Diagnosed with DIABETES? Keep in mind following points!

WHAT IS THE REASON FOR DIABETES?

Diabetese is divided into 2 types based on the reason of diabetes

  • TYPE 1 DIABETES
  • TYPE 2 DIABETES

What is reason of TYPE 1 DIABETES?

Diabetes type 1 is an auto immune disorder unlike Type 2 diabetes.

It occurs due to anti-bodies formed against pancreatic cells. There is presence of Islet cell anti-bodies and anti-bodies against insulin present in blood of these patients. As a result, the amount of insulin present in these patients is less or nil !

Unlike Type 2 Diabetes, obseity does not play a role in pathogenesis of Type 1 Diabetes. Rather, weight remains normal in these patietns.

Some cases, even viral infections may trigger Islet cell destruction and lead to Type 1 Diabetes. These viral infections include-

  • Rubella
  • Cytomegalo virus (CMV)
  • Coxacie
  • Mumps

What is the reason of TYPE 1 Diabetes ?

Various environmental factors play a role in causing Type 2 Diabetes. Obesity plays a major role in formation of Type 2 diabetes.

Environmental factors responsible for Type 2 Diabetes-

  • Sedentary life style
  • Dietary habits
  • Obesity
  • Genetic factors – this is more significant in Type 2 diabetes than in Type 1 diabetes.

What is INSULIN RESISTANCE? How does it occur?

Inability of insulin to bring about the required change in various cells of the body is called INSULIN RESISTNCE.

Insulin does the work of carrying glucose from the intestines to muscles and liver and fat cells. in these organs, glucose is stored in the form of glycogen or fats.

All of these functions take place by means of various receptors present at various locations in body.

When there is excess fat cells in the body, there is excess of free fatty acids present in body. This excess free fatty acids cause blocking in the pathway of metabolism discussed above. As a result, insulin is not able to cary out its required work. This is called insulin resistance.

Apart from this, 2 other reasons are also responsible for formation of insulin resistane in an obese patient.

  • excess of inflammatory cytokines
  • excess of hyperglycemic and hypoglycemic adipokines

Due to insulin resistance, the pancreas tries to secreat more insulin. Hence, the levels of insulin in patients suffering from Type 2 Diabetes is higher than normal.

In the long run, the continuous excess secreation of insulin leads to atrophy of pancreas!

How is OBESITY related to DIABETES?

Diabetes and OBESITY have a close relation and this is a vicious cycle. One leads to another, and another leads to one! Let’s see how!!

The fat cells in the body are a store house of free fatty acids (FFA). The FFA are circulated from these fat cells to various parts of the body as and when required.

But excess of fat cells produce excess free fatty acids (FFA). These excess FFA leads to accumulation of toxic intermediates which block the signals of insulin receptor pathway.

This leads to Insulin Resistance.

Why is CENTRAL BELLY FAT linked more to DIABETES?

As discusse earlier, the excess fat cells lead to more formation of free fatty acids (FFA) and this leads to insulin resistance.

The fat cells located near the belly area are more lipolytic than the fat cells located in the peripheral area. Hence, these create more FFA. This is the reason why people with pot belly are at more risk of having insulin resistance leading to diabetes.

What is the Most Common Cause of Death in Diabetes patient?

The most common cause of death in a diabetic apatietnnt is MYOCARDIAL INFARCTION (HEART ATTACK) followed by KIDNEY FAILURE.

In diabetes, the levels of triglycerides are raised more than normal and the level of HDL are lower than the normal. This is means that there is high bad cholesterol in blood and low good cholesterol in blood. Bad cholesterol can easily deposit in the peripheral areas such as the arteries. Diabetic patietns have presence of atherosclerosis in their arteries. This is mainly present in large and medium sized arteries.

All these reason make the diabetic patient more susceptible to myocardial infarction

RANGE OF GLUCOSE – for NORMAL and DIABETES patient

 FastingPost prandialRandom blood glucose
Normal (non-diabetic)<100 mg/dl<140 
Pre-diabetic101-125141-199 
Diabetic>126>200>200
Fasting state means no food/liquid intake except waterfor 8 hours. Post Prandial means 2 hours after food

Pre-diabtes is a range where in the glucose level ar not that high t start medcaitons but the oatietn need to be cautions.

If your blood glucose level start to fall in this range, then this should be a warning warning bell for you.

A pre-diabetic patient can bring back his glucose levels back to normal by regular exercie and strict diet cntrol. by doing this he may never need medication or atleast delay the start of his medications.

What does it mean by presence of Glucose in Urine ?

Kidneys usually can absorb back the glucose from urine into blood. This is done with the help of receptors present in the nephrons. When the level of glucose increases beyond 180 – 200 ng/dl, these receptors are completely occupied and can not absorb any more glucose back into the blood from urine. As a result, this excess glucose remains in urine.

Signs and symptoms

The classical triad of Diabetes-

  • Polydipsia
    • Excessive urge to drink water
  • Polyuria
    • Excessive urge to urinate
  • Weight loss
    • these patients may eat a lot but still may be loosing weight!

These include fungal infections and bacterial infections such as –

  • Recurrent bacterial or fungal infections
  • Malignant otitis externa
  • Mucormycosis
  • Emphysematous pyelonephritis
  • Recurrent urinary tract infections

Diseases associated with Diabetes

There are some disease which may or may not lead to formation of diabetes either at the time of presentation or later time of life.

  • Pancreatitis
  • Cancer of pancreas
  • Cystic fibrosis
  • Hemochromatosis
  • Acromegaly
  • Cushing’s disease
  • Glucagon
  • Pheochromocytoma
  • Hyperthyroidism

Can you control diabetes using Exercise?

If any one is diagnosed with Diabetes, he/she is told to exercise. So it might be a question in many, that can you control diabetes with only Exercise?

Before you start to have symptoms of diabetes, your pancrease is already worknig too hard in order to control this excess of glucose. This asymptomatic period time period is called honeymoon time period!

hence if you try, exercising at this time may not help lower your glucose levels to that level that you may not need any medications. Yes, you may need less dosage of medication, and you will face less severe complication of diabetes if you continue exercising. But you will still need to take you medications.

BUT, If your blood sugar is in the range of Pre-diabetic then strict diet control and exercise may help you get your sugar back to normal range. And u may not need to take medications or atleast delay the onset of Diabetes!

Can a Diabetic patient consume Alcohol ?

Alcohol inhibits the gluconeogenesis. This means it inhibits the conversion of glucose from glycogen or fat cells. This can lead to formation of hypoglycaemia (lower than normal glucose levels). This is possible especially if your are taking your anti-diabetic medications. And if you are taking metformin tablets as medications then it may precipitate lactic acidosis (excess amount of acid in body).

Hence, consuming alcohol must be avoided during diabetes.

Effect of Exercise in Diabetes

  • Improves Insulin Sensitivity (reduces insulin resistance)
  • Reduces fasting and Post Prandial Glucose
  • Has metabolic, cardiovascular and psychological benefits

American Diabetes Association (ADA) recommends 30-60 minutes of aerobic activity 3-4 times a week.

  • Hypoglycaemia – the most common complication. This occurs as an imbalance between the requirement and dose of insulin. The risk of hypoglycaemia is maximum just before meals, during night and during exercise. This also a common complication short acting insulin injections, if the patient delays the food after injections. Look out for the following signs of hypoglycaemia
    • Sweating
    • Tremor
    • Tachycardia
    • Anxiety
    • Dizziness
    • Clouding
    • Decreases mental clarity
    • Confusion
    • Convulsions
    • Loss of consciousness

Hence, it is advised that a diabetic person; especially if newly diagnosed; should keep a packet of biscuit or toffee with them.

Irregular eating habits, unusual exertion and alcohol excess may precipitate hypoglycaemia episodes.

  • Lipodystrophy

Fatty lumps may develop due to over use of same injection site. This is due to lipolytic effect of insulin injections.

How medications help in reducing the complications of diabetes ?

Medications can help you reduce the macro-vascular complication of diabetes such as heart attack, pvd, stroke.

But they may not help in controlling micro-vascular complications such as nephropathy, retinopathy and neuropathy. These micro-vascular complications can be reversed only on tight glycaemic control.

But tight glycaemic control will not have any effect on macro-vascular complications. Hence, if you are diabetic, make sure that you carry out diet control and exercise along with your medications.

Targets for adults with diabetes

  • HbA1C less than 7%
  • Blood pressure less than 130/80
  • HDL more than 1 mmol/L ( 40 mg/dl) in men and more than 1.3 mmol/L ( 50 mg/dl)
  • LDL less than 2.6 mmol/L ( 100 mg/dl)

TGA less than 1.7 mmol/L ( 150 mg/dl)

Insulin delivery systems

  • Insulin syringes

These are available as disposable plastic syringes in the required size.

  • Insulin pen

This holds a prefilled cartridge contain the desired type of insulin. This is suitable for multiple usages.

  • Implanted insulin pump therapy-

Controlled pumps can be implanted in peritoneal cavity. The insulin is absorbed in the peritoneal cavity and absorbed and delivered into the splanchnic system.

  • External pump therapy-

Portable infusion pump or continuous subcutaneous insulin infusion

Uncontrolled levels of glucose for long time can lead to complications such as-

  1. Acute complication
    1. Diabetic ketoacidosis
    1. Hyperosmolar coma
  2. Chronic complication
    1. Macro-vascular complications
      1. Myocardial infarction (Heart attack)
      1. Peripheral vascular disease
      1. Brain stroke
      1. gangrene
    1. Micro-vascular complications
      1. Diabetic retinopathy (affecting retina of eye)
      1. Diabetic nephropathy (affecting the nephrons of kidney)
      1. Diabetic neuropathy (affecting the nerves)

Depending upon complications seen in the types of diabetes

  • Complications seen in type 1 diabetes
  • Diabetic ketoacidosis

Complications seen in type 2 diabetes

  • Hyperosmolar non ketotic coma

Necrobiosis lipoidica

Macro-vascular complications

The hallmark of Diabetic Macro-vascular disease is – Accelerated Atherosclerosis. This occurs due to endothelial injury. Large and medium sized arteries such as the aorta, abdominal arteries, renal arteries are affected. There is deposition of hyaline in the arteries leading to Hyaline Arteriosclerosis (hyaline deposition in the wall of the arteries causing narrowing of the lumen).

This leads to complications in all the major organs of the body such as heart, kidneys, liver. Problems that can occur due to above reasons include-

HEART – block in heart blood vessels causing Myocardial Angina or Myocardial Infarction (Heart Attack)

KIDNEY – due to atherosclerosis in arteries carrying blood into and out of the kidney, there is decrease in blood flow to kidney. This affects the elasticity and regulation of blood flow to kidneys.

BRAIN – similar in mechanism as in heart. This can lead to Brain Stroke. LIMBS- blockages in blood vessels lead to decreased blood flow in minute vessels carrying blood to peripherals of limb. Due to less blood flow, the tissues start to die leading to Gangrene.

Diabetic Nephropathy

Observing the pieces of kidney of a diabetic patient under micro scope shows deposition of proteins and fats in the kidney cells (nephrons). This is called as Diffuse glomerulosclerosis. This may even be in form of small irregular drops known as Nodular Glomerulosclerosis.

After suffering these damages, the patient starts to loose albumin protein in urine. After a certain level of blood glucose, there is also presence of glucose in urine. This represents that now the level of glucose has risen so high level that even kidneys are not able to absorb them back.

In diabetes, the kidney undergo the following step by step changes-

  1. Increased Glomerular Filtration Rate (GFR)
  2. Loss of albumin from blood into urine (micro-albuminuria)
  3. increasing loss of albumin in urine (macro-albuminuria)
  4. End Stage Renal Disease (ESRD)

These changes along with the atherosclerosis lead kidney to a state where it can not be reversed. This is called as Chronic Renal Failure (CRF). This is the second most common cause of death in patients of diabetes after heart attack.

From here, the reversal is next to impossible and the patient may need renal transplant if he/she is eligible for that!

Diabetic Retinopathy

Excess glucose in blood damages blood vessels of retina. Not just retina, damage is also seen in various other parts such as the lens.

Complications of diabetes seen in eye are-

  • Retinopathy
    • Damage to retina
  • Cataract formation
  • Glaucoma
    • Increased intra ocular pressure
  • Vitreous haemorrhages
    • Bleeding in the retinal blood vessels into the vitreous humor
  • Retinal detachment
    • Bleeding from the retinal blood vessels may cause

Retinopathy initially starts as non proliferative complication and is followed by proliferative complication.

The damage caused to retinal blood vessels leads to microscopic haemorrhages, microscopic exudates dilatations, thickening. This, in long term, can cause infarction of retina.

There is formation of new blood vessels in retina. There is presence of blood leaks or plasma leaks, small blockages, infarcts in the blood vessels of the eye. This leads to blood leaking into the vitreous humor causing vitreous haemorrhages and blindness.

The chance of blindness in diabetic patient is 25 times more then in a normal person

Blindness caused by diabetes is slow, painless and irreversible.

Time period for occurrence of complication in diabetes-

In Type 1 Diabetes-

Retinopathy and Nephropathy takes 5 years to start

In type 2 diabetes-

Retinopathy takes 15-20 years to develop

Type 2 diabetes has longer asymptomatic period. As a result, till the time patient is diagnosed with diabetes, patient may already be suffering from retinopathy !

Hence, regular eye check-up is recommended for patients of diabetes and in case of type 2 diabetes, eye-check should be done immediately being diagnosed with diabetes.

Treatment of Diabetic Retinopathy

Initially, the minor complication of diabetes are reversible and can be controlled by strict diet control and proper medications. Photocoagulation can also be done in some cases where blood vessels are affected.

But in cases of major complication, the treatment may not be effective and may lead to permanent blindness in the patient.

Recommended eye examination time-

In Type 2 diabetes– immediately on diagnosis of diabetes followed by yearly check-up.

In Type 1 diabetes – 3-5 years after diagnosis followed by yearly check-up.

Diabetic Neuropathy

The frequent pattern of diabetic neuropathy is peripheral symmetric neuropathy, mostly involving lower limbs, both motor and sensory parts of the nerves are affected.

So far, we have discussed how glucose affects blood vessels. Even the nerves of our body are supplied by blood vessels. Decreased flow in blood vessels supplying nerves leads to following symptoms-

  • Tingling sensation
  • Loss of touch/pain sensation
  • Weakness in movement of limbs

In some cases; especially in rural area; due to loss of touch and pain sensations, the patient is unaware of any injuries caused in foot. As a result he/she does not pay attention to it and that injury keeps growing. Plus, as there is high glucose in the blood; a suitable environment is created for bacteria, parasites and maggots to grow.

These patients usually come to hospital with excessive injury. And as this is a suitable environment for maggots to grow, often there is presence of maggots in these tissues.

Prevention-

The main prevention is to keep glucose levels in control

And if your glucose levels are high, then make sure –

  • To wear full covering footwear- such as shoes
  • Keep checking soles for any injury
  • If there is any injury visible, make sure to get adequate dressing done on it.
  • Keep taking regular medications to bring glucose in control.

Treatment-

The treatment of gangrene is amputation. Amputation must be done till above the visible area of amputation. In some cases, complete limb might need amputation.

In case of maggots, maggots are killed by dressing using turpentine. Amputation needs to delayed to make sure that all maggot are killed.

In some cases, neuropathy may not cause injury as discussed above, but may show any of the following symptoms-

  • Sudden foot drop
  • Sudden wrist drop
  • Cranial nerve palsy
  • Bowel/bladder dysfunction

Delayed gastric emptying

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