Dr Kumar's BASIC HEALTHCARE FOR ALL
One of the most major lifestyles diseases that is demographically seen afflicting people across the globe. Along with high blood pressure, it is often referred to as a 'silent killer'. It can be inherited or acquired during an individual's lifetime. It may either be of early-onset type (juvenile diabetes, Type I, or the one present since childhood), or can be acquired during adulthood (Type II), or the late-onset variety. Diabetes mellitus (as it is technically called) is a hormonal disease, attributed to the malfunctioning of Pancreas in regard of the secretion of one its hormones, called insulin. Diabetes is a chronic metabolic disease in which the body either doesn't produce or somehow doesn't fully utilize the endogenously-produced insulin. As a result, it can't properly metabolize carbohydrates and, to a somewhat lesser extent, proteins & fats too. Sugar (glucose) this builds up in the blood, to rid the body of this excess sugar, the kidneys begin to eliminate it in the urine.
In the diabetic syndrome although excess sugar is in circulation all over the body, the brain and other tissues that need it for fuel are unable to use it. Therefore, in the absence of this sugar supply, the body begins to breakdown fat and protein in an attempt to provide alternate source source for fuel, resulting, at times, in serious biochemical imbalances. At the same time, the high levels of circulating glucose begin to damage the body almost all over, considerably increasing the risk of complications such as heart attach, progressive loss of vision, renal failure, stroke (paralysis), predisposition towards several disease like tuberculosis, gout, hypertension, and peripheral nerve diseases. Despite effective treatments being readily available, diabetes is one of the leading causes of death in the United States.
As described in the introduction above, there are two major forms of diabetes. Type I, in which the body just stops making insulin completely, and Type II, in which the body produces inadequate insulin or is somehow unable to use it fully. The first type (insulin-dependent or the juvenile variety), usually develops during the first 20 years of life when the insulin-producing islets cells in the pancreas are totally destroyed. Symptoms are frequent urination (polyurea), weight loss (considerable body emaciation), unusual thirst (polydipsia), weakness, fatigue, and almost constant hunger (polyphagia).
Type II, also called non-insulin dependent or adult-onset diabetes, is probably most common amongst older overweight people, although it can also occur in persons of normal weight as well. It develops more slowly than Type I, indeed, many individuals may have this disease for years, before they ever get to know that they are i fact afflicted. Besides the symptoms experienced in Type I diabetes, signs may include frequent infections, clammy and tingling sensations, slow healing of wounds.
DIAGNOSTIC STUDIES & PROCEDURES
Diagnosis is based upon a blood test that measures blood glucose levels. Elevated blood glucose (hyperglycemia) doesn't necessarily indicate diabetes mellitus, but it does call for more extensive clinical investigation. In general, a diagnosis is established if two separate blood tests, done after fasting for at hours, show glucose levels of 140 milligrams of glucose per deciliter of blood (mg/dl). In borderline cases, a glucose challenge test may be prescribed. This involves measuring glucose after fasting, and again after drinking sugar water.
There is just no cure for either type of diabetes, but the progression of the disease can be controlled with a combination of therapies. Type I diabetes-afflicted people need measured insulin shots as per individual need, and a special diet and exercise regimen. More than 80% of people with Type II diabetes can control it with just diet & exercise, especially if they lose weight as well. Others may need oral hypoglycemic drugs to enhance insulin production from pancreas. These drugs include chlorpropamide (Diabenese), glipizide (Glucotrol), glyburide (Diabeta & Macronase), tolbutamide (Orinase), and tolazamide (Tolinase). A new Type II diabetes drug, acarbose (Precose), works by delaying the digestion of carbohydrates, resulting in a slower rise in blood sugar after food intake.
When the disease has progressed over a fairly long period of time, patients with Type II diabetes may have to resort to insulin shots to control their sugar levels. Mere hypoglycemic tablets aren't sufficient anymore. Most of these tablets stimulated the pancreatic islets to produce whatever little insulin they can. Such constant stimulation and over-stimulation ultimately causes these islet cells to atrophy and become functionally defunct. So, now, the required insulin dosage must be supplied exogenously. As of now purified human insulin is available for injection, though earlier one had to make do with porcine insulin. Chemically, insulin is a peptide protein, and thus can't be taken orally, as it would be readily digested and functionally destroyed by the proteolytic enzymes of the digestive tract.
Patients with both types of diabetes require extra medical care and should establish a close working relationship with their doctor, who should preferably be a diabetologist. This is imperative, as poor diabetes control and somewhat neglected treatment may go on to affect heart, blood vessels, kidneys, nerves, and even eyes, impairing vision to almost total blindness. At times even other specialists may need to consulted, e.g., an ophthalmologist for proper eye-examination, a cardiologist for assessing and treating heart and vascular damage, and a nephrologist for taking care of the deteriorating renal function. Diabetic retinopathy and cardiovascular complications such as hypertension, CAD are particularly common in chronic diabetes. A significant number of patients develop renal failure as well, and may eventually required dialysis or a kidney transplantation. Progressive degenerative problem with peripheral circulation and reduce circulation to legs & feet, which may develop gangrene as almost static blood catches infection because of poor foot hygiene. This may require specialized vascular surgery, or, at times, even amputation of the affected part of the limb, to prevent spread of infection to other parts of the body.
There is, however, good news for most diabetics, as clinical studies have shown that maintaining normal blood sugar levels may dramatically slow down (though not entirely avoid) the progression of aforelisted complications. More & more physicians are now encouraging diabetic patients to follow a strict regimen that lets them maintain blood glucose levels as near to normal as possible. This of course involves frequent blood glucose monitoring using a simple home-monitoring 'glucometer', adjusting the dosage of insulin or other medication accordingly, modification in the exercise patterns, intensity & frequency, and, not the least, modifying one's diet towards maintaining optimum blood glucose levels throughout the day.
Blood sugar too low (hypoglycemic shock) : patients must familiarize themselves with symptoms of hypoglycemia. Certain drugs like beta-blockers (used by hypertensive patients) may in fact mask certain symptoms of hypoglycemia. So, hypertensive patients with diabetes have to be that much more careful in their understanding of such incidents. If hypoglycemia remains unchecked, patient may pass out. And, since oral glucose-administration in such a scenario is not possible, the patient is administered instant shots of 'glucagon' - the sugar raising hormone. This hormone mobilizes whatever glucose it possibly can from liver and skeletal muscle. And, as the patient regains consciousness, he/she may then be administered glucose orally or intravenously.
Diabetic coma : just as too low blood sugar throws a patient into a crisis, so does a very high sugar level over a period of time. This causes a metabolic malaise known as as 'diabetic ketosis' (fruity smell emanates from the breath of the afflicted patient).. This is as urgent a medical emergency and crisis as hypoglycemic shock is. The patient cannot now be treated at home with the routine hypoglycemic drugs, and MUST be rushed to the nearest hospital emergency. He will be instantly administered a shot of fast-acting, soluble insulin intravenously, and discharged only as and when his condition is found to be stable. A simple testing strip (ketostix, shown in the image above) will let diabetic patients check their blood ketone levels from time to time. A somewhat better testing strip is keto-diastix, that lets one check the urinary level of both glucose & ketone levels. If by any chance that such urine testing reveals that you have both glucose & ketone levels HIGH, just do a repeat test, and if it confirms the initial testing, just don't waste any time, rush to the nearest ER, preferably not driving the vehicle yourself, and ensuring that someone does accompany you.
Needless to add, all diabetics MUST always keep sugar tablets on their person, and gulp it as soon as they identify any of the hypoglycemia symptoms emerging - general weakness, confusion, disorientation, sweating, tingling sensation, labored speech etc. If you're not 100% sure of these symptoms of if a quick blood test reveals near about normal or high sugar levels, so MAKE SURE of getting yourself checked in the nearest ER, to dispel the probability of any other threatening underlying cause for such symptoms.
To make insulin injections easier to administer, there is now an insulin pump, which is carried in the patient's pocket or simply worn on a belt. It can be easily programmed to administer small amounts of insulin at specific time intervals through a micro-syringe left in place in the abdomen or at some other convenient bodily site.
FOR THE PATIENTS
All patients must learn to test their own blood sugar levels at home and adjust their food-exercise-medication regimens on daily basis. Especially so if the patient is also afflicted with conditions like hypertension/obesity/coronary artery disease/gout. Parents should assume the responsibility for doing all this for their diabetic kids, at least as long as they aren't able to carry out all these tasks by themselves.
Do always carry a 'DIABETIC' tag on your wrist (or somewhere in your pockets). A diabetes diet is similar to the routine healthful diet recommended for all, with refined carbohydrates being minimized or almost totally eliminated. Obtain most of your calories from complex carbohydrates contained in wholesome foods like vegetables, legumes, fruits, and whole grains, and relying less on animal food for fats or proteins. Patients afflicted with both diabetes and gout need to be more careful, as they should prefer including only 'low purine' items in their diet. So, some carbohydrates & vegetables may have to be eliminated from the food list, as will be meat items like organ meats, some fishes, and high-fat red meat etc.
People with diabetes often have poor circulation and are susceptible to skin ulcers and carbuncles etc especially in their legs & feet. Use well-fitting footware to avoids corns and other foot problems that may have the potential to develop into a serious infection. Also, keep your nails well trimmed, and be extra careful while trimming the toe nail (to prevent an ingrown toe nail malady). If you do suspect any foot problem, do see a qualified chiropodist after consultation with your primary diabetologist.
All patients must realize that they have to be extra careful about maintaining normal-range blood glucose levels when they are sick or have developed even mild, moderate or acute infection. In fact infections tend to raise blood glucose, and raised blood glucose further invites infections. If you have an infection (with or without fever) that is slow-healing or not healing (in spite of antibiotics), do make it a point to check you blood sugar a few times. In fact it is well established by now that in may patients a chronic infection like tuberculosis and diabetes do occur together.
Patients undergoing treatment with corticosteroids for inflammatory diseases for any length of time must keep checking their sugar throughout the course of their treatment. NSAIDs (anti-inflammatory pain-killers) may also raise blood glucose level, although only as long as they are being used.
Pregnant women sometimes develop gestational diabetes, which soon goes into remission after delivery. Do check up with your gynecologist if it doesn't !
PSEUDO-DIABETES (Diabetes insipidus)
Just like in uncontrolled diabetes mellitus, one may pass huge volumes of urine (without any trace of glucose though) in another hormonal disorder, called diabetes inspidus. and the hormone involved is (the deficiency of) ADH or the anti-diuretic hormone produced by the posterior lobe of the pituitary gland.
Chemical diabetes or the so called induced diabetes in an experimental condition in which a chemical "Alloxane" is injected in experimental animals. This chemical selectively destroys the insulin-producing beta-cells in the 'islets of langherans' inside pancreas, thereby producing full-blown diabetes mellitus in the injected animals in just a couple of hours.