Relation between malnutrition and development of diabetes mellitus.

Abstract

Obesity and increased dietary intake of high fat are considered important factors involved in the development of type 2 diabetes, as they correlate to the prevalence of diabetes in different populations and are both associated with insulin resistance, which is an important pathogenic event for diabetes (1,2). However, epidemiological studies have shown that diabetes is common also in populations where obesity is not a major concern for health (3). In fact, in some developing countries, the prevalence of diabetes exceeds that of more developed countries, as, for example, has been shown in studies in Bangladesh (4) and India (5). The question of whether also malnutrition is detrimental for glucose metabolism and may contribute to the development of diabetes has therefore been raised. This would also be supported by clinical studies showing distinct and specific clinical characteristics of diabetes in malnourished subjects when compared to nonmalnourished subjects, such as early age of onset, requirement of insulin to control hyperglycemia in conjunction with ketosis resistance in the absence of insulin therapy, and the presence of pancreatic calculi, in addition to the clinical manifestations of malnutrition (6–9). Based on these epidemiological and clinical observations, WHO recognized, in 1985, malnutrition-related diabetes mellitus (MRDM) as a special subtype of diabetes, different from type 1 (IDDM) and type 2 diabetes (NIDDM) (6). However, using malnutrition in the classification of diabetes has been questioned, because malnutrition has also been considered to be a mere coincidence with diabetes, which exaggerates or modulates the clinical feature of the disease (10,11). In fact, several arguments have been put forward against the use of MRDM as a distinct entity of diabetes. One argument is that it has not been convincingly demonstrated that malnutrition results in permanent diabetes and another argument is that the classification of diabetes into type 1 or type 2 relies on clinical aspects, not pathogenesis (6,10). In addition, malnutrition by itself is a vague condition that is difficult to define, as it is usually assessed by combined interpretation of data from the dietary history, anthropometric data, clinical examination, and laboratory investigations without strict criteria. Malnutrition is also inhomogeneous, because it includes both single and combined nutrient deficiencies as well as global energy deficiency. Moreover, the clinical characteristics thought to be specific for MRDM may also be identified in diabetic subjects without a history of malnutrition (10,12). Therefore, the new classification system of the American Diabetes Association does not consider MRDM a distinct entity of diabetes (11). Instead, fibrocalculus pancreatic diabetes (FCPD), being a former subgroup of MRDM, has been classified as an exocrine pancreatic disease, and protein-deficient diabetes mellitus (PDDM) is considered a condition modulating the clinical features of existing diabetes. Nevertheless, apart from the issue of classification, the role of malnutrition on glucose homeostasis remains elusive and needs further studies to designate it as a modulating factor in diabetes. As previously reviewed by Rao (7), malnutrition may cause diabetes as a priInternational Journal of Pancreatology, vol. 26, no. 3, 125–130, December 1999 © Copyright 1999 by Humana Press Inc. All rights of any nature whatsoever reserved. 0169-4197/99/26:125–130/$11.50