Abstract
Diabetes mellitus is a condition that involves blood glucose levels. According to the literature, there are many different types of diabetes, some of which are insulin dependent. Other types are temporary and are not insulin dependent. When insulin secretion or production is defected, it takes a toll on an individuals’ body. It can cause mild and severe symptoms ranging from nausea to death. One main ethical issue involved with diabetes is newborn screening. Newborn screening is a process that screens newborn children for a predisposition for diabetes. This proposes an ethical issue because it causes great stress on the children and the children’s families. There is a strong basis for future investigations in diabetes. In the future, researchers will continue to investigate different causes and treatments for diabetes.
Literature review
Diabetes mellitus is a metabolic disease that affects an individuals’ cells. This condition can be developed by many different pathogenic processes, some of which are independent or dependent of insulin production and efficiency. One of those processes is an autoimmune destruction of beta cells in the pancreas. This destruction leads to a deficiency in insulin and is also the known cause for type 1 diabetes (Mellitus, 2005). Insulin plays an important role in a cell’s function because it allows glucose to enter a cell in order for the cell to obtain energy.
Type 1 diabetes accounts for about five to ten percent of all individuals with diabetes. This type of diabetes is also known as juvenile-onset diabetes. This autoimmune destruction is most commonly inherited on the HLA genotypes, and very rarely is associated with obesity. It can also be trigger by an environmental factor such as a virus or toxin. These factors will initiate beta cell destruction. A study performed in 2004 ruled out the notion that childhood vaccinations can trigger type 1 diabetes. It is common that beta cells are destroyed faster when diabetes occurs at a younger age, therefore, some individuals with type 1 diabetes become dependent on insulin for survival and need monitoring and screening in order to maintain health. Older patients compared to younger patients are more likely to be positively affected by immune interventions which are developed in order to preserve insulin secretion. (Daneman, 2006)
Individuals with type 1 diabetes have a higher risk of developing other autoimmune disorders. This disorders can range from Graves’ disease and Addison’s disease. It is also said that the development of diabetes can be dependent on certain variables within childhood. Some observations conclude that children who receive day care are more likely to develop diabetes compared to those who did not attend. This was concluded to be true because those children who do not attend day care are less exposed to infections, therefore, having a less chance of triggering beta cell destruction. This theory can be supported by an example of a migrating population in Asia. More incidences of developing diabetes were reported in Asian children whose families immigrated compared to others in that same location. This helps conclude that moving to new and foreign location can increase the risk of developing diabetes. (Daneman, 2006)
Type 2 diabetes, also known as non-insulin-dependent diabetes, accounts for about ninety to ninety-five percent of patients with diabetes. This type is generally developed in adults with insulin resistance and relative insulin deficiency. Type 2 diabetes is not caused by the destruction of beta cells but instead is caused many different factors. The most common reasoning behind type 2 diabetes is obesity. Obesity can correlation with insulin resistance, therefore, leading to the development of diabetes. Also, a patient that isn’t considered obese but still has a high amount of body fat in their abdominal region is still at risk for diabetes. This type of diabetes can go undiagnosed for years without any symptoms. (Mellitus, 2005)
In patients with type 2 diabetes, insulin secretion is defective therefore not compensating for insulin resistance. There are many treatments available in order to deal with insulin resistance. One treatment involves pharmacological treatment. This treatment with help with hyperglycemia which is the over-accumulation of glucose in the blood. Another viable treatment is exercise and diet change which will eventually lead to weight reduction. Since diet change and exercise can help treat diabetes, it is also a leading cause to developing this disease. The risk of developing this autoimmune disease increases with age as is also common in individuals with hypertension or dyslipidemia. This type of diabetes is also considered to have genetic predisposition with influences the likelihood of developing the disease. (Mellitus, 2005)
Another common type of diabetes is gestational diabetes mellitus. Gestational diabetes is a glucose intolerance that occurs only during pregnancy. Gestational diabetes occurs in about seven percent of all pregnancies and is usually tested for during the first prenatal doctor appointment. It is more common for women who are obese or have a family history of diabetes to develop this type of diabetes during their pregnancy. For gestational diabetes, a plasma glucose level greater than 126 milligrams per deciliter after fasting, meets the requirements to be diagnosed as diabetes. Also, a casual plasma glucose level that is greater than 200 milligrams per deciliter is also an indicator for gestational diabetes. (American, 2004)
Gestational diabetes is a temporary and manageable type of diabetes. All women diagnosed with gestational diabetes needs to undergo nutritional counseling. This counseling contains a change in calories intake so that it can be consistent with the required blood glucose levels. For women who are considered obese, a calorie restriction is necessary to maintain health. Some women also use insulin pharmacologic therapy based on maternal glycemia. Some treatments for diabetes are not recommended for pregnant women, for example, oral glucose-lowering agents. (American, 2004)
After delivery, women with gestational diabetes should be reevaluated for maternal glycemia. If glucose levels have returned back to normal, reevaluation of glycemia should be performed in three year intervals. If glucose levels are not back to normal, reassessment should be done every year. All women with gestational diabetes should become well educated before planning another pregnancy. Also, the children whose mothers’ had gestational diabetes should be monitored because they have a potential of becoming obese or developing other abnormalities. (American, 2004)
Most of the different forms of diabetes are associated with defects in the beta cell function. These defects are inherited and are caused by mutations on about six different genetic loci on chromosomes. The most common chromosome mutation occurs on chromosome 12. Another defect can occur on chromosome 7p and this mutation causes glucokinase molecules to become defective. When these molecules become defective it affects insulin secretion because glucokinase helps convert glucose to glucose-6-phosphate. Therefore, this defective gene leads to increased plasma glucose levels. Mitochondrial DNA mutations are also a known cause for diabetes mellitus. The most common defect in mitochondrial DNA occurs in the tRNA leucine gene. Other genetic defects can affect an individuals’ ability to convert proinsulin to insulin. These defects are usually inherited by an autosomal dominant pattern. (Mellitus, 2005)
According to Edghill (2008), a study was performed that concluded that there were sixteen different mutations in thirty-five probands. Three of these mutations resulted in diabetes in forty-six percent of their cases. These mutations were A24D, F48C, and R89C. This study also showed that many families experienced autosome dominant inheritance INS mutations. These mutations can be diagnosed at a variety of ages. The median age of patients diagnosed with this mutations was eleven weeks. Eighty-three percent of the families within this study had a child diagnosed with diabetes even though the parents were not affected. Forty-one percent of patients in this study had symptomatic hyperglycemia while fifty-nine percent of the patients had diabetic ketoacidosis. Diabetic ketoacidosis is a condition that can lead to coma and even death. All the patients within this study received insulin therapy.
Hypoglycemia is a side effect that can occur in patients with diabetes when too much insulin is taken or a meal is skipped. There are many mild, moderate, and severe symptoms and treatments of hypoglycemia. The mild symptoms include things such as trembling, sweating, nausea, hunger, and palpitations. A mild case of hypoglycemia can be treated by intake of simple sugars. Moderate hypoglycemia can be self-treated and has symptoms such as weakness, blurred vision, and dizziness. Severe hypoglycemia is a more serious condition that requires glucose injections in order to treat. The symptoms involved in this condition include unconsciousness and confusion. Diabetic patients should be well educated in the requirements needed to maintain health in order to be able self-treat themselves. Patients should be informed about how to properly distribute insulin and monitor blood glucose levels. (Daneman, 2006)
Monitoring glucose is a vital component in maintaining health for those with diabetes. Glucose monitoring requires a small amount of blood to be tested. This test allows for a patient to monitor and make any changes needed to their diet, activity, and insulin injection doses. A change in insulin dosage is determined from a glucose logbook. This logbook detects patterns of glucose levels and control and this data system allows for a doctor to determine any changes that need to be made. (Daneman, 2006)
Patients with diabetes are at a high risk of nephropathy. Nephropathy is known as renal failure and kidney disease. The percentage of patients with nephropathy is continuing to decrease due to an increase in control over glycaemia and hypertension. Diabetic nephropathy begins out as subclinical disease. It then proceeds to microalbuminuria then to macroalbuminuria. Finally, it will continue on to become end-stage renal disease. Patients with type 1 diabetes should be tested for microalbuminuria every year beginning at the early stage of their diagnosis. Individuals with type 1 diabetes and reach end-stage renal failure are less likely to respond to dialysis compared to others with different diseases. (Daneman, 2006)
Diabetes mellitus is common among older generations especially those in an ethnic minority. Older individuals with diabetes are more likely to suffer from premature death, hypertension, and heart disease. They are also more likely to suffer from a stroke compared healthy individuals. Depression and the likelihood of injurious falls are also more likely to occur in diabetic patients. These patients are required to have intensive blood glucose level control and are required to focus on the inhibition of microvascular complications. In order for an older patient to maintain health, it is necessary to maintain and develop self-management skills. Most patients are recommended to a diabetic mellitus educator for counseling and classes. It is also recommended that any close family members or caretakers should also attend classes in order to learn more about how to control and live with diabetes. (Foundation, 2003)
The Ethical Issue
Type 1 diabetes is one of the most common diseases seen in childhood. In order to determine if a child is at risk of developing diabetes mellitus, two states are now offering newborn screenings. These screenings are used to determine if and when a child will eventually develop autoantibodies that lead to the development of diabetes. The ethical issues involved in this newborn screening is discussed by Ross (2003). It is discussed that the research and testing involved in newborn screening should conform to meet more ethical principles, thus making it safer for children.
The screening performed on newborns has many risks and benefits. It has been evaluated that some individuals experience more risks than benefits. This process is also known to cause great distress within the children’s families. The data evaluated was gathered from families whose children had the presence of islet cell antibodies. This data revealed that some subgroups experienced more distress than others. This distress can be caused by multiple things including the fact that even if a child is diagnosed, there is no treatment to avoid the child from developing diabetes. (Ross, 2003)
According to Ross (2003), many research designs have been theorized in order to maintain ethical requirements. Some of those designs include minimizing the participants to families with a higher risk of diabetes due to a first-degree relative. TRIGR is one study performed that focused only on high-risk children in order to decrease the distress involved. Researchers believe this strategy is more ethical because it prevents many risks involved with unsuspecting parents. This strategy is also more ethical since newborn screening is just a prediction on whether or not a child might develop diabetes.
Future Directions and Conclusion
Diabetes mellitus is a common disease experienced around the world. It affects individuals of all ages and races. Diabetes will continue to be a popular topic for research and testing. There will constantly be studies developed on beta cell mutations and insulin secretion. As discussed in Daneman (2006), diabetic patients are more likely to develop other diseases and problems. This topic will continuously be studied and evaluated. Researchers will evaluate the reasoning behind this theory in order to hopefully develop a way to prevent it.
My personal opinion on newborn screening is that restricting the patients to high-risk families only is the more ethical way to approach the testing. Every precaution available to minimize risk and increase ethical values should be taken. I also believe that only families with a long history of diabetes should partake in newborn screening.
Many future directions and developments could be made about diabetes. Once development could potentially be a drug that helps maintain insulin levels for a longer period of time so that patients have to take fewer injections. This would be beneficial because it would help avoid any problems that occur when someone forgets to take an insulin injection. Another future development could be a treatment to help fix the function of the beta cells in order to prevent diabetes.