CHAPTER 9
Diabetes Mellitus
JULIE LANDEL-GRAHAM, SUSAN E. YOUNT, AND SUSAN R. RUDNICKI
191SPECIAL ISSUES IN DIABETES 203
Sexual Dysfunction 203
Hypoglycemia 205
Weight Management 206
ROLE OF HEALTH PSYCHOLOGY IN DIABETES
MELLITUS 208
CONCLUSIONS AND FUTURE DIRECTIONS 209
REFERENCES 210ADHERENCE IN DIABETES 192
PSYCHOSOCIAL FACTORS IN DIABETES
MANAGEMENT 193
Knowledge 193
Stress 195
Depression in Diabetes 197
Social Support 199
Patient-Practitioner Interactions 200
Barriers to Adherence, Coping, and Problem Solving 202
diabetes should be seen as a prominent public health problem
(Glasgow, Wagner, et al., 1999).
The Expert Committee on the Diagnosis and Classi“cation
of Diabetes Mellitus (2000) presented a revised diabetes clas-
si“cation system that differentiates four types of diabetes on
the basis of etiology and pathogenesis: type 1, type 2, gesta-
tional diabetes, and other speci“c types. Most patients have
either type 1 diabetes (historically referred to as insulin-
dependent diabetes mellitus or juvenile onset diabetes) or type
2 diabetes (historically referred to as noninsulin-dependent
diabetes mellitus or adult onset diabetes). Thus, the material
in this chapter focuses on adults with type 1 or type 2 diabetes.
The Expert Committee on the Diagnosis and Classi-
“cation of Diabetes Mellitus (2000) provides a thorough
discussion of the types of diabetes, their etiologies, and
pathogenesis. A brief review of this information is provided
here for type 1 and type 2 diabetes. Type 1 diabetes, which
accounts for approximately 5% to 10% of cases of diabetes,
occurs as a result of the gradual destruction of the insulin-
producing beta cells in the pancreas. In most patients, this
destruction is caused by an identi“able autoimmune process,
which leads to an absolute de“ciency of endogenous insulin.
Thus, use of exogenous insulin is required for survival to
prevent the development of diabetic ketoacidosis (a life-
threatening metabolic imbalance), coma, and death. It ap-
pears that genetic in”uences, as well as environmental
factors, may play a role in the pathogenesis of type 1 diabetes.
Although the majority of patients with type 1 diabetes areDiabetes mellitus represents a group of metabolic disorders
of varying etiologies that are all characterized by hyper-
glycemia (i.e., high blood sugar levels). Across all subtypes
of diabetes, this chronic hyperglycemia is associated with
acute symptoms as well as a variety of serious long-term
medical complications, including retinopathy, peripheral and
autonomic neuropathies, nephropathy, and cardiovascular
disease. Diabetes is the leading cause of blindness, amputa-
tions, and kidney transplants.
Diabetes occurs in approximately 15.7 million people in
the United States, with 5.4 million of these persons undiag-
nosed and approximately 800,000 additional new cases diag-
nosed per year (Centers for Disease Control and Prevention
[CDC], 1998). Importantly, recent research indicates that
the prevalence of diabetes continues to increase rapidly in the
United States, rising by 33% between 1990 and 1998
(Mokdad et al., 2000). These authors suggest that diabetes
will become even more common in subsequent years because
of the increasing prevalence of obesity. Diabetes is more fre-
quent in the elderly and certain racial and ethnic groups (e.g.,
African Americans, Hispanic/Latino Americans, American
Indians) and is the seventh leading cause of death in the
United States (CDC, 1998). The annual costs of diabetes, in-
cluding both direct medical costs and indirect costs due to
disability, work loss, and premature mortality, were estimated
to be $98 billion in 1997 (American Diabetes Association
[ADA], 1998). Because of its increasing prevalence, disease
burden on the individual, and economic costs to the nation,