Diabetes

Contents

•  Definition
•  Types

 Diabetes mellitus Type – 1
 Diabetes mellitus Type – 2
              Gestational diabetes mellitus

•  Signs & Symptoms
•  Prevention
•  Diagnosis
•  Cure
•  Diabetes Diet
•  Do’s
•  Donts

10. Chronic Complications
         11. Things to remember
         12. Patient’s desk

Definition

Diabetes mellitus, often referred to simply as diabetes is a syndrome of disordered metabolism, usually due to a combination of hereditary and environmental causes, resulting in abnormally high blood sugar levels. Diabetes mellitus refers to the group of diseases that lead to high blood glucose levels due to defects in either insulin secretion or insulin action in the body.

Diabetes develops due to a decreased production of insulin or resistance to its effects. Acute signs of diabetes: excessive urine production, resulting compensatory thirst and increased fluid intake, blurred vision, unexplained weight loss, lethargy and changes in energy metabolism.

All forms of diabetes have been treatable since insulin became medically available but remember there is no cure. The injections by a syringe, insulin pump or insulin pen deliver insulin, dietary treatment, exercise, medications and insulin supplementation are some of the basic treatments for different types.

Diabetes and its treatments can cause many complications. Acute complications (hypoglycemia) may occur if the disease is not adequately controlled. Serious long-term complications include cardiovascular disease, chronic renal failure, retinal damage, nerve damage, and micro vascular damage, which may cause erectile dysfunction and poor wound healing. Poor healing of wounds, particularly of the feet, can lead to gangrene and possibly to amputation.

Types

The term diabetes, without qualification, usually refers to diabetes mellitus, which is associated with excessive sweet urine. The most common of this is in which the urine is not sweet it can be caused by either kidney or pituitary gland damage. Among the body systems affected are the nerve, digestive, circulatory, endocrine and urinary systems.

Type-1
Type 1 diabetes mellitus is characterized by loss of the insulin-producing beta cells of the islets of Langerhans in the pancreas leading to a deficiency of insulin. This type of diabetes can be further classified as immune-mediated or idiopathic. There is no known preventive measure which can be taken against type 1 diabetes. Most affected people are otherwise healthy and of a healthy weight when it commences. Type 1 diabetes can affect children or adults but was traditionally termed "juvenile diabetes" because it represents a majority of the diabetes cases in children.

The principal treatment of type 1 diabetes is the delivery of artificial insulin via injection combined with careful monitoring of blood glucose levels using blood testing monitors. It is also possible to deliver insulin by a pump, which allows continuous infusion of insulin 24 hours a day at present levels and the ability to program doses of insulin as needed at meal times.

Type 1 treatment must be continued indefinitely in essentially all cases. Treatment need not significantly impair normal activities, if sufficient patient training, awareness, appropriate care, discipline in testing and dosing of insulin is taken. However, treatment is burdensome for patients; insulin is replaced in a non-physiological manner and this approach is therefore far from ideal.

Type-2

Type 2 diabetes mellitus is characterized differently and is due to insulin resistance or reduced insulin sensitivity, combined with relatively reduced insulin secretion which in some cases becomes absolute. Type 2 diabetes is the most common type.

In the early stage of type 2 diabetes, the predominant abnormality is reduced insulin sensitivity, characterized by elevated levels of insulin in the blood. As the disease progresses, the harm of insulin secretion worsens and therapeutic replacement of insulin often becomes necessary.

Central obesity (fat concentrated around the waist in relation to abdominal organs) is known to predispose individuals to insulin resistance. Abdominal fat is especially active hormonally, secreting a group of hormones called adipokines. Obesity is found in approximately 55% of patients diagnosed with type 2 diabetes. Other factors include ageing and family history. Type 2 diabetes has increasingly begun to affect children and adolescents, likely in connection with the increased occurrence of childhood obesity.
Type 2 diabetes may go unnoticed for years because visible symptoms are typically mild, non-existent or sporadic and usually there are no ketoacidotic episodes. However, severe long-term complications can result including renal failure due to diabetic nephropathy, vascular disease and vision damage due to diabetic retinopathy, loss of sensation or pain due to diabetic neuropathy, liver damage and heart failure.

Type 2 diabetes is usually first treated by increasing physical activity, decreasing carbohydrate intake and losing weight. However, the underlying tendency to insulin resistance is not lost, and so attention to diet, exercise and weight loss must continue. The next step, if necessary, is treatment with oral anti-diabetic drugs.

Gestational diabetes mellitus

Gestational diabetes mellitus (GDM) resembles type 2 diabetes in several respects, involving a combination of relatively inadequate insulin secretion and responsiveness.
It occurs in about 2%–5% of all pregnancies and may improve or disappear after delivery. Even though it may be short-lived, untreated gestational diabetes can damage the health of the fetus or mother. Risks to the baby include high birth weight, congenital cardiac and central nervous system irregularity.

Signs & Symptoms

Diabetes symptoms are frequent urination, increased thirst, consequent increased fluid intake and increased appetite. Symptoms may develop quite rapidly (weeks or months) in type 1 diabetes, particularly in children.
In type 2 diabetes symptoms usually develop much more slowly and may be slight or completely absent. Type 1 diabetes may also cause a rapid yet significant weight loss and irreducible mental tiredness. All of these symptoms except weight loss can also apparent in type 2 diabetes.

Prolonged high blood glucose causes glucose absorption, which leads to changes in the shape of the lenses of the eyes, resulting in vision changes; maintained glucose control usually returns the lens to its original shape. Blurred vision is a common complaint leading to a diabetes diagnosis; type 1 should always be suspected in cases of rapid vision change.

Patients (usually with type 1 diabetes) may also suffer by the smell of acetone, a rapid deep breathing, vomiting and abdominal pain can altered states of consciousness or arousal (such as mania or, equally, confusion and lethargy). In severe cases, coma may follow, progressing to death.

A rarer but equally severe state, which is more common in type 2 diabetes is mainly the result of dehydration due to loss of body water. Often, the patient has been drinking extreme amounts of sugar-containing drinks, leading to an unnatural circle in regard to the water loss.

Diagnosis

Patient education, understanding, and participation are vital since the complications of diabetes are far less common. Wider health problems accelerate the harmful effects of diabetes. These include smoking, elevated cholesterol levels, obesity, high blood pressure and lack of regular exercise.

Some evidence suggests that those with type 2 diabetes who exercise regularly, lose weight, and eat healthy diets may be able to keep some of the disease or some of the effects of the disease in control. However patients should talk to their doctors about this for real expectations before undertaking it; few people actually seem to go into total decrease but some may find they need less of their insulin medications since the body tends to have lower insulin requirements during and shortly following exercise.

The way diabetes is managed changes with age. Insulin production decreases because of age-related impairment of pancreatic beta cells. Additionally, insulin resistance increases because of the loss of lean tissue and the accumulation of fat, particularly intra-abdominal fat and the decreased tissue sensitivity to insulin. Glucose tolerance progressively declines with age, leading to a high prevalence of type 2 diabetes.

Age-related glucose intolerance in humans is often accompanied by insulin resistance, but circulating insulin levels are similar to those of younger people. Treatment goals for older patients with diabetes vary with the individual and take into account health status, as well as life expectancy, level of dependence and willingness to adhere to a treatment procedure.

Prevention

Type 1 diabetes risk is known to depend upon a genetic tendency, an unknown environmental trigger and an uncontrolled autoimmune response that attacks the insulin producing beta cells. Giving children 2000 IU of Vitamin D during their first year of life is associated with reduced risk of type 1 diabetes.

Risk of Type 2 diabetes can be reduced in many cases by making changes in diet and increasing physical activity. The ADA (American Diabetes Association) does not recommend alcohol consumption as a preventive, but it is interesting to note that moderate alcohol intake may reduce the risk, though heavy consumption absolutely and clearly increases damage to body systems significantly.

Diabetes screening is recommended for many people at various stages of life. The screening test varies according to situations and may be a random blood glucose test, a fasting blood glucose test, a blood glucose test two hours after 75 g of glucose, or formal glucose tolerance test. Many healthcare providers recommend universal screening for adults at age 40 or 50, and often periodically thereafter. Earlier screening is typically recommended for those with risk factors such as obesity, family history of diabetes.

Cure

Cure for type-1

There is no practical cure, at this time, for type 1 diabetes. The fact that type 1 diabetes is due to the failure of one of the cell types of a single organ with a relatively simple function has led to the study of several possible schemes to cure this form of diabetes mostly by replacing the pancreas or just the beta cells. Only those type 1 diabetics who have received either a pancreas or a kidney-pancreas transplant and has become insulin-independent may now be considered "cured" from their diabetes. A simultaneous pancreas-kidney transplant is a promising solution, showing similar or improved survival rates over a kidney transplant alone. Still, they remain on medication.

Transplants beta cells have been performed experimentally in both mice and humans, but this measure is not yet practical in regular clinical practice partly due to the limited number of beta cell donors. Stem cell research has been suggested as a potential path for a cure since it may permit re-growth of cells which are genetically part of the treated individual. This has been done in mice and a 2007 trial of 15 newly diagnosed patients with type 1 diabetes treated with stem cells raised from their own bone marrow after immune suppression showed that the majority did not require any insulin treatment for prolonged periods of time.

Cure for type-2

Type 2 has had no definitive cure, although recently it has been shown that a type of gastric bypass surgery can normalize blood glucose levels in 80-100% of severely obese patients with diabetes. The precise causal mechanisms are being intensively researched; its results are not simply attributable to weight loss, as the improvement in blood sugars precedes any change in body mass. This approach may become a standard treatment for some people with type 2 diabetes in the relatively near future. This surgery has the additional benefit of reducing the death rate from all causes by up to 40% in severely obese people. A small number of normal to moderately obese patients with type 2 diabetes have successfully undergone similar operations.

Diabetes Diet

Diet plays a significant role in controlling the diabetes. The diabetic diet may be used alone or else in combination with insulin doses or with oral hypoglycemic drugs. Main objective of diabetic diet is to maintain ideal body weight, by providing adequate nutrition along with normal blood sugar levels in blood. The diet plan for a diabetic is based on height, weight, age, sex, physical activity and nature of diabetes.
With respect to the above factors, a dietician will assess calories to be given, like scheming the carbohydrates, proteins, fats, type of carbohydrate, amount of fiber and so on.

Exchange meal plan is a diet program which balances the amount of carbohydrate that we intake per day. Glucose is a sugar released from carbohydrate. So, if we want to control blood sugar we have to limit the consumption of simple carbohydrate. Carbohydrate foods are given as value per portion, known as the exchange. This plan helps us to decide on the type of food to be taken, the amount of food and also the time to eat. While planning diabetes diet we should adhere to certain important factors, they are as follows:

• Fiber should be at least 1.4 oz / day
• Instead of 3 heavy meals, we should go for 4-5 small mid intervals
• Replace bakery products and fast foods by simple whole cooked cereals, and don't eat carbohydrates 2 hours before bedtime.
• Consume fresh fruit and vegetables at least 5 exchange/ day.

Diabetic Food Pyramid

Fats (Limit to 1 serving per meal) A serving can be:-

    * 10 Peanuts.
    * 1 Tbsp Salad Dressing
    * 2 Tbsp light salad dressing or saur cream.
    * 1 Tsp margarine, Oil or mayonnaise.
    * 1/8 Avocado.

Sweets (Substitute for starch or fruit serving occasionally) A serving can be:-

    * 2 Small Cookies.
    * 1 Small Cupcake or Muffin
    * ½ Cup Ice cream.
    * 1/3 Cup Frozen Yoghurt.
    * ¼ Cup Sherbet.
    * 1 tsp Syrup or Honey.

Milk (2-3 Servings per day) A serving can be:

    * 1 cup Milk.
    * 1 Cup Low Fat.
    * 1 Cup Artificially Sweetened yogurt (No sugar)

Meat / Fish/Chicken (2-3 Serving per day) A serving can be:

    * 2 oz Cooked Lean Meat/Poultry/Fish.
    * ½ - ¾ Cup Tuna or Cottage Cheese.
    * 1 Egg or 4 oz Tofu or 1 oz cheese.
    * 2 Tbsp peanut Butter.

Vegetables (3-5 Serving Per day) A Serving can be:

    * 1 Cup Raw Vegetables.
    * ½ Cup Cooked Vegetables.
    * ½ Cup Tomato or Vegetable Juice.

Fruits (3 Serving per Day) A Serving Can be:

    * 70 gm small fruit.
    * ½ Cup canned fruit.
    * ¼ cup Dried Fruit.
    * ½ Cup Fruit Juice. (No sugar)

Grains, Starchy Vegetables and Beans. (6 plus Servings Per Day) A Serving Can be:-

    * 1 Slice of 1 oz bread or ½ (1 oz) Bagel or 5 Crackers or 1 Granola bar.
    * ½ Hamburger or Hot dog Bun or a tortilla of 6 inch or 2 tacos.
    * ½ Cup Cooked Cereal, Cooked beans, Lentils, Corn, Peas, S. Potato, Potato or Pasta.
    * 1 Cup winter Squash, 1 Cup Soup.
    * 1/3 Cup Rice or 3 Cup Plain Popcorn (Fat free)

Diet Management

Most of the food items contain carbohydrate, protein and fat. Cereals are rich in carbohydrate, lentils, lean meat, chicken and fish are rich in protein while oils, nuts and milk creams are rich in fat. Fat foods are high in calories; 1g of it provides 9 calories, while 1g carbohydrate or 1g protein gives only 4 calories.

Carbohydrate is easily digested than fat and protein. The rise in blood glucose after a meal is due to absorption of glucose from a carbohydrate digestion and increase in production of glucose by liver. Sucrose (cane sugar), sweets and syrups cause a rapid rise in blood glucose than whole cereals like finger millet and wheat products. Glucose is constantly needed to provide ready energy for the proper functioning of brain, heart, kidneys, liver and blood cells.

In people with no diabetes, the rise in blood glucose after a meal comes down to the pre-meal level with in 2 hrs. In diabetes, the rise in blood glucose after a meal is not only higher but the fall to pre-meal level is slower (3-4 hrs). Therefore, snacks in between meals or frequent meals at short intervals tend to cause progressive increase in blood glucose in people with diabetes.

Glucose is constantly needed to provide ready energy for the proper functioning of brain, heart, kidneys, liver and blood cells. When glucose is not available from ingested food, our liver produces from its store of carbohydrate (glycogen) and body stores of fats and proteins.

In a typical day’s meals and snacks, you should have 1500-1800 calories with – 60% contribution from the carbohydrate, 20% from fat and 20% from proteins. You may need extra weight reduction. If you are on calorie-restricted diet, make sure to take 50-60% of calories as complex carbohydrate to prevent any feeling of weakness.

Diabetes Care

    * Eat food at fixed hours
    * Do not overeat
    * Do not eat immediately after a workout
    * Make sure you have three proper meals & light snacks in between
    * Eat about the same amounts of food each day
    * Eat your meals and snacks at about the same times each day
    * Make sure the gaps between your meals are short
    * Do not eat fast; masticate and munch your food well before you swallow
    * Drink a lot of water that will help flush the toxins off your system
    * Avoid fried foods and sweetmeats
    * Include fresh vegetable salad in every meal
    * Include sprouts in the diet
    * Take your medicines at the same times each day
    * Exercise at about the same times each day
    * Avoid smoking. Smoking leads to heart disease and poor circulation
    * Check your feet for cuts, blisters, and swelling which are likely to result from diabetes- related nerve damage
    * Take good sleep daily
    * Check your blood sugar level regularly
    * Try to stick up to the plan made up for sugar control
    * Check the other tests such as kidney function, liver function, heart function etc
    * Check your weight periodically and maintain ideal body weight

Do’s for a Diabetic

• For breakfast, take cholesterol-lowering oatmeal
• Have nuts rich in mono unsaturated fat, such as pecans, walnuts, and almonds
• Eat pasta, stews and leafy salads along with beans-- kidney beans, chick peas, and dry beans, navy beans and peas which can reduce cholesterol
• Fat free milk, yogurt, and cheese to be taken
• Eggs whites to be included
• White meat chicken and Fish and shellfish (not battered) are good
• Increase intake of dry beans and peas
• Have at least 20 to 25 grams of raw onion daily
• Add wheat bran to your wheat flour (50% wheat flour + 50% wheat bran). This helps increase fiber in your diet
• You can also add flaxseed and fenugreek seeds into the wheat flour
• Increase fiber intake in the form of raw fruits, vegetables, whole cereals etc
• Intake of cinnamon, garlic, onion, bitter melon, guar gum is known to considerably reduce blood glucose level

Donts for a Diabetic

• Don't fry foods instead bake, boil, poach or sauté in a nonstick pan. Steam or microwave vegetables. Buy tuna packed in water, not oil

• Eat less high-fat red meat and more low-fat turkey and fish. Avoid organ meats
• Limit the use of condiments such as ketchup, mustard and salad dress ion--they're high in salt and can be high in sugar, too
• Rinse processed foods in water and wherever possible, choose fresh foods over canned
• Limit your salt (sodium content)
• Read labels carefully. Soy sauce, brine and MSG, for example, contain a lot of sodium
• Don't select ready to eat and junk foods items available to you
• Don't smoke and stop alcohol consumption
• Don't skip meals and medicine times

Chronic complications

Chronic elevation of blood glucose level leads to damage of blood vessels. The endothelial cells lining the blood vessels take in more glucose than normal, since they don't depend on insulin. They then form more surface than normal, and cause the basement membrane to grow thicker and weaker. In diabetes it is of two types:
1. Due to damage to small blood vessels (micro-vascular disease) 
2. Due to damage to the arteries (macro-vascular disease)

Microangiopathy can cause the following:

• Diabetic retinopathy, growth of friable and poor-quality new blood vessels in the retina which can lead to severe vision loss or blindness.
• Diabetic neuropathy, abnormal and decreased sensation, usually in a 'glove and stocking' distribution starting with the feet but potentially in other nerves, later often fingers and hands. When combined with damaged blood vessels this can lead to diabetic foot    
• Diabetic nephropathy, damage to the kidney which can lead to chronic renal failure, eventually requiring dialysis.
• Diabetic cardiomyopathy, damage to the heart, leading to diastolic dysfunction and eventually heart failure.

Macrovascular disease leads to:

• Coronary artery disease, leading to angina or heart attack
• Stroke
• Peripheral vascular disease, which contributes to exertion-related leg and foot pain as well as diabetic foot.

   
Diabetic foot, often due to a combination of sensory neuropathy and vascular damage, increases rates of skin ulcers and infection and, in serious cases, necrosis and gangrene. It is why diabetics are prone to leg and foot infections and why it takes longer for them to heal from leg and foot wounds.

Things to remember

• The average glucose level for the type 1 patient should be as close to normal (80–120 mg/dl, 4–6 mmol/l) as is safely possible. 
• Values above 400 mg/dl (20 mmol/l) are sometimes accompanied by discomfort and frequent urination leading to dehydration.
• Values above 600 mg/dl (30 mmol/l) usually require medical treatment although they are not immediately life-threatening.
• According to one study, overweight patients treated with metformin compared with diet alone, had relative risk reductions of 32% for any diabetes endpoint, 42% for diabetes related death and 36% for all cause mortality and stroke.
• A 2008 study completed in the U.S. found that more American women are entering pregnancy with preexisting diabetes.
• If a pregnant lady suffered GDM during pregnancy, it is likely that they may develop type 2 diabetes later in life. About 20%–50% of women are affected.
• The American Diabetes Association (ADA) recommends maintaining a healthy weight, getting at least 2½ hours of exercise per week, having a modest fat intake, and eating sufficient fiber.
• Breastfeeding may also prevent type 2 of the disease in mothers according to some researchers.
• People with a confirmed diagnosis of diabetes should be tested routinely for complications. This includes yearly urine testing for and examination of the retina of the eye.
• There is no practical cure, at this time, for type 1 diabetes.
• The World Health Organization projects that the number of diabetics will exceed 350 million by 2030.

Patient’s Desk

Some precautions to be taken by a Diabetic-

• It is always better to maintain oral hygiene

• You should detect and treat skin ailments quickly.

• You should have periodic check up of blood and urine.

• One diabetic should not marry another diabetic.

• You should never stop medication even if you have fever, nausea, and/or even when you are fasting.

• You should carry your diabetic identity with you, along with your name, address and telephone number to enable immediate relief and/or rescue.

• Make it a habit to have monthly weight check-up.

• You should get yearly X-ray examination of your chest.

• Blood relatives of a diabetic patient must get their own check-up done regularly.

• Herbal medicine can help in prevention without any side effects.

• Wear shoes all the time if you are a diabetic patient. If you do not want to wear shoes indoors, wear slippers with hard soles and good support.

• Exercise is the most important of all.