Diabetes Mellitus

Diabetes mellitus is a disease characterized by absolute or relative inadequacy of Insulin hormone and consequent high blood sugar. Diabetes mellitus is a metabolic cum vascular disorder in which the body’s capacity to utilise glucose, fat and protein is disturbed due to insulin deficiency and/or insulin resistance. This could lead to damage of blood vessels if left uncontrolled. In people with diabetes there is insufficient insulin activity in the body. Insulin is a hormone produced by beta cells of islets of Langerhans in the pancreas.

Normal Plasma Glucose Levels :

Types :

Type 1 Diabetes (Insulin dependent diabetes) : The pancreas does not produce sufficient insulin, due to self destruction of the cells producing insulin.

Type 2 Diabetes (Non Insulin dependent diabetes) : Stress, Obesity, Poor dietary habits, Lack of physical exercise, having bad lipid profile and heredity.

Warning Symptoms of Diabetes :

• Frequent urination.
• Excessive thirst.
• Excessive hunger.
• Unexplained weight loss.
• Sudden changes in vision.
• Tingling or numbness in the hands and feet.
• Poor sleep, Fatigue, Irritability, Dry skin.
• Delayed healing of wounds, Repeated infections.

Risk Factors of Diabetes :

• Family history of diabetes.
• Over weight / Obesity.
• High blood pressure orhyperlipidemia.
• Those with previous bad obstetric history. a) Recurrent abortions b) Still births c) Congenital malformations d) Big baby (over 3.5 kg at birth)
• Mental stress.
• Physically inactive people (sedentary jobs)

• Absence of protective sensation due to peripheral neuropathy
• Arterial insufficiency
• Foot deformity and callus formation resulting in focal areas of high pressure
• Autonomic neuropathy causing decreased sweating and dry, fissured skin
• Limited joint mobility
• Obesity
• Impaired vision
• Poor glucose control leading to impaired wound healing
• Poor footwear that causes skin breakdown or inadequately protects the skin from high pressure and shear forces
• History of foot ulcer or lower extremity amputation

2. Peripheral Arterial Occlusive Disease -

Peripheral arterial occlusive disease is four times more prevalent in diabetics than in nondiabetics. The arterial occlusion typically involves the tibial and peroneal arteries but spares the dorsalis pedis artery. Smoking, hypertension and hyperlipidemia commonly contribute to the increased prevalence of peripheral arterial occlusive disease in diabetics.

3. Sensory and Autonomic Neuropathy -

Distal symmetric polyneuropathy is perhaps the most common complication affecting the lower extremities of patients with diabetes mellitus. This complication occurs in up to 58 percent of patients with longstanding disease.19 Neuropathy, a major etiologic component of most diabetic ulcerations, is present in more than 82 percent of diabetic patients with foot wounds.4 This lack of protective sensation, combined with unaccommodated foot deformities, exposes patients to undue sudden or repetitive stress that leads to eventual. ulcer formation with a risk of infection and possible amputation

4. Structural Deformity and Limited Joint Mobility -

Foot deformities, which are common in diabetic patients, lead to focal areas of high pressure.

5. Recurrent infections -

They are due to persistent high Glucose level which is a nutrient medium for organisms.

6. Retinopathy -

Loss of vision, blurring, early cataract are all seen in uncontrolled diabetics,Sudden blindness could be caused due to retinal detachment.

Highlights of Diabetic Retinopathy -

• Diabetic retinopathy can be assessed only by retinal examination.
• Retinal test is different from glasses testing.
• Beware! Early stages of diabetic retinopathy will not produce any sight loss.
• Hence only by retinal examination diabetic retinopathy can be diagnosed.
• Retinal examination should be done once a year.

7. High lipids and consequent heart problems

8. Risk Factors Leading to Kidney Disease Diabetics -

• 1. Poor control of diabetes.
• 2. Long duration of diabetes.
• 3. Uncontrolled blood pressure.
• 4. Genetic Factors (Family History of kidney disease).

Note -

• 1. Diabetic kidney disease is one of the commonest causes of kidney failure.
• 2. Kidney disease is asymptomatic till late stages.
• 3. Kidney disease is preventable by early detection of diabetes and good control of diabetes and blood pressure.
• 4. Screening for diabetic kidney disease should be done at least annually.

Prevention -

• 1. Eliminate refined carbohydrates like white flour, bakery products, white sugar etc.
• 2. Yoga aids in reduction of weight and also burns the calories.
• 3. Avoid fruits such as ripened mango, banana, Sitafal, Chiku because of their high glucose content.

Prevention -

• 4. Drink 8-10 glasses of water everyday.
• 5. Have complex carbohydrates with fibres like fruits, raw vegetables, sprouts, whole wheat flour will help to reduce the speed of absorption of the sugar
• 6. Brisk Walking is the best exercise to prevent and control diabetes.

Precautions to be followed in diet and life style -

Continue the life style and dietary modifications. Diabetic complications could be arrested by following the above mentioned precautions and modifications in life style.

Prevention of Ulcer Formation -

• 1. Meticulous attention to foot care and proper management of minor foot injuries are key to preventing ulcer formation.
• 2. Yoga aids in reduction of weight and also burns the calories.
• 3. Daily foot inspection by the patient (or a caretaker if the patient lacks sufficient visual acuity or mobility to perform the examination) is the cornerstone of proper foot care.
• 4. Gentle cleansing with soap and water, followed by the application of topical moisturizers, helps to maintain healthy skin that can better resist breakdown and injury.
• 5. The physician should inspect the patient's shoes for areas of inadequate support or improper fit.
• 6. Minor foot injuries and infections, such as cuts, scrapes, blisters and tinea pedis, can be unintentionally exacerbated by home remedies that impede healing. Patients should be reminded to avoid hot soaks, heating pads and harsh topical agents such as hydrogen peroxide, iodine and astringents
• 7. Gentle cleansing of minor wounds and the application of a topical antibiotic to maintain a moist wound environment can help to prevent ulcer formation. In addition, the physician should inspect any minor wound that does not heal rapidly.

How to prevent kidney disease in Diabetics -

• 1. Diagnosing diabetes at an early stage by regular screening.
• 2. Once diabetes is diagnosed, it should be kept under very good control.
• 3. Tight control of blood pressure (130/80mm/Hg) helps to prevent kidney damage.
• 4. Regular screening for microalbuminuria to identify early stages of kidney damage.
• 5. Use of ACE inhibitors or other drugs, which have very good effect in early stages of kidney disease.
• 6. Regular check up at diabetes centre.
• 7. Strict diet as advised. If there is proteinuria, the protein intake in the diet may have to be reduced.

Treatments -

• 1. Do lifestyle modifications (appropriate diet and increased physical activity),
• 2. Take Towel pack/ Jelly pack, GH pack, Hip bath, steam bath, etc.
• 3. Practice Yogasanas and Kriyas like Vamana Dhouti under a trained Yoga instructor.
• 4. Make dietary changes by including high fibrous, low calorie diet consisting of Methi, Karela, Jamun, Guava, cucumber, tomato, green salads etc
• 5. Exercise everyday at least for one hour.
• 6. The line of treatment varies with the condition of the patient time to time depending upon the blood sugar levels.

How to self examine your feet ?

• 1. Sit on a bed or comfortable flat surface with legs drawn close to your body.
• 2. Hold a big size mirror beneath your feet 6 – 12 inches away.

Look for -

• 1. Any cracks
• 2. Peeling of the skin.
• 3. Abnormally dry skin.
• 4. Colour change in any area.
• 5. Any wound that has occurred.
• 6. Any shiny appearance on the feet.

Feel your feet with your hands for -

• 1. Abnormally cold feet
• 2. Any thickening of skin in the soles, especially beneath the big toe.
• 3. Any protruding bone beneath the feet.
• 4. Any change in the shape of the feet.
• 5. Swelling of the feet
• 6. Localised redness or warmth of the feet.
• 7. Ulcers or wounds

Diet & Diabetes -

Diet is the most important aspect in the treatment of diabetes, but there is no single diabetes diet.. The old idea that Rice should not be taken is a fallacy. All cereals contain the same amount of starch. e.g., rice, wheat, jowar etc. It is the quantity that matters PICTURE. Vegetable proteins like dal, pulses and legumes are better than animal proteins. Combination of cereals and pulses will enhance the protien quality. Mushrooms are low in calorie, but rich in protein.

Fibre rich food are very good in controlling diabetes and for reducing serum cholesterol. Rich sources of natural fibre are whole cereals, pulses like bengal gram, black gram, green gram and green leafy vegetables. Soluble fibres from fenugreek seeds taken either as sprouted or in powder form can be used as a supportive therapy. Intake of saturated fat should be reduced to prevent increase in serum cholesterol. Use vegetable oils in moderation and a mixture of monounsaturated oils like groundnut or gingilly oil and polyunsaturated oils like saffola or Sunola is best.

The intake of total calories is to be reduced by those who are overweight. CHART Food should be distributed into small frequent feeds. Skipping a meal or fasting is not really advisable.

Vegetables that can be taken in unlimited amounts are - Ash gourd, Beans, Bitter gourd, Bottle gourd, Brinjal, Brussels sprouts, Broccoli, Cabbage, Cucumber, Cauliflower, Chow-chow, Cluster beans, Coriander leaves, Cowpea-pod (Karamani), Capsicum, Drumstick, Ginger , Greens (all varieties), Knol khol, Kovai, Ladies finger, Mint, Onions, Papaya (raw), Plantain flower, Plantain stem, Ridge gourd, Snake gourd, Tomato (raw and ripe), Turnip, White Radish.

Carrot, beetroot, peas and double beans can be used in moderation. Potatoes, yam, colocasia and tapioca are better avoided.

Free Foods : Skimmed buttermilk, unsweetened lime/tomato juice, clear soup, pepper water(rasam), vegetable salads like tomatoes, cucumber, onion, white raddish, lettuce and capsicum.

A BOWL OF SALAD 100 gms = 25 Calories

AVOID Sugar, honey, glucose, jam, jaggery, sweets, cakes, pastries, tender coconut water sweetened, soft drinks, banana, mango, jack fruit, custard apple (Sitaphal) and dry fruits, especially if overweight. Apple, orange, sweetlime, papaya, guava, pear, muskmelon and watermelon etc., may be taken in consultation with Diabetologist/Dietitian when blood sugar is under control.

Food items that are equivalent to 200 calories are : 3 Idlies (or) 3 Chappaties (or) 2 Dosas (or) 1-3/4 cups of Rice. (Remember : any one and not all of these)

KEY MESSAGES :

NO FASTING OR FEASTING
AVOID DIRECT SUGAR
RESTRICT CALORIES OF OBESE
USE UNLIMITED AMOUNTS OF LOW CALORIE FOODS

EXERCISE & DIABETES :

Why exercise? 1. Reduces weight 2. Improves blood sugar control 3. Reduces the dose of diabetic medications 4. Improves the quality of life

How often, How much and How long? Clip of a joggers

• Try to do exercise every day, minimum of 5 days a week.
• Start slowly and work up gradually every week.
• Brisk walking of 5 to 6 km/hr should be done if possible. If not, whatever best you can achieve, will suffice.

Time : Exercise should last for at least 30 minutes and go up to one hour if possible. There should be a warm up and cool down period for each session.

Warm up : Prepares body for vigorous activity; helps prevent strains and injuries to muscles. It should last for 5-10 minutes.

Cool down : Helps restore circulation to normal levels, prevents cramps, sore muscles and post-exercise dizziness. This should also last for 5 - 10 minutes.

Choose your exercise : Walking, running, cycling, swimming, playing team games, dancing, jogging, brisk walking, tennis – choose whatever suits your personality, but stick to it. Regularity is more important

Prevention of diabetes : stills and charts

The prevalence of Diabetes Mellitus in the Indian population now ranks first in the world even ahead of China. In the last twenty years there has been a three fold increase in the prevalence of diabetes and today it is estimated that there are over 32 million people with diabetes in India. The problem in diabetes is that very often it is silent. The symptoms of diabetes such as increased thirst and urination, etc., occur only when the diabetes is severe. In early stages it can remain totally asymptomatic. Moreover after 10-15 years duration of diabetes, the prevalence of all diabetes related complications increase markedly. These include Retinopathy leading to blindness, Nephropathy leading to kidney failure, Heart attacks, Gangrene of the feet, Stroke and even less known complications like Impotency, or sexual weakness. Thus diabetes is a serious threat to public health and this shows the urgent need for prevention of diabetes.

I. Primary prevention : chart

Primary prevention refers to the prevention or the postponement of diabetes in those who are susceptible to diabetes. Early detection is the key to prevent and control diabetes. As diabetes is largely asymptomatic, regular screening for diabetes is most important.

Indications for screening :

1. Positive Family History

It is a well known fact that diabetes is caused mostly due to hereditary factors. Hence it is clear that screening of diabetic families would be the first priority.

Risk of diabetes :

• If both parents are diabetic 99%
• If one parent is diabetic 50%
• If any other relative is diabetic 25%

Hence it is clear that any one who has positive family history should be screened for diabetes.

At what age the screening should be started?

The onset of diabetes is earlier in Indians i.e., around 20-30 years of age. If the family history is strong, e.g., members of more than two generation in the family have diabetes, the first screening could be done even by 20 years of age and thereafter on a yearly or two yearly basis.

2. Obesity

Obesity causes resistance to Insulin. Your body makes insulin but the extra weight prevents it from using the insulin the way it should be used. For this reason, obesity is another risk factor for diabetes.

3. Physical inactivity (those with sedentary jobs)

Which test is to be done?

The Glucose Tolerance Test (GTT) is the confirmatory test since it helps to diagnose even the early stage of diabetes. Most people check only Fasting, Postprandial or Random Blood Sugar which may not reveal diabetes until it is at a more advanced stage. Even if the GTT results show normal values at the time of testing, it does not mean that the person will never develop diabetes. Such individuals should have an annual GTT done if the family history of diabetes is very strong.

II. Secondary Prevention : chart

Secondary Prevention refers to the prevention of complications once diabetes set in. This can be achieved by good control of diabetes with the help of diet, exercise, medication and regular monitoring of blood sugars. Blood sugars can be checked even on daily basis with the help of blood sugar meters which facilitates quick determination of blood sugars. Since blood sugars tend to fluctuate a lot, from day to day or hour to hour, HbA1C (Glycosylated haemoglobin) test should be done to assess the blood sugar for the previous 2-3 months.

III. Tertiary prevention : chart

Tertiary prevention refers to the rehabilitative measures once the complications have set in. For example, for Diabetic Retinopathy, Laser Photocoagulation will help to prevent or reduce the incidence of blindness. Laser photocoagulation helps to seal leaking blood vessels in the retina and thus prevent visual loss. It is recommended that at least once a year every diabetic individual should do a complete check-up of all complications especially the eyes, kidneys, heart and feet in order to reduce the morbidity due to diabetes.

Key Messages :

• DIABETES IS PREVENTABLE
• EAT LESS; WALK MORE
• FATNESS IS NOT FITNESS
• FIGHT CHILDHOOD OBESITY
• PREVENT DIABETIC COMPLICATIONS at any cost

STILL PICTURE OF PANCREAS
STILL PICTURE OF INSULIN TARGET ACTIONS AND ORGANS
Video of SELF MEDICATION / injection OF INSULIN
Still picture of Glucometer.