Diabetes - How much do you know?

By Dr. Indu WAIDYATILAKA,

Diabetes is a disorder of glucose metabolism leading to high levels of glucose in your blood causing problems in the heart, kidney, eye, nerves, blood vessels, digestive system, teeth and many other organs in the body.

Much of the food we eat is eventually broken down to glucose. Glucose comes from the food we eat and is also made in our liver and muscles. It is the main source of fuel for the body.

After digestion, glucose passes into the bloodstream, where it is used by cells for growth and energy. For glucose to get into cells, insulin must be present. Insulin is a chemical (a hormone) produced by the beta cells of pancreas, a large gland located behind the stomach.

Insulin works like a key that opens the doors to cells and lets glucose enter. Without insulin, glucose cannot get into the cells and so it stays in the bloodstream. So, the level of glucose in the blood rises. Your blood glucose level then gets too high, causing diabetes. Diabetes can cause many health problems due to high blood glucose levels and its complications.

Complications of diabetes can affect almost every part of the body and may result in blindness, kidney failure, stroke, heart attacks, nerve damage, amputations and sexual problems. They can even lead to loss of life.

Often, long-term diabetes complications can be prevented or delayed by keeping blood glucose, blood pressure, cholesterol, and triglycerides in a normal or near normal range.

Main types

There are two main types of diabetes and they are type 1 diabetes type 2 diabetes Type 1 Diabetes Mellitus is also known as Insulin Dependent Diabetes Mellitus (IDDM), or Juvenile diabetes. Type 1 diabetes is usually first diagnosed in children, teenagers, or young adults. It occurs when the body's own immune system destroys the insulin-producing beta cells of the pancreas.

Normally, the body's immune system fights off foreign invaders like viruses or bacteria. But in people with type 1 diabetes, the immune system attacks various cells in the body. This results in a deficiency of the hormone, insulin. The body can still get glucose from food, but the glucose cannot get into the cells due to the lack of insulin. Glucose remains in the blood. This makes the blood sugar level very high.

Type 2 diabetes far more common than type 1, and makes up most cases of diabetes seen in clinical practice. It is usually diagnosed in adulthood hence the earlier name Adult Onset Diabetes. This is different from Type1.

In contrast to someone with type 1 diabetes, one with type 2 diabetes still produces insulin, but it may not be producing enough, or cells ignore insulin (insulin resistance).Since insulin is necessary for the body to be able to use sugar, when there is lack of insulin or insulin action, glucose builds up in the blood instead of going into the cells.

This causes the blood sugar level to rise, making the pancreas produce even more insulin. Eventually, the pancreas can wear out from working overtime to produce extra insulin. Then, the pancreas may no longer be able to produce enough insulin to keep person's blood sugar levels within a normal range. This may lead to problems-cells may be starved for energy and over a period of time high levels of glucose in the blood may damage the eyes, kidneys, nerves or heart.

Gestational diabetes

Gestational diabetes is a type of diabetes that starts during pregnancy.

About 3 to 8 % of pregnant mothers develop this around the 24th to 28th week of pregnancy. Some women have a greater tendency towards developing gestational diabetes, risk factors being over 30 years of age, obesity, family history of Type 2 diabetes, having had diabetes during previous pregnancies, history of polycystic ovary syndrome and acanthosis nigricans (a skin disorder characterized by the appearance of darkened velvety patches of skin).. Most often Gestational diabetes resolves after the baby is born.

Risk factors

The latest medical findings show that the chances of getting type 2 diabetes mellitus increase in proportion to the health risk factors you have. These risk factors include. A family history of diabetes. If a parent or a sibling has diabetes, your risk of developing type 2 diabetes increases.

Age over 45. The chance of getting type 2 diabetes increases with age.

Being overweight. If you are overweight, defined as body mass index (BMI) greater than 25, you're at a higher risk of type 2 diabetes.

History of gestational diabetes. Getting diabetes during pregnancy or delivering a baby over nine pounds can increase your risk of type 2 diabetes.

Race or ethnic background. The risk of type 2 diabetes is greater in Hispanics, blacks, Native Americans and Asians.

Metabolic syndrome (also called insulin resistance syndrome) Hypertension. High blood pressure increases the risk of developing type 2 diabetes.

Abnormal cholesterol levels. HDL cholesterol (good cholesterol) level under 35 mg/dL and/or a triglyceride level over 250 mg/dL increase your risk of type 2 diabetes.

High-fat diet. Those who are on a diet rich in fat are more vulnerable.

High alcohol intake. Alcohol increases the risk of diabetes.

Sedentary lifestyle can lead to diabetes.

A history of polycystic ovarian syndrome (PCOS).

History of vascular disease (such as stroke)

Symptoms

Common symptoms of diabetes are as follows.

Fatigue: In patients with diabetes, the body is inefficient and is unable to use glucose as fuel. The body starts metabolizing fat, partially or completely, as a fuel source. This process requires the body to use more energy. As a result one may feel fatigued or constantly tired.

Unexplained weight loss: Lack of normal insulin function has effects on protein, fat and carbohydrate metabolism. Insulin is an anabolic hormone, that is, one that encourages storage of fat and protein. A relative or absolute insulin deficiency eventually leads to weight loss despite an increase in appetite. Losing sugar and water in the urine and the accompanying dehydration also contribute to weight loss.

Excessive urination (polyuria): The body's response to excess glucose in the blood is to get rid of it through urination. Frequent urination with large volumes of urine is one of the classic symptoms of diabetes.

Despite an increased intake of water, dehydration can also occur.

Excessive thirst (polydipsia): The body tries to counteract high blood glucose by sending a signal to the brain to dilute the blood, which translates into thirst. In addition, the excessive water loss through urine needs to be compensated. The body encourages more water consumption to dilute the high blood sugar back to normal levels.

Excessive eating (polyphagia): If the pancreas is able, it will secrete more insulin in order to bring down the excessive blood sugar levels.

Although the body is resistant to the action of insulin in type 2 diabetes the pancreas nevertheless tries to counteract this by increasing the insulin output. One of the functions of insulin is to stimulate hunger.

Therefore, higher insulin levels may lead to increased hunger and eating.

Despite increased caloric intake, the person may gain very little weight and may even lose weight.

Infections: Certain infections, such as yeast infections of the genitals, skin infections, and frequent urinary tract infections, may result from suppression of the immune system by diabetes, which allows bacteria to grow well. They can also be an indicator of poor blood sugar control in a person known to have diabetes.

Poor wound healing: High blood sugar levels prevent white blood cells, which are important defending agents against bacteria and other germs, from functioning normally. When these cells do not function properly, wounds take much longer to heal and become infected more frequently. Also, long-standing diabetes is associated with thickening of blood vessels, which prevents good circulation resulting in our body tissues not getting enough oxygen and other nutrients.

Unexplained aches and pains: Patients with diabetes almost always complaints of aches and pains.

Dry or itchy skin: Peripheral nerve involvement in diabetes impairs blood circulation and proper sweat gland function, leading to this.

Blurry vision: Fluctuation in blood sugar level can lead to blurry vision by changing the consistency of the lens.

Acanthosis nigricans Velvety dark skin changes of the neck, armpit and groin, are a feature of insulin resistance.

Dry mouth: Due to dehydration they complain of dry mouth.

Male impotence: Almost half of all diabetics are impotent, making it one of the most common complications of the disease. Achieving and maintaining an erection is a complex action involving the circulatory, nervous, and endocrine systems, and diabetes can affect any or all of these systems.

Altered mental status: Confusion, agitation, unexplained irritability, inattention or extreme lethargy, can all be signs of very high blood sugar or very low sugar levels.

How is Diabetes diagnosed? It is recommended that testing for diabetes be carried out in all individuals over the age of 35 years and in those who are even younger if they are at risk of developing type 2 diabetes. That is if they are overweight , habitually physically inactive, have a first-degree relative with diabetes, have delivered a baby weighing more than 3.5 kg or have been diagnosed with gestational diabetes mellitus, have high blood pressure (140/90 mmHg), have an HDL cholesterol (good cholesterol) level (35 mg/dl and/or a triglyceride level) 250 mg/dl. Those who have a past history of heart disease, stroke or diseases of blood vessels should also under go testing if they are not already being tested.

There are several symptoms that you may experience if you have diabetes mellitus.

You may feel very thirsty and pass lots of urine. You may also find that you are losing weight and that you feel tired all the time. Sometimes, patients complain of blurred vision. Others notice itching around the genitals, suffer from frequent skin infections or notice that wounds take a long time to heal.

If you have these symptoms, you should see your doctor and he/she will test you for diabetes.

The first thing doctors do when they suspect somebody with diabetes, is taking a detailed history especially regarding the symptoms of diabetes, about your family members and their health, your diet etc. Then the doctor will do a physical examination and later he will request some blood tests to make sure that his/her assumptions are correct.

The following tests are used for diagnosis: A fasting plasma glucose test measures your blood glucose after you have gone at least 8 hours without eating. This test is used to detect diabetes or pre-diabetes.

An oral glucose tolerance test measures your blood glucose after you have gone at least 8 hours without eating and 2 hours after you drink a glucose-containing beverage. This test can be used to diagnose diabetes or pre-diabetes. In a random plasma glucose test, your doctor checks your blood glucose without regard to when you ate your last meal. This test, along with an assessment of symptoms, is used to diagnose diabetes but not pre-diabetes.

The doctor will diagnose you as having diabetes, if you have symptoms of diabetes and a plasma glucose reading of greater than or equal to 200 mg/dl any time of day without regard to time since last meal.

A fasting plasma glucose reading of greater than or equal to 126 mg/dl (fasting is defined as no caloric intake for at least 8 hours).

An oral glucose tolerance test (OGTT) with a two hour post load glucose of greater than or equal to 200 mg/dl.

(Positive test results should be confirmed by repeating the fasting plasma glucose test or the oral glucose tolerance test on a different day if the patient has no symptoms).

HbA1C

The HbA1C test is a simple blood test, and is currently one of the best ways to check your diabetes control.

Haemoglobin is present in everyone's red cells (Hb); this makes your blood red. Glucose sticks to the haemoglobin to make a `glycosylated haemoglobin` molecule called haemoglobin A1C or HbA1C. The more glucose in the blood, the more HbA1C will be present in the blood.

The average life span of a red cell is 120 days and therefore if we measure how many red cells have glucose attached to them, it gives us an idea about the glucose levels in your blood over the last 120 days.

So, instead of measuring your blood sugar at one specific point in time, HbA1c test provides you with the average blood sugar control over a period of several months.

It is recommended to do this test every 3-6 months, depending on your results.

In people without diabetes, a normal HbA1c value is between 3.5% and 5.5%.For those who are having diabetes, the goal should be to maintain it under 7% (or the target/goal set for you by your doctor).

Management of Diabetes

A five step approach

Step 1-Get to know your `Diabetic Team` a) Primary physician Everyone with diabetes needs to be in the care of a doctor who is experienced in taking care of patients with diabetes. He should be a person whom you like, trust, available and are comfortable with. He may recommend the other members of your health care team.

b) Dietitian One of the most important aspects of managing diabetes is diet control.

You should have a close relationship with your dietitian and should follow his/her advice regarding diet.

c) Ophthalmologist Diabetics are more prone for eye damage than any other single disease. So it is essential that you get your eyes checked by an ophthalmologist periodically. It is advisable that people with type 1 diabetes get an eye assessment once a year starting five years after the onset of diabetes.People with type 2 diabetes should have an annual eye check starting immediately after the diagnosis, as they may have eye damage even at the time of diagnosis.

d) Podiatrist People with diabetes are more prone to nerve damage. This can result in loss of sensation especially in hands and feet. This decreased ability to feel pain in the legs may lead to injuries that you are not able to feel.

It is recommended to encourage foot self inspection daily, and to use protective footwear. Any kind of injuries, cuts, wounds, bruises etc should be taken seriously. Foot injuries in people with diabetes can be hard to heal. Ideally you must pay a visit to your podiatrist at least once a year. In Sri Lanka the role of the podiatrist is usually carried out by the primary care physician.Step 2-Learn about Diabetes It is very important to know the basics of the disease and how to manage it. You should learn how to recognize the symptoms of low blood sugar (hypoglycaemia) and high blood sugar (hyperglycaemia), what to eat and when, how to take insulin or oral medication, how to test and record blood glucose, how to test urine for sugar, how to adjust insulin or food intake when changing exercise and eating habits and how to handle sick days etc..With the help of your doctor and rest of your healthcare team you, managing your own disease is the most practical way to achieve the best results.

Step 3-Make a plan After meeting your healthcare team and learning about your disease, get organized and make a plan of action.

Step 4-Maintain a positive attitude Adjusting to the diagnosis of any chronic condition may take a considerable time.

You may go through a series of feelings (shock and denial, anger, bargaining, adaptation and finally acceptance).It is very important to have a positive attitude right from the time of diagnosis. It helps you to manage your condition better.Your doctor and your healthcare team will provide you with support and education you may need.

Step 5- Get started Start managing your blood sugar level (and complications if there are any) as early as possible.

to be continued

The writer is attached to the Colombo South Teaching Hospital Kalubowila