Diabetes
also known as diabetes mellitus is a condition where there is an absence, or
inadequate secretion of insulin, or the body is resistant to insulin, a hormone
produced by the pancreas. The function of insulin is to promote the storage
of carbohydrate, fat and protein. It is responsible for glycogenesis (which
is the conversion of glucose to glycogen in the liver and muscle). Insulin
also causes lipogenesis, namely the formulation of triglycerides and fat. It
also prevents the breakdown of fat and the output of glucose by the liver.
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Type I (IDDM)
This form of diabetes is
known as Insulin Dependent Diabetes Mellitus, as there is profound deficiency
in the insulin made in the body. This form of diabetes is more commonly found
in younger children and adolescents and only in about 10% of diabetics over
sixty-five. This condition is treated by controlling the diet and through insulin
injections.
Type II (NIDDM)
This type of diabetes is also known as Non-insulin
Dependent Diabetes Mellitus. 90% of diabetes cases fall in this group. In Type
II diabetes, the pancreas produces insufficient insulin. It usually occurs in
people above the age of 40. An appreciable number of the patients (about 85%)
are also obese. This condition is usually hereditary. Treatment usually consists
of dietary control alone or dietary control and medication. Some may also need
insulin injections.
Secondary Diabetes
This
diabetes is the result of other disease of the pancreas, abnormal demands on
the pancreas such as in gestational diabetes and due to drugs and toxins. About
20-50% of women who have gestational diabetes, or diabetes during pregnancy,
develop diabetes in their later life. The treatment in gestational diabetes
is diet alone or diet with medication.
Symptoms
The most common symptoms
are v Frequent
urination v Constant
thirst v Increased
appetite v Tiredness v Weight
loss v Frequent
skin infection such as fungal infections in the genital area v Slow
healing of wounds. v Occasionally
blurred vision
Most people have one or more
symptoms but some do not have any.
Treatment
Once diabetes sets in, it is usually a lifetime
disease. The aim of diabetes treatment is to relieve the symptoms and return
blood sugar to within normal levels and to prevent complications. Diabetes left
uncontrolled over time can lead to damage of the kidneys, eyes, feet and skin.
Management of diabetes includes diet, weight control, exercise and medication.
Diet
Diet control is important
in the management of diabetes. A proper diet does not mean only avoiding sweet
food and drinks.
v Diabetic
should have 3 regular meals daily and they should not miss any meal. v Foods high in fibre should be
taken, such as whole-meal bread, noodles, oats,
unsweetened crackers, chickpeas, lentils and vegetables. v Foods high in sugar such as refined
sugar, chocolate and honey should be avoided. v Saturated fats should be kept
at a minimum, as increased intake of fat adds to the
risk of heart attacks. Food should be grilled whenever
possible instead of frying. v Salt and salty food intake should
be reduced. Avoid foods such as crisps and
peanuts. v Meals of diabetics should be planned
in advance. Meals should be balanced
and the intake of calories consistent. This ensures that
there is a consistent load
of glucose which the body must handle. v Controlled caloric intake is desirable
so as to maintain a normal body weight.
Alcohol intake should be
kept at minimum or avoided because alcohol alters the blood glucose level.
Diabetics should eat a balanced diet. They
can eat what the family eats but in moderation, avoiding sweets and sweetened
foods. It is not essential to buy special "diabetic food" as they
are expensive and the advantages are not much. There are also special nutrition
formulas for diabetics who are unable to follow a diabetic diet. However, it
is important to remember that healthy eating is the key to the diabetic diet.
Exercise
About 50% of diabetics with Type II diabetes
are overweight. It is important to maintain the ideal body weight with regular
exercise. Exercise enables the insulin to work better and keeps the body fit
and the patient healthier. The ideal exercise for the diabetics should be planned
after consultation with the doctor, so that complications such as hypoglycaemia
can be avoided. Consult the doctor treating the patient before starting any
exercise programme.
Insulin
Insulin is the drug of choice for
Type I diabetics and
in some Type II diabetics.
Insulin was first produced for treatment of diabetes in 1921. At that time the
types of insulin available were only bovine (from cattle) and porcine (from
pigs). Now there are synthetic forms, identical to the insulin made in our body,
produced from yeast and bacteria. Insulin is given only by injection as it is
destroyed in the stomach if taken by mouth. The doctor will decide on the type
of medication to be taken. If insulin is given the doctor will customise the
treatment for each patient. Classification of insulin is based on
v The onset of action
( which is related to the speed of absorption of insulin into the
blood stream). v Peak
effect. The time the insulin reaches its maximum effect. v Duration of action.
The time period during which the insulin acts.
Anti-Diabetes Tablets
These tablets do not contain insulin but
drugs, which stimulate the pancreas to produce more insulin, or help the cell
to use the existing insulin more effectively. After starting medication, the
doctor should be notified of any side effects such as low blood sugar attacks ,
diarrhoea or rash. There are a few classes of anti-diabetic
drugs. They are:-
v Sulphonylureas
– these drugs stimulate the pancreas to produce more insulin e.g.
chlorpropamide, glibenclamide, glipizide. v Other drugs that
stimulate insulin secretion – these drugs like repaglinide, stimulate
the pancreas to produce insulin but they are particularly effective for preventing high
blood glucose levels after meals because they are fast-acting and rapidly
metabolised. v Biguanides – these
drugs reduce glucose production in the liver and also make the
tissues more sensitive to insulin e.g. metformin. v Thiazolidinediones
– these drugs increase insulin sensitivity by activating certain
genes involved in fat synthesis and carbohydrate metabolism e.g. troglitazone,
rosiglitazone. v Alpha-glucosidase
inhibitors – these drugs reduce the absorbtion of glucose in the
small intestine e.g. acarbose.
Hypoglycaemia
Hypoglycaemia or low blood sugar attacks
can occur while on diabetic treatment. This is commonly due to the following
reasons:
v Eating
too little v Irregular
meals v Too
much insulin or anti-diabetic drugs v Not
enough food before exercise or too strenuous exercise v Illnesses
e.g. diarrhoea
According to the patient’s lifestyle it is
important to make adjustments in the medical treatment. This is to avoid a decrease
below the normal level of the glucose in the blood stream resulting in hypoglycaemic
attacks.
Symptoms
Hypoglycaemia symptoms are:-
v Lack
of concentration or confused state of mind v Irritability v Giddiness v Nausea and weakness v Sweating,
pale and cold skin v Blurred
vision
The treatment is to immediately take sugar
by mouth in the form of glucose tablets, sweets or sweet drinks. Recovery is
usually very fast. However if symptoms persist, the patient should be quickly
taken to the hospital for immediate treatment.
Complications
All forms of diabetes if not controlled properly
can lead to complications affecting several organs and parts of the body. Some
of the worst complications involve the kidneys, eyes and blood vessels. Early
detection is sometimes difficult as some complications do not have very obvious
symptoms in the early stage.
Complication End
Results
v Retinopathy Impaired
vision and leading to blindness. v Neuropathy Nerve
damage which can lead to pain or lack of sensation in the hands
and feet. Complications may require amputation of a foot or leg. Gastric motility is
disturbed causing diarrhoea and / or constipation. v Nephropathy Kidney
disease which may lead to kidney failure and early death. v Large
blood vessel injuries. These can lead to heart attacks, strokes or lack of
blood
supply to the lower limbs.
It is important that diabetes is controlled.
More than one complication can occur in a diabetic if the disease is not properly
controlled for a long time.
Control of Blood Glucose Level
In diabetics, regular monitoring
of blood glucose levels is essential, as this will indicate whether the treatment
is adequate or needs adjustment. Normal fasting level
of sugar in the blood for non-diabetics is between 4 and 6.6mmol of glucose/L.
However, levels of up to 7.8mmol/L are acceptable. A post-prandial (after meals)
blood glucose level of up to 10mmol/L is acceptable. A level below 4mmol/L indicates
a low blood glucose level. With such a low value usually symptoms of hypoglycaemia
are present. A glucose tolerance test can be done after a fasting blood glucose
measurement is done. A blood test is done 2 hours after drinking a strong glucose
solution. In normal subjects, there will be an initial elevation of blood glucose
and returning to normal after 2 hours. In diabetics, there is a high initial
increase and the level remains high (11.1mmol/L or more) after 2 hours. Another
test that can be done is the HbA1c or "Glycosylated Haemoglobin Test".
This test indicates the blood glucose level during the preceding 6-8 weeks.
It gives an indication of the diabetes control over a longer period as compared
to a blood glucose level which only gives an indication of diabetes control
at the time of testing..
Blood Glucose Monitoring
The glucose level in the body can be determined
by testing the urine. However testing the blood gives a more accurate indication.
Blood glucose levels can be tested at home using simple blood glucose meters.
Your doctor or pharmacist can be contacted for advice regarding the type of
meters and how to use them. Blood glucose testing is simple to do. Diabetics
are recommended to test their blood regularly 2-3 times a week or whenever the
patient experiences symptoms of hypoglycaemia. The reading should be recorded
and shown to the doctor during the routine visit. If at any time the reading
is found to be too high or too low, the patient should see his doctor who will
advice on what should be done to maintain the blood glucose within the normal
levels by adjusting the medicine, diet or the exercise programme.
Diabetic Self-Care Needs
Diabetics have to adhere to a regulated diet
and exercise programme and have to take prescribed medications regularly. Besides
that, because diabetics are prone to certain complications, they have to take
preventive steps. Special care has to be taken about the most problematic areas
namely the skin, feet, eyes and teeth.
Skin Care
Diabetics have to take special care of the
skin because they are more prone to skin infections. They should always keep
their skin clean. Even small cut and abrasions have to be given prompt attention
and referred to the doctor, if there is no improvement. Some measures to be
taken are:-
v Use cleaning agents
which are acidic, with a pH of 5.5. This ensures that the skin’s
natural protective function is maintained. v Cleansers should
be mild, as strong ones may irritate the skin. v Use lukewarm water
to wash. v Alkali based cleansing
agents should be avoided, especially if the skin is itchy or
inflamed. v Refrain from scratching
the skin because a break in the skin can encourage
infection. v When washing pay
special attention to areas such as armpits, genitals and perianal
areas, skin folds and the area between the toes. v After washing,
avoid dryness of the skin and keep it supple by applying a
moisturising lotion.
Foot Care
Diabetics should take special care of their
feet because due to lack of sensation, they may not feel cuts and ulceration.
v Diabetics should
wash their feet daily and dry them thoroughly especially the
spaces between the toes. v For dryness of
the skin, diabetics should apply a little moisturising cream. v Toe nails should
be cut straight across avoiding injury to the skin. v Shoes should be
comfortable and not tight. Diabetics should ensure that the interior
of shoes are free from grit or small objects before putting them on. v The feet should
be checked daily for cuts abrasions or ulcers. v Do not apply any
chemical agents to the feet such as corn plasters or callous
removers as these
contain acids which cause irritation of the skin leading to ulcers.
Eye Care
Eye disease such as cataracts, glaucoma
and even blindness due to retinopathy are more common in diabetics. There
is a higher incidence of cataracts among the diabetics and the progression of
the disease is faster. Glaucoma, which is also common
in diabetics, should be diagnosed early. Prompt treatment can minimise optic
nerve damage and loss of vision. One of the leading causes
of blindness in diabetics is retinopathy. The longer the person suffers from
diabetes, and, more so, if improperly treated or controlled, the risk of diabetic
retinopathy increases.
Diabetics must:-
v Go for
annual medical check-ups. v Carry out blood
pressure checks routinely. v Consult an ophthalmologist
if there are any visual problems.
Dental Care
Diabetics should visit the
dentist once in six months. Any lesions in the mouth including gum disease should
be identified and prompt treatment should be received. Once
diagnosed as having diabetes, a person should change his lifestyle and be more
responsible for his own health.
