis Type 2 diabetes is the more prevalent form and results from insulin resistance with a defect in compensatory insulin secretion (Table 27 2)
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Polyuria, polydipsia, and weight loss associated with random plasma glucose 200 mg/dL Plasma glucose of 126 mg/dL or higher after an overnight fast, documented on more than one occasion Ketonemia, ketonuria, or both Islet autoantibodies are frequently present
A Type 1 Diabetes Mellitus
This form of diabetes is immune-mediated in over 90% of cases and idiopathic in less than 10% The rate of pancreatic B cell destruction is quite variable, being rapid in some individuals and slow in others Type 1 diabetes is usually associated with ketosis in its untreated state It occurs at any age but most commonly arises in children and young adults with a peak incidence before school age and again at around puberty It is a catabolic disorder in which circulating insulin is virtually absent, plasma glucagon is elevated, and the pancreatic B cells fail to respond to all insulinogenic stimuli Exogenous insulin is therefore required to reverse the catabolic state, prevent ketosis, reduce the hyperglucagonemia, and reduce blood glucose 1 Immune-mediated type 1 diabetes mellitus The highest incidence of immune-mediated type 1 diabetes mellitus is in Scandinavia and northern Europe, where the annual incidence is as high as 37 per 100,000 children aged 14 years or younger in Finland, 27 per 100,000 in Sweden, 22 per 100,000 in Norway, and 19 per 100,000 in the United Kingdom The annual incidence of type 1 diabetes decreases across the rest of Europe to 10 per 100,000 in Greece and 8 per 100,000 in France Surprisingly, the island of Sardinia has as high an annual incidence as Finland (37 per 100,000) even though in the rest of Italy, including the island of Sicily, it is only 10 per 100,000 per year In the United States, the annual incidence of type 1 diabetes averages 15 per 100,000, with higher rates in states more densely populated with persons of Scandinavian descent such as Minnesota Worldwide, the lowest incidence of type 1 diabetes (< 1 case per 100,000 per
Type 2 diabetes:
Most patients are over 40 years of age and obese Polyuria and polydipsia Ketonuria and weight loss generally are uncommon at time of diagnosis Candidal vaginitis in women may be an initial manifestation Many patients have few or no symptoms Plasma glucose of 126 mg/dL or higher after an overnight fast on more than one occasion After 75 g oral glucose, diagnostic values are 200 mg/dL or more 2 hours after the oral glucose Hypertension, dyslipidemia, and atherosclerosis are often associated
Epidemiologic Considerations
In 2002, an estimated 182 million people in the United States had diabetes mellitus, of which approximately 1 million have type 1 diabetes and the rest mostly have type 2 diabetes A third group that was designated as other specific types by the American Diabetes Association (ADA) (Table 27 1) number only in the thousands Among these are the rare monogenic defects of either B cell function or of insulin action, primary diseases of the exocrine pancreas, endocrinopathies, and drug-induced diabetes Updated information about the prevalence of diabetes in the United States is available from the Centers for Disease Control and Prevention (http://wwwcdcgov/diabetes/pubs/estimateshtm)
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