What is Diabetes ?


When blood glucose signicantly increases above normal range than it is called Diabetes.

DIABETES DIAGNOSIS CRITERIA
1) Fasting Blood Sugar more than 126 mg. /dl.
2) Post prandial (P.P.) Blood Sugar more than 200 mg./dl
3) HBA1C (Glycosylated Haemoglobin ) more than 6.5%


Symptoms of Diabetes


The classical symptoms of diabetes are excess thirst, excess urination, weight loss inspite of good eating, weakness, fatigue, leg pain, easy fatigability, decreased vision, recurrent itching deposition of whitish deposits & fissuring on glans pennis & foreskin in men, itching in & around vulva, difficulty in healing of wound so that wound may not heal for long time. Sometimes patient may have sugar for long time without their knowledge & they manifest directly with various complications of diabetes. Thus patient may directly present with complications of diabetes as burning & numbness in feet (nerve involvement), chest pain or breathlessness (heart involvement), decreased vision (eye involvement), selling over feet or body (kidney involvement) etc.

Remember many patients with Diabetes are asymptomatic i.e. they have no symptoms & they are diagnosed only when they go for routine blood sugar test during routine investigations for some other problem, then it was found that their blood sugar is high. Sometimes patient’s blood sugar may become too high leading to coma (Diabetic ketoacidotic coma due to high blood ketone. Ketone is an acid which is produced when blood sugar becomes very high due to severe insulin deficiency.


Why Diabetes Occurs (Causes)


Causes of Diabetes in Adult: Diabetes in adult is known as Type 2 Diabetes. This usually occurs after the age of 30 year. This type of Diabetes occurs due to decreased secretion of insulin as well as decreased effect of Insulin (already less produced) in body i.e. Insulin Resistance. Thus Diabetes in adults occurs due to twin defect namely insufficient Insulin production in the body as well as what ever Insulin is being produced works less meaning Insulin is less effective in lowering the blood sugar (i.e. less ineffective also known as Insulin Resistance).

Hereditary and Genetic factors Drugs such as Steroids, Growth Hormone, Diuretics used to treat High Blood Pressure.

Hormone disorders, as excess of Cortisol Hormone, Growth Hormone, Hyper Aldosteronism etc decreases Insulin secretion & lead to Diabetes.

Chronic Alcohol use may lead to Pancreatic damage leading to Insulin deficiency & Diabetes.

Diabetes during pregnancy occurs due to release of certain hormone during pregnancy which decreases the effect of Insulin secreted from pancreas leading to diabetes. The diabetes which develops during pregnancy is called Gestational Diabetes.



Causes of Diabetes in children: There are following types of diabetes in children:

1) Type I (i.e. Insulin dependent diabetes mellitus): Type I diabetes is also known as Insulin dependent Diabetes. It occurs at young age often below 25 yr. of age due to destruction of insulin forming beta cells in pancreas by a particular type of viral infection. These viruses infect the pancreas & then damaging insulin forming beta cells leading to total deficiency of insulin hormone so that blood sugar rises. Such children are dependent on insulin injection for their survival. If they miss insulin injection for few days then their blood sugar level reaches very high & they may go in coma. Some times ketones appear in blood & urine (called as diabetic keto-acidosis). This may be sometimes life threatening also.

2) Type II i.e. Non Insulin Diabetes of young (NIDDY): This usually occurs in obese children with positive family history. In such children diabetes is initially controlled on tablets, later insulin may be required by some.

3) MRDM (Malnutrition related Diabetes

4) Fibrocalcific Pancreatic Diabetes (FCPD)

5) Drug induced: steroid induced

6) Auto-antibody induced.

7) Secondary diabetes

In Children after investigating the type of Diabetes appropriate treatment should be prescribed.

Risk of Type-II diabetes to Children & other family members:


If one parent has Non-Insulin Dependent Diabetes risk of developing diabetes to children is 36% i.e. one out of 3 children will develop diabetes. If both parents have diabetes then 75% of their children will become diabetic (i.e. if they have four children then 3 out of four will become diabetic). If one brother or sister has diabetes risk to other siblings is 33% i.e. one out of every 3 will become diabetic.

If parent has Type-1 Diabetes i.e. insulin dependent diabetes then risk to offspring is very little.


Treatment of Diabetes


Treatment of diabetes consists of Diet, Exercise, and Drugs or Insulin


Diet control (What to Eat)


Diet: For detail diet advice meet our doctor at our centre. Tips for diet in diabetes:

•  Take every food in proper amount, not more not less.
•  Consistency in meal timings, in meal composition & Calorie intake.
•  Spacing of meals: Eat 3 major meals & 3 small snacks.
•  Matching diet & insulin therapy.
•  For variety in food, use food exchange system.
• Do not miss meal or delay meal too much.
•  Do not starve, eat free foods when hungry.
• On holidays: you may be at risk of eating too much, to deal this, take small meal more frequently.
• If ate too much, Do a little more exercise either before or after.

Glycemic Index: You should consume only those foods which have low glycemic index.

Sweeteners:

a) Saccharin (available as Sweetex): It is safe even if you take for long time in proper doses. Side Effects: it leaves a bitter after taste, otherwise no side effect It should not to be used by Pregnant & breast feeding mothers.

b) Aspartame (available as Sugar Free or equal tablets): It is safe even if you take for long time in proper doses. It should not to be taken during pregnancy

High Fiber Diet: Select fiber rich foods because they decrease blood sugar, cholesterol & help in reducing other diabetic complications etc.

Fat & Oils: Use Low Fat Diet. Avoid saturated fats & use more of unsaturated fats. Use two types of oils daily. One should be refined oil with predominantly monounsaturated fatty acid & other should be that with predominant polyunsaturated fatty-acid. You should use only those oil with safe ratio of omega 3 fatty-acid & omega 6 fatty-acid. Because if you eat oil with more of omega 6 fatty acid ,then risk of heart problem, kidney problem & other diabetic problems increases. Saturated fat should be used as less as possible because they increase the cholesterol & heart & neurological problems.

Use Fat Free milk (Preferably double toned)

Vitamins: Supplementations of certain specific vitamins has been shown to decrease diabetes complications.

Antioxidants may be taken.

Micronutrients & Minerals: Certain micronutrients should also be replaced as they help in controlling diabetes & help in preventing complications


Diet in Special Situation
1. In case of High Cholesterol = Eat less fat & oil, No yellow of egg
2. In case of High Blood Pressure = Eat less salt, fat & yellow of egg
3. In case of Pregnancy = Eat more calories every 2 hourly
4. In case of Child = Additional calorie & protein for growth.


Diabetes & Alcohol


Either should not be taken or if feel like then take in moderate & safe prescribed dose. Remember regular alcohol intake increases weight, B.P., Sugar, damages nerves, heart and increases blood pressure, lipids as Cholesterol & Triglyceride. It is strictly prohibited if patient is suffering with Uncontrolled Blood Pressure, High Blood lipids, Pancreas is damaged (Pancreatitis) & Nerves are affected (Neuropathy)


Diabetes & Smoking


Smoking is not good for diabetic. They should not smoke.
Harms of smoking are:
•  Decreases insulin effect so blood sugar rises.
•  Increases risk of heart attack.
•  Increases risk of eye, kidney & nerve complication.
•  Decreases blood flow to leg.
•  Impotency in male.


Exercise


What Exercise should i do ?
Walking: best especially if you can do brisk walk for 30-60 min. Jogging, Treadmill, Swimming, Playing Badminton or other game.
How Often?
Daily/or at least 4 days per week.
What time?
Excellent time of exercise is before breakfast but it can be done at anytime in the day.

• If you want to do intense exercise – get fitness by getting your Treadmill Test done especially if your age is above 35 or have heart disease or have diabetes for more than 10 yrs.
• Do 10 min. warm-up, 20-30 minute of active exercise & finally 10 minute of cool down phase.
• Remember at time of exercise insulin should not have been given in exercising limb.
• If going on a new non-routine exercise, check your blood glucose before & after exercise & during exercise (every 30 minute) if it is prolonged exercise.
• May need extra food for 30 hours after prolonged or heavy exercise.
• If doing new exercise either decrease short acting insulin before exercise or eat 20 gm. Carbohydrate every 30 minutes.

Precautions Regarding Exercise
• Use well fitting canvas shoes or sport shoe with laces.
• Don’t exercise if blood sugar is uncontrolled (Bl. Sugar >300 ml/dl)
• If you have Heart problem – don’t do wt. Lifting, strenuous exercise.
• If severe eye problem – should not do heavy lifting, head low positions & excess head jerks, jogging, Racquet - sports.
• If you have lost sensation in feet – check feet more carefully after exercise, avoid treadmill, prolonged walking, jogging, step exercises.
• Patient with Diabetic kidney involvement – should not do heavy strenuous exercise as it worsens nephropathy.
• Should carry diabetes identification card & source of readily available carbohydrates to treat hypoglycemia.
• If feel low blood sugar take some carbohydrate.


Drugs to Control Diabetes


The five groups of medications used for diabetes control are:

1) Those medicines which improve the insulin secretion in the body
2) Those medicines which improve the action of insulin on liver
3) Those medicines which improve the action of insulin on muscles
4) Those medicines which decrease the absorption of glucose from the intestine into the blood.
5) There are many new drugs are available which controls diabetes well as prevent complication
6) There are many new drugs are available which are very effective in preventing diabetic complications.


Insulin Therapy:


Insulin is considered best for the treatment of Diabetes including in Adults, Childrens, Pregnant women , people with failure of Liver and Kidneys. They can be used by either Insulin Injections or Insulin Infusion Pumps Misconcept About Insulin: This is a Misconcept that once insulin started it can never be stopped.

But It is Wrong, in 80% cases insulin can be stopped after 2-3 months of insulin therapy.

Why in some inspite of insulin diabetes is not controlled?

Possible causes may be:-
• Insulin being given may not be right one.
• Inadequate doses.
• Insulin not being injected properly
• Wrong site
• Wrong technique
• Injecting at same site
• Other causes as stress, steroid, hormonal disorder.

Remember in upto 50% patients who are taking insulin still there diabetes is not controlled because they are doing one of the above mistakes. So you need to meet us to find out the exact cause of uncontrolled diabetes.

Insulin Injection Techniques:
• Wash hands with soap water.
• Mix insulin by gentle shake & rolling.
• Take the required amount of insulin in syringe, roll that syringe on palm to bring at room temp.
• Clean injection site & allow to dry.
• Pinch a fold of skin.
• Inject at 45° to 90°.
• Withdraw needle, apply pressure.
• Recap syringe for reuse (2-5 days). Insulin: Stability & Storage
• In Refrigerator –it is stable for many months till expiry.
• At room temperature : In winter (less than 25°C) – stable for 2-3 months In summer (less than 35° C) in dark corner stable for 1 month.
• In Peak summer if no refrigerator keep in cool place
• Avoid direct sun exposure
• If large clubbed particle visible means insulin has become degraded.


CAN INSULIN BE STOPPED


Stopping of Insulin is now possible because many new drugs have now come in market which are very effective in controlling sugar after stopping insulin if given in right combination.


What you should do when you are sick?


Check blood glucose 4 hourly.
Do not stop insulin or tablet.
Often during sickness the effect of tablet or insulin decreases so that the medicine dose is often need to be increased.
Take liquid diet as juices, cold drinks, biscuits if unable to take normal food.
If on insulin – check urine ketone if blood Sugar >350
If vomiting , pain abdomen, drowsiness – Consult Doctor—may be D.K.A.


Precautions During Travel


Carry double the dose of medicine & keep all medicine/insulin at two separate places.

Do not keep at extreme temperature.
• Remember – You can keep insulin without refrigerator for 30 days in cool dark corner of room.
• Always carry enough eatables during travel for emergency.

BY AIR : If crossing time zone
• When you lose hours from day say traveling from west to east you may need to skip or reduce insulin dose.
• When adding hours to your day (East to West) you need an extra dose of insulin.

BY CAR : If going by car if temperature is very high carry in thermos with ice or keep insulin in glove compartment.


CURE OF DIABETES


As you know in majority of cases diabetes can not be cured permanently but can be controlled only. But in some patients in whom diabetes is secondary to some hormone disorder or due to some drugs or due to some lifestyle disorder, in them it can be cured.


PREVENTION OF DIABETES


• Doing regular exercise
• Losing body weight If overweight or obese
• Quitting smoking and alcohol ( if consumed )
• Regular blood checkups
• There are three drugs which were being used to prevent Diabetes, these are Metformin, Acarbose & piogtlizone These should be taken along with regular exercise, normalization of weight, less stress full life etc


Diabetes during pregnancy


Diabetes during pregnancy is called Gestational Diabetes. Persistent high blood sugar during pregnancy leads to defect in foetus so that child may develop many body defect. Thus during pregnancy fasting blood glucose should be below 95 mg./dl. & after food (PP) should be below 140 mg./dl. & HbA1C should be below 7.0%. For this initially diet therapy & regular physical exercise is advised. If above measures do not bring blood sugar in normal range then insulin therapy is suggested. Now there are various new devices for insulin therapy are available which has made insulin injection therapy painless. During pregnancy Glycosylated Hemoglobin (HbA1C), fetal ultrasonography & fetal echocordiography should be done to monitor fetal well being. Once baby is born he should be examined for various defects & should be monitored for risk of hypoglycemia.


How to Monitor Diabetes Control


Following tests are required to asses diabetes control.

1) Get Blood sugar fasting & PP regularly
2) Glycosylated Hemoglobin (HbA1C) is the best test to assess diabetes control. It tells us about average blood sugar status of previous 2 months. It should be tested every 3 months
3) Urinary Microalbuminuria is the best test to assess earliest kidney complications.
4) Other tests which should be done yearly are Lipid Profile, Urea, Creatinine, Urine R & ME etc.
5) ECG,
6) Eye Check-up (Fundus)
7) Checking for urine ketones:

Whenever blood sugar >350 mg. - check urine ketone Ketone is an acid, when it increase in blood, it adversely affect heart & brain functions even can lead to coma. If vomiting, pain in abdomen, drowsiness & Urine ketone +ve means patient is suffering with Diabetic Ketoacidosis. Then Admission & I.V. insulin, needed. Prevention - whenever infection/stress monitor blood sugar & urine ketone. Take a algorithm from doctor to adjust insulin doses in case of emergency.