Diabetes mellitus is a silent chronic disorder characterized by elevated blood sugar levels either due to defective insulin secretion or action or both. It is caused by altered metabolism of carbohydrates, fats and proteins. Elevated blood sugars cause changes in the blood vessels thus affecting almost all organs in our body especially the eye, kidney, nerves, heart, brain and the feet.
Type 1 Diabetes
Type 1 diabetes is an autoimmune disease. In diabetes, the immune system attacks and destroys the insulin-producing beta cells in the pancreas. The pancreas then produces little or no insulin. These individuals require insulin for their survival and have to take a minimum of 2 doses of insulin a day.
Type 2 Diabetes
Type 2 Diabetes
The most common form of diabetes is type 2 diabetes. This form of diabetes is most often associated with older age, obesity, family history of diabetes, previous history of gestational diabetes, physical inactivity, and certain ethnicities. It may occur more frequently in obese individuals(with increased insulin resistance). These patients usually respond to medications. However, as the duration increases, they may require insulin.
Gestational Diabetes
Gestational Diabetes
Gestational diabetes is seen in pregnant women. These women have to be put on insulin and diet for control of blood sugars. Oral hypoglycemic agents have not been proved to be safe for use in pregnancy. Diabetes usually settles after delivery, with blood sugars remaining in the normal range. However, some women may continue to have diabetes even after pregnancy. In general, women who develop gestational diabetes are at higher risk of developing type 2 diabetes later in life.
Other types
There are several rare causes of diabetes mellitus that do not fit into type 1, type 2, or gestational diabetes:
Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by demonstrating any one of the following
Other investigations
Other types
There are several rare causes of diabetes mellitus that do not fit into type 1, type 2, or gestational diabetes:
- Genetic defects in beta cells.
- Genetically-related insulin resistance,(abnormal body fat deposition)
- Diseases of the pancreas
- Hormonal defects
- Chemicals or drug
- Frequent urination
- Excessive thirst
- Excessive hunger
- Weight loss
- Delayed healing of wounds
- Tiredness
- Itching especially in the private parts
- Persistent ache in the limbs
Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by demonstrating any one of the following
- fasting plasma glucose level at or above 126 mg/dL or 7.0 mmol/l.
- plasma glucose at or above 200 mg/dL or 11.1 mmol/l two hours after a 75 g oral glucose load in a glucose tolerance test.
- random plasma glucose at or above 200 mg/dL or 11.1 mmol/l.
Other investigations
Once the patient is diagnosed to have diabetes, he should undergo a complete check up at least once a year. In addition to blood sugar values (fasting and post postprandial), HbA1c (a three month average control of blood sugars) must be checked on minimum of quarterly basis. A HbA1c of less than 7 % is indicates good blood glucose control.
Kidney parameters such as blood urea, serum creatinine, PCR (protein to creatinine ratio) and microalbuminuria which detects any leakage of protein from the kidney into the urine should also be checked. Leakage of protein into the urine is the first sign of kidney changes due to diabetes and hence has to be monitored regularly.
An ECG should be taken yearly to rule out any cardiac abnormality.
The feet of a diabetic patient need special attention. They should be thoroughly examined for any fissures, calluses, injuries and infections by both the patients and the treating physicians.
In addition to clinic monitoring, Self Monitoring of Blood Glucose(SMBG) is also of utmost importance.The record of blood sugar levels using SMBG will help the physician in the management of Diabetes.
Diabetes and its management
A. Diet Management
A diabetic can eat almost any food that other people normally eat except sugars. The food should be well distributed between the different meals.
Dietary Fibre
Fiber in diet is good as it helps to control the blood sugar by slowing the absorption of the carbohydrate, hence avoiding rapid rise in blood glucose after meals. It helps in reducing blood cholesterol and also prevent constipation.It is recommended that fibre intake should be around 20-35 g/day. Intake of 25 gm of dietary fibre per 1000 calories is considered to be optimum for a diabetic.
Glycemic Index
Different carbohydrates raise the blood sugar to a variable extent. The glycemic index indicates the extent of rise in blood sugar in response to a food in comparison with the response to an equivalent amount of glucose. Generally cereals like wheat and rice and root vegetables such as potato, carrots have high glycemic index (65-75 %). Fruits have intermediate glycemic index (45-55 %). Legumes and lentil such as dries beans, peas, green grams and bengal grams and have low glycemic index (30-40 %) and are beneficial to diabetics in moderate amounts. Diets with a lower glycemic index are generally rich in fibre.
A diabetic patient should preferably avoid complete fasts. Fasting alters the metabolism of the body, adversely affecting the diabetic states.
B.EXERCISE
Regularly controlled exercise has a very important role in the diabetes management. Exercise helps to increase glucose utilization and helps to attain ideal weight and also improves circulation.
Exercise aids in diabetes control by stimulating insulin functioning, and may reduce your need for medication.
C.Drug treatment
Oral Hypoglycemic Agent
OHAs are oral preparations used to control diabetes when diet, exercise and lifestyle modifications fail to achieve good control. The OHAs work only in case of type 2 diabetes and in a few cases of secondary type of diabetes.
In type II diabetes the main cause is the deficiency of insulin production from pancreas. Oral anti diabetic drugs enhance the release of insulin from pancreas, enhance the utilization of glucose by the tissues and delay the absorption of carbohydrates from the gastrointestinal tract. These drugs include sulfonyl ureas, Biguanides and acarbose.
OHAs are best avoided in pregnant ladies, type 1 diabetic subjects and patients with significant heart, kidney or liver diseases.
Insulin
Kidney parameters such as blood urea, serum creatinine, PCR (protein to creatinine ratio) and microalbuminuria which detects any leakage of protein from the kidney into the urine should also be checked. Leakage of protein into the urine is the first sign of kidney changes due to diabetes and hence has to be monitored regularly.
An ECG should be taken yearly to rule out any cardiac abnormality.
The feet of a diabetic patient need special attention. They should be thoroughly examined for any fissures, calluses, injuries and infections by both the patients and the treating physicians.
In addition to clinic monitoring, Self Monitoring of Blood Glucose(SMBG) is also of utmost importance.The record of blood sugar levels using SMBG will help the physician in the management of Diabetes.
Diabetes and its management
The control of diabetes is not adequate only with drugs. The following measures are also recommended for the better management of this sweet disease the experience of which is definitely bitter.
A. Diet Management
A diabetic can eat almost any food that other people normally eat except sugars. The food should be well distributed between the different meals.
Dietary Fibre
Fiber in diet is good as it helps to control the blood sugar by slowing the absorption of the carbohydrate, hence avoiding rapid rise in blood glucose after meals. It helps in reducing blood cholesterol and also prevent constipation.It is recommended that fibre intake should be around 20-35 g/day. Intake of 25 gm of dietary fibre per 1000 calories is considered to be optimum for a diabetic.
Glycemic Index
Different carbohydrates raise the blood sugar to a variable extent. The glycemic index indicates the extent of rise in blood sugar in response to a food in comparison with the response to an equivalent amount of glucose. Generally cereals like wheat and rice and root vegetables such as potato, carrots have high glycemic index (65-75 %). Fruits have intermediate glycemic index (45-55 %). Legumes and lentil such as dries beans, peas, green grams and bengal grams and have low glycemic index (30-40 %) and are beneficial to diabetics in moderate amounts. Diets with a lower glycemic index are generally rich in fibre.
A diabetic patient should preferably avoid complete fasts. Fasting alters the metabolism of the body, adversely affecting the diabetic states.
B.EXERCISE
Regularly controlled exercise has a very important role in the diabetes management. Exercise helps to increase glucose utilization and helps to attain ideal weight and also improves circulation.
Exercise aids in diabetes control by stimulating insulin functioning, and may reduce your need for medication.
C.Drug treatment
Oral Hypoglycemic Agent
OHAs are oral preparations used to control diabetes when diet, exercise and lifestyle modifications fail to achieve good control. The OHAs work only in case of type 2 diabetes and in a few cases of secondary type of diabetes.
In type II diabetes the main cause is the deficiency of insulin production from pancreas. Oral anti diabetic drugs enhance the release of insulin from pancreas, enhance the utilization of glucose by the tissues and delay the absorption of carbohydrates from the gastrointestinal tract. These drugs include sulfonyl ureas, Biguanides and acarbose.
OHAs are best avoided in pregnant ladies, type 1 diabetic subjects and patients with significant heart, kidney or liver diseases.
Insulin
Insulin is the mainstay for treatment of both types I and many type II diabetic patients.
There are different insulin preparations which are available. They are called short acting and long acting insulin depending on depending on duration of action. The dosage is adjusted as the requirement.
Human insulin is obtained by recombinant DNA technique. It is free from allergic reactions, when compared to bovine and (cattle) and porcine insulin. (pigs).
Insulin is essential for survival in type 1 patients, who require a minimum of 2 doses of insulin. Type 2 patients generally do not require insulin in the initial stages but may need it to control their diabetes as the duration of disease increases. Insulin may also be required in diabetic patients during periods of stress like infections, surgery, heart attack etc.
Complications of Diabetes
The complications occur in two ways. One is acute complication and other is long-term complication which is otherwise called as chronic complications.
Acute Complications
Acute complications include hypoglycemia, diabetic ketoacidosis and hyperosmolar hyperglycemic state.
The patients with type2 diabetes who neglect to control high blood sugar may loose excessive amounts of water and salts often leading to dehydration, coma that can be fatal.
Chronic Complications
The long term complications in case of uncontrolled diabetes can affects different organs. The main organs affected are the eyes, kidneys, heart, feet, nerves and brain.
Diabetic retinopathy
Diabetes affects the blood vessels in the retina and other structure of the eye and leads to diabetic retinopathy. Hence it is necessary to examine the eyes regularly, according to the advice of the doctor.
Patients with retinopathy have to undergo angiograph of the retina called FFA, based on which the ophthalmologist can decide the further line of management. When indicated, laser treatment may be given to control the bleeding in the eye.
Diabetic Nephropathy
Diabetic nephropathy occurs in uncontrolled diabetic patients of longer duration. Uncontrolled diabetics are susceptible to the infections of urinary bladder and kidneys. This may lead to kidney failure.
Diabetic Neuropathy
It is the commonest chronic complication of diabetes. Involvement of nerves causes symptoms like tingling, numbness, burning in feet and sometimes even pain. Absence of sensation especially in the feet makes the patient more susceptible to injuries which may go undetected for a long time. This may lead to infection and diabetic foot.
Blood vessels
Diabetes leads to thickening of capillary basement membrane. The arteries may develop fat deposits hindering blood flow. This may reduce the blood supply to the limbs. In case of injuries, it can develop infections and it may even develop gangrene. Smoking makes this problem worse.
There are different insulin preparations which are available. They are called short acting and long acting insulin depending on depending on duration of action. The dosage is adjusted as the requirement.
Human insulin is obtained by recombinant DNA technique. It is free from allergic reactions, when compared to bovine and (cattle) and porcine insulin. (pigs).
Insulin is essential for survival in type 1 patients, who require a minimum of 2 doses of insulin. Type 2 patients generally do not require insulin in the initial stages but may need it to control their diabetes as the duration of disease increases. Insulin may also be required in diabetic patients during periods of stress like infections, surgery, heart attack etc.
Complications of Diabetes
The complications occur in two ways. One is acute complication and other is long-term complication which is otherwise called as chronic complications.
Acute Complications
Acute complications include hypoglycemia, diabetic ketoacidosis and hyperosmolar hyperglycemic state.
The patients with type2 diabetes who neglect to control high blood sugar may loose excessive amounts of water and salts often leading to dehydration, coma that can be fatal.
Chronic Complications
The long term complications in case of uncontrolled diabetes can affects different organs. The main organs affected are the eyes, kidneys, heart, feet, nerves and brain.
Diabetic retinopathy
Diabetes affects the blood vessels in the retina and other structure of the eye and leads to diabetic retinopathy. Hence it is necessary to examine the eyes regularly, according to the advice of the doctor.
Patients with retinopathy have to undergo angiograph of the retina called FFA, based on which the ophthalmologist can decide the further line of management. When indicated, laser treatment may be given to control the bleeding in the eye.
Diabetic Nephropathy
Diabetic nephropathy occurs in uncontrolled diabetic patients of longer duration. Uncontrolled diabetics are susceptible to the infections of urinary bladder and kidneys. This may lead to kidney failure.
Diabetic Neuropathy
It is the commonest chronic complication of diabetes. Involvement of nerves causes symptoms like tingling, numbness, burning in feet and sometimes even pain. Absence of sensation especially in the feet makes the patient more susceptible to injuries which may go undetected for a long time. This may lead to infection and diabetic foot.
Blood vessels
Diabetes leads to thickening of capillary basement membrane. The arteries may develop fat deposits hindering blood flow. This may reduce the blood supply to the limbs. In case of injuries, it can develop infections and it may even develop gangrene. Smoking makes this problem worse.
Heart and diabetes
Diabetes accelerates thickening of arteries leading to increased risk of heart attacks, especially if the patient is a smoker or has high blood pressure and cholesterol. Hence control of blood sugars is vital.
Epidemiology
In 2006, according to the World Health Organization, at least 171 million people worldwide suffer from diabetes. Its incidence is increasing rapidly, and it is estimated that by the year 2030, this number will double. Diabetes mellitus occurs throughout the world, but is more common (especially type 2) in the more developed countries. The greatest increase in prevalence is, however, expected to occur in Asia and Africa, where most patients will likely be found by 2030. The increase in incidence of diabetes in developing countries follows the trend of urbanization and lifestyle changes, perhaps most importantly a "Western-style" diet. This has suggested an environmental (i.e., dietary) effect, but there is little understanding of the mechanism(s) at present, though there is much speculation, some of it most compellingly presented.
