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Malnutrition-Related Diabetes: Pathophysiology, Factors, and Management

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Malnutrition-related diabetes is considered young-onset diabetes associated with chronic malnutrition.

Written byDr. Dharmashree. R. D

Medically reviewed byDr. Nagaraj

Published At October 27, 2023
Reviewed AtJuly 18, 2024

Introduction:

Diabetes (diabetes mellitus) is a chronic metabolic disease that causes high blood glucose (sugar) levels. This may be due to a lack of enough insulin produced by the pancreas and available insulin not effectively being used by the body. This may also develop when the body cannot respond properly to the effects of insulin. Diabetes is a public health problem that has been increasing globally and may affect all age groups.In 1985, the World Health Organization (WHO) classified DM into three categories - insulin-dependent (type 1 or juvenile diabetes), non-insulin-dependent (type 2 or adult-onset diabetes), and malnutrition-related diabetes (MRDM).

Malnutrition, on the other hand, is a state where nutrients are deficient, which may lead to unhealthy behaviors and low socioeconomic status. Though obesity is a risk factor for diabetes, researchers have found an association between malnutrition and diabetes.

What Is Malnutrition?

Malnutrition is defined as either deficiency due to a lower intake of nutrients or an excess intake. It may occur when there is an imbalance in the intake of essential nutrients or a defect in nutrient utilization. Malnutrition may lead to undernutrition, overweight and obesity, and diet-related noncommunicable diseases, which can be identified as wasting (weight for height), stunting (low height for age), being less weight (low weight for age), and deficiency of micronutrients (lack of vitamins and minerals). The condition may have effects on the composition and functions of the body. It may cause insulin deficiency, glucose intolerance, and insulin resistance. This may be the reason for increased diabetes mellitus.

What Is Malnutrition-Related Diabetes Mellitus?

MRDM (malnutrition-related diabetes mellitus) tends to occur among young individuals with nutritional deficiencies, especially in low and middle-income countries. The WHO (World Health Organization) previously set a criterion for identifying MRDM. Still, WHO removed it in 1999, saying there was a lack of evidence for its cause, which was malnutrition, or it may also be due to protein deficiency.

MRDM shows insulinopenia (fasting-C peptide level less than or equal to 110 percent of the normal lower limits of laboratory measurements), insulin resistance, hyperglycemia (high blood glucose levels), and partial failure of beta cells in the pancreas.

Symptoms of MRDM Include:

  • Loss of weight or muscle mass.

  • Changes in hair and skin.

  • Enlargement in the parotid gland.

What Is the Classification of Malnutrition-Related Diabetes Mellitus?

1. Fibrocalcific or Fibrocalculous Pancreatic Diabetes (FCPD) -This type of MRDM is observed in young individuals who are generally below the age of 30 years. These are found to have;

  • Malnutrition.

  • Require insulin for the control.

  • Resistance to ketosis (a metabolic state of high levels of ketone bodies in urine and blood).

  • Pancreatic calcifications (calcium build-up in blood vessels, body tissues, and organs).

  • Exocrine pancreatic dysfunction (inability to digest food due to lack of digestive enzymes in the pancreas.

Etiology of FCPD:

  • Exocrine pancreatic B cell dysfunction is the cause of FCPD.

  • Genetic susceptibilities like undernutrition (deficiency of calories or one or more essential nutrients), deficiency of micronutrients and sulfur-containing amino acids, and decreased free radicals like organic nitrides or cytochrome p450 cause damage to B cells of the pancreas.

  • Excess consumption of alcohol among old people causes pancreatic damage.

  • Pancreatic calculi (calculi are large, multiple, and intraductal).

  • Ducts usually show dilatation and fibrosis (scarring of the tissues). Fibrosis is due to inflammatory changes. FCPD is more prone to pancreatic cancer.

2. Protein-Deficient Pancreatic Diabetes (PDPA) - It is also known as protein-deficient diabetes mellitus (PDDM). Due to malnutrition, this type of MRDM is observed among young individuals who dwell in developed countries. It shows similar findings of FCPD but differs in findings like:

  • Absence of pancreatic dysfunction.

  • Relative insulin resistance.

  • Low body mass index (BMI).

  • Malnutrition.

  • Growth retardation.

Etiology of PDPD:

  • When this type of DM remains untreated for a long time, it indicates resistance to ketoacidosis (excess production and build-up of ketones in the blood, making it more acidic).

  • Ketosis resistance occurs as the liver fails to reduce glucose. This may be due to less active B cells. This, in turn, leads to insulin interruption.

  • This may lead to a shrunken fibrotic pancreas without calculi. Malnutrition is the cause of the initiation of functional impairment of pancreatic B cells.

What Is the Pathophysiology of Malnutrition-Related Diabetes Mellitus?

Factors involved in the etiopathology of MRDM include:

  • Malnutrition.

  • Infection.

  • Increased intake of cassava.

  • Destruction of pancreatic beta cells.

  • The exact etiology of MRDM is controversial.

Diabetes mellitus (DM) is a major health issue growing in the world. Many studies were conducted to determine the association between malnutrition and DM. A study has shown a link between chronic undernutrition and DM and reported that protein energy malnutrition (PEM) may be the cause.

Factors involved with malnutrition are as follows:

1. Prenatal Factors:

Some studies show a link between maternal malnutrition and type II DM may be due to decreased total food intake during pregnancy or early postnatal life that may lead to decreased glucose tolerance and diabetes in offspring. Another study indicates that permanently altered genes are involved in the signaling of insulin and lipids.

Maternal malnutrition causes a decrease in the fetal intrauterine development rate called intrauterine growth retardation (IUGR). Undernutrition during pregnancy leads to altered genes related to hepatic (liver) and pancreatic functions. A low protein diet during pregnancy may lead to increased oxidative stress (an imbalance between the antioxidants and free radicals in the body causing cell damage), fibrosis, dysfunction of mitochondria, and β-cell dysfunction. All these reasons may increase the risk of contracting type II DM later in life.

Not only undernutrition but even overnutrition also causes diabetes mellitus. A study has found that increased high-protein and high-fat diet consumption during pregnancy may cause insulin resistance.

2. Postnatal Factors:

Malnutrition during postnatal life may decrease glucose tolerance and increase the risk of offspring developing DM. A study has shown that poor nutrition, low socioeconomic status during childhood, and unhealthy behaviors may alter body composition later in life, which may be responsible for metabolic disorders like DM. A study has also shown that childhood undernutrition may increase the risk for type II DM in adulthood.

How to Diagnose Malnutrition-Related Diabetes?

Criteria to identify and diagnose MRDM are as follows:

  • The condition may occur between the ages of 10 to 30 years.

  • Background from low socioeconomic status.

  • Malnutrition during childhood.

  • BMI is less than 18 Kg/m² (kilogram per meter square).

  • The blood glucose level is greater than 200 mg/dl (milligram per deciliter) or 11.1mmol/L (millimoles per liter).

  • Absence of ketosis on insulin withdrawal.

  • The required insulin is 1.5 U/kg/day (unit per kilogram per day).

  • Clinical features overlap with type I and type II DM. It can be differentiated from type II DM, a defect in insulin secretion rather than resistance to peripheral insulin.

How to Manage Malnutrition-Related Diabetes?

MRDM can be managed by the following:

  • Self-diet management is recommended.

  • Adopting a healthy lifestyle with a balanced diet and regular exercise is recommended.

  • Restricting fat to greater than 30 percent of calorie intake and high sugars.

  • Multivitamin supplementation may be given.

  • Consuming high protein and fiber-rich foods.

  • Medications can be used to control diabetes.

Conclusion:

Nutrition has played an important role among humans. Diabetes mellitus is a condition that may affect the body in various ways if not treated properly. Since malnutrition is linked to diabetes mellitus, it is important to know about malnutrition-related diabetes. One should seek help from a healthcare professional as early diagnosis helps achieve effective treatment. This, in turn, helps in maintaining a good quality of life.

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Frequently Asked Questions

Several factors play pivotal roles in precipitating malnutrition-induced diabetes (a metabolic disorder characterized by high blood sugar levels in the blood), encompassing diminished protein consumption, deficiencies in essential micronutrients such as zinc, prenatal exposure to detrimental habits like smoking and alcohol consumption, prolonged fasting episodes like those endured during famine, enduring states of chronic undernourishment, and the presence of disorders like celiac disease impeding nutrient absorption.

Insufficient nutrition may hinder insulin production and diminish cellular responsiveness to insulin, allowing blood sugar levels to elevate unchecked. Insufficiency in carbohydrate consumption can limit glucose availability in circulation, potentially leading to hypoglycemia (low blood sugar). Furthermore, diets devoid of fiber pose a risk of erratic blood sugar fluctuations, as fiber aids in moderating sugar absorption, averting sudden surges.

The potential for reversing malnutrition-related diabetes mellitus hinges upon the degree of pancreatic impairment. In instances where severe malnutrition induces pancreatic atrophy, timely intervention holds promise for ameliorating the condition. Early identification coupled with thorough treatment protocols is imperative for maximizing prognosis among those afflicted with malnutrition-induced diabetes.

Malnutrition-induced diabetes may manifest with symptoms akin to other forms of diabetes, encompassing weight loss, swelling of the parotid glands, frequent urination, unquenchable thirst, heightened appetite, persistent fatigue, alterations in vision, drowsiness, parched and itchy skin, delayed wound healing, shifts in hair and skin condition, and the potential development of neuropathy over time.

To thwart the onset of malnutrition-induced diabetes, implementing diverse strategies is imperative. Embracing a well-rounded, nourishing diet packed with various foods—from vegetables and fruits to lean proteins and wholesome fats—stands as a cornerstone. Maintaining a consistent physical activity regimen proves pivotal in this endeavor. Heightening awareness regarding the perils of malnutrition is paramount. Regular monitoring of blood sugar levels serves as a proactive measure. Addressing root causes, be it insufficient food accessibility, substance misuse, or socioeconomic hindrances, is integral in preventing the emergence of malnutrition-induced diabetes.

Adhering to dietary recommendations requires fostering the consumption of a well-rounded diet teeming with vital nutrients. Encouraging the establishment of steady and predictable meal schedules is essential. Mitigating the intake of sugary fare and beverages is a prudent measure. Embracing sources abundant in healthy fats is advised. Maintaining proper hydration levels is crucial. Prioritizing consuming foods abundant in protein and fiber can be a preventive measure against malnutrition-induced diabetes.

Malnutrition, characterized by a deficiency in vital nutrients and chronic undernourishment, can damage the pancreatic beta cells responsible for insulin production. This impairment renders the body more susceptible to environmental triggers and genetic predispositions, thereby fostering the development of diabetes.

Malnutrition has the potential to induce insulin resistance through mechanisms such as starvation, wherein insulin levels decrease, affecting glucose transport in target cells and precipitating insulin resistance. Skipping meals can disrupt insulin and blood sugar levels, prompting increased fat accumulation in the abdominal region, consequently heightening the body's propensity to resist insulin.

The enduring ramifications linked to malnutrition-induced diabetes encompass a heightened susceptibility to cardiovascular afflictions such as strokes (a condition where blood flow to the brain is blocked) and heart attacks. Additionally, neuropathy may ensue, characterized by nerve damage resulting in sensations of numbness and tingling in the extremities. Prolonged diabetic states can precipitate renal impairment and compromised kidney function. Furthermore, adverse effects on the retinal blood vessels may lead to diabetic retinopathy, while mental health concerns can also arise as consequential complications.

Indeed, malnutrition can precipitate a cascade of health complications, including heightened susceptibility to heart disease and the potential for kidney damage, which, left unaddressed, may culminate in kidney failure. Vision impairment can ensue alongside nerve damage spanning the body, contributing to poor circulation and nerve afflictions in the feet. Furthermore, malnutrition-induced ailments may manifest as sluggish wound healing, exacerbating the risk of bacterial and fungal infections if not promptly managed.

Although malnutrition-related diabetes shares similarities with other diabetes types, its primary causative factors stem from malnutrition, starvation, and chronic undernourishment. While insulin therapy may be requisite, akin to other diabetic conditions, prioritizing nutritional rehabilitation and addressing underlying malnutrition form indispensable facets of treatment. Enhancing nutritional status is pivotal in this process, and in certain instances, individuals may achieve full recovery, obviating the need for continued insulin therapy.

Indeed, the treatment protocol for malnutrition-related diabetes diverges from approaches tailored to other diabetes variants. Central to MRDM (malnutrition-related diabetes mellitus) management is the imperative task of addressing the underlying malnutrition. Embracing a healthy lifestyle underscored by regular exercise is paramount in this endeavor. Additionally, supplementation with multivitamins is advised to bolster nutritional adequacy. Insulin therapy may be warranted to regulate blood sugar levels effectively, depending on the severity of hyperglycemia.

Implementing lifestyle modifications is pivotal in managing malnutrition-induced diabetes. This entails adopting a diet rich in essential nutrients and maintaining a balanced intake. Establishing consistent meal timing helps regulate blood sugar levels effectively. Regular engagement in physical activity contributes to overall health and aids in managing diabetes. Incorporating stress-reducing techniques into daily routines promotes emotional well-being, crucial in diabetes management. Ensuring adequate hydration by drinking plenty of water supports optimal bodily functions. Regular monitoring of blood sugar levels provides valuable insights into the effectiveness of dietary and lifestyle interventions.

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