Malnutrition-Related Diabetes: Pathophysiology, Factors, and Management

Introduction:

Diabetes is a public health problem that has been increasing globally. Malnutrition 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 Diabetes Mellitus?

Diabetes mellitus (DM) is a condition in which there is high blood sugar (glucose). This may be due to a lack of or insufficient insulin that the pancreas produces. This may also develop when the body cannot respond properly to the effects of insulin. DM may affect all age groups.

There are different types of diabetes. They are type I DM, type II DM, gestational DM, etc.

In 1985, the world health organization (WHO) classified DM into three categories. They are insulin-dependent, insulin-independent, and malnutrition-related diabetes (MRDM).

What is Malnutrition-related diabetes?

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. Undernutrition may 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).

Malnutrition 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 DM.

MRDM:

Malnutrition-related diabetes tends to occur among young individuals with nutritional deficiencies, especially in low and middle-income countries. There was a criterion set to identify MRDM by WHO previously. Still, it was removed in 1999 by WHO itself saying there was a lack of evidence for its cause as malnutrition or it may also be due to protein deficiency.

MRDM shows insulinopenia, insulin resistance, hyperglycemia, and partial failure of beta cells in the pancreas.

Classification of MRDM:

MRDM is further classified into

• Fibrocalcific or fibrocalculous pancreatic diabetes (FCPD).

• Protein-deficient pancreatic diabetes (PDPD).

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.

• Pancreatic calcifications (radiological finding).

• Exocrine pancreatic dysfunction.

PDPD:

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.

What Is the Pathophysiology of MRDM?

Factors involved in the etiopathology of MRDM.

They are

• Malnutrition.

• Infection.

• Increased intake of cassava.

• Destruction of pancreatic beta cells.

The exact etiology of MRDM is controversial.

Symptoms of MRDM include

• Loss of weight or muscle mass.

• Changes in hair and skin.

• Enlargement in the parotid gland.

Etiology of FCPD:

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

• Genetic susceptibilities like undernutrition, 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.

• Pancfeatic calculi (alculi are large, multiple and intraductal).

Ducts usually show dilatation and fibrosis. Fibrosis is due to inflammatory changes. FCPD is more prone to pancreatic cancer.

Etiology of PDPD:

• When this type of DM remains without treatment for a long time indicates resistance to ketoacidosis.

• 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.

How Malnutrition Is Related to DM?

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 that there is a link between chronic undernutrition and DM and also reported that protein energy malnutrition (PEM) may be the cause of it.

Factors involved with malnutrition are

• Prenatal factors.

• Postnatal factors.

Prenatal Factors:

Many studies have been done and found that there is a link between maternal malnutrition and type II DM. The reason may be that decreased total food intake during pregnancy or early post-natal life may lead to decreased glucose tolerance and diabetes in offspring.

Another study has shown that there are permanently altered genes 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 and pancreatic functions. A low protein diet during pregnancy may lead to increased oxidative stress, 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 cause DM. A study has found that increased high-protein diet consumption during pregnancy may cause insulin resistance.

Another study has shown that increased high-fat diet consumption during pregnancy may cause insulin resistance and obesity.

Postnatal Factors:

Malnutrition during post-natal life may decrease glucose tolerance and increase the risk of offspring to DM. A study has shown that poor nutrition, low socioeconomic status during childhood, and unhealthy behaviors may alter body composition later in life. This may in turn responsible for metabolic disorders like DM. A study has shown that childhood undernutrition may increase the risk for type II DM in adulthood.

How to Diagnose Malnutrition-Related Diabetes?

Criteria to identify MRDM are as follows

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

• Background from low socioeconomic status.

• Malnutrition during childhood.

• BMI <18 Kg/m².

• The blood glucose level is >200 mg/dl or 11.1mmol/L.

• Absence of ketosis on insulin withdrawal.

• The required insulin is 1.5 U/kg/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 >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 DM.

Conclusion:

Nutrition has played an important role among humans. DM is a condition that may affect the body in various ways if not treated properly. Malnutrition is linked to DM. Hence, it is important to know about malnutrition-related diabetes. Knowing how to seek help from a healthcare professional early. Early diagnosis helps in achieving effective treatment. This, in turn, helps in maintaining a good quality of life.