DIABETES

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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Primary Diabetes
Secondary Diabetes
Symptoms
Treatment
Diet
Exercise
Insulin
Anti-Diabetes Tablets
Hypoglycaemia
Complications
Complication End Results
Control of Blood Glucose Level
Blood Glucose Monitoring
Diabetic Self-Care Needs
Skin Care
Foot Care
Eye Care
Diabetics must:-
Dental Care

Primary Diabetes

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.

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