COGENT db+: MAKING LIFE BETTER FOR DIABETICS
DIABETES: 21ST CENTURY GLOBAL HEALTH CHALLENGE
Diabetes mellitus is a chronic disease which
affects an estimated 371 million people
worldwide and which causes serious health
complications including renal (kidney) failure,
heart disease, stroke and blindness. It is a
leading cause of adult blindness and end
stage renal disease.
Approximately 60-70% of diabetics develop some form of peripheral nerve damage which can lead to amputation. Additionally, diabetics are two to four times more likely to have heart disease or to suffer a stroke. It has been projected that by the year 2030, the number of diabetics worldwide will increase from 371 million to 552 million. Diabetes is therefore identified as one of the major public health challenges of the 21st century.
WHAT IS DIABETES?
Diabetes mellitus can be defined as a group of metabolic diseases characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action or both, resulting in impaired function of carbohydrate, lipid and protein metabolism. As a result of this, the glucose in the blood cannot be absorbed into the cells of the body.
TYPES OF DIABETES
Two types of diabetes have been recognized:
This type of diabetes develops when the body's immune system destroys pancreatic beta- cells, the cells responsible that produces little or no insulin. The mechanism of attack on the beta-cells is unknown but genetic, autoimmune, environmental and viral factors have been implicated.
The classical symptoms include thirst, polyuria, wasting or ketoacidosis. This form of diabetes has been reported among children and young adults. They need several injections of insulin a day or an insulin pump to survive. This condition has been reported in 5-10% of all diagnosed diabetic cases.
Type 2 diabetes can further be divided into non-obese, obese and maturity-onset diabetes of the young. This accounts for 90-95% of all diabetic cases. This is the most common form of diabetes.
Patients with Type 2 diabetes have two defects:
a. abnormal insulin secretion (leading to insufficient insulin)
b. resistance to insulin action in target tissues (inability to utilize the insulin that is produced)
In insulin deficient diabetes, the secretion of the hormone is either totally defective or severely impaired. The failure of the pancreatic beta-cells to secrete insulin probably involves genetic, viral and autoimmune processes among others. Viral infections are capable of damaging the pancreas. To become diabetic, an individual must not only be affected by viruses but must also develop antibodies to islet cells.
Type-2 diabetes is associated with obesity, older age (40 years and above), family history, physical inactivity, impaired glucose tolerance, prior history of gestational diabetes and certain races. It may present itself with classical symptoms but often is asymptomatic. Despite the presence of hyperglycemia, the concentration of ketone bodies in the blood and urine is low. Today, this condition is increasingly being reported among children and adolescents (individuals who are at high risk of developing Type 2 diabetes).
This condition has been reported among pregnant women and treated with insulin. It can have deleterious consequences for both the mother and the fetus. This condition is temporary and disappears after birth. However, women with this form of diabetes have a higher incidence of developing Type 2 diabetes later.
Every cell in our body requires energy in order to function. The body's primary energy is derived when our body breaks down carbohydrates into glucose in the blood stream. The more carbohydrates are consumed, the higher the blood glucose levels. The glucose from the digested food circulates in the blood as a ready source of energy. The beta-cells of the pancreas produce a hormone called insulin whose function is to push the blood glucose into the various cells of the body.
On each cell surface are insulin receptors whose function is to regulate the inflow of glucose to provide the cells with energy. The insulin binds to the receptor site on the outside of cells and acts as a key to open the cell through which glucose can enter. In a healthy individual, the pancreatic beta-cells produce the exact amount of insulin needed to match the amount of food ingested. The controlled system of the body maintains and regulates the blood glucose. Blood glucose has to remain within normal limits, i.e. between 70 to 120 mg/dl (milligrams per deciliter) after a heavy meal. In diabetes mellitus, this metabolic process is altered.
Due to factors identified (that includes lifestyle changes and high carbohydrate diet) and with so much insulin (consequences of high insulin elevation and resistance), these receptors begin to malfunction. Blood glucose builds up in the blood stream and the cells starve. With defects on the receptors, the body needs to produce more insulin to push the glucose into the cells. This process continues and eventually type 2 diabetes sets in. Once the blood glucose reaches a certain level, unused glucose naturally spills into the urine as the body's natural response is to get rid of excess glucose. This results in frequent urination (polyuria) and unquenchable thirst (polydipsia) because of the continued removal of fluids to transport the extra glucose into the urinary bladder. The body then is forced to turn to other sources of energy in the body (polyphagia). It breaks down the stored fats for its glucose. A by- product of this is the ketone bodies which builds up in the blood and may result in dangerous events. Ketoacidosis has been reported in 10% of diabetic deaths (warning signs and symptoms of diabetes).
Long-term complications affecting the vasculature, eyes, kidneys, nervous system, and the probable development of drug dependency are the two major problems that are confronted all around the world.
Consequences of high insulin elevation and insulin resistance:
Polydipsia - The increased level of glucose in the blood leads to hyper-osmolarity and depletion of intra-cellular water. This triggers thirst centers in the brain.
Polyphagia - Insulin deficiency leads to catabolism of proteins and fat leading to a negative energy balance and increased appetite.
Polyuria - Increased blood glucose spills over into the kidney as well as promoting an osmotic diuresis leading to increased urination.
Consequences of high insulin elevation and insulin resistance:
- Weight gain
- Fat accumulation and storage leading to obesity
- Heart diseases
- Hardening of the arteries
- Increased blood cholesterol and triglyceride levels
- Kidney diseases
- Mineral and vitamin deficiencies
Warning signs and symptoms:
- Frequent thirst
- Frequent urination and urine is foamy
- Unexplained weight loss
- Increased hunger
- Lethargy and tiredness
- Frequent or recurring skin infections
- Extreme fatigue
- Wounds that don't heal
COMPLICATIONS AND SYMPTOMS
- Impotence and loss of libido
- Numbness and pain in the extremities
- Blurry vision leading to blindness
- Sweet-smelling breath (ketoacidosis - effect of fat metabolism)
- Amputation of the lower limbs
- Kidneys have repeated episodes of infections leading to a non-functioning kidney
- Skin may show rare changes - an unusual degenerative change occurring within the dermis
- Cardiovascular diseases and stroke
- Peripheral neuropathy - pain and numbness in the extremities usually in the legs and feet
Individuals who are at high risk of developing type 2 diabetes:
- People who are obese (more than 20% above their ideal weight)
- Family history of diabetes
- Have a blood pressure above 140/90 mm Hg or above
- Have a high density lipoprotein cholesterol less than or equal to 35 mg/dL and/or a trigly- ceride level greater than or equal to 250 mg/dL
- Have impaired glucose tolerance or impaired fasting glucose on previous testing
- Females who have been diagnosed with gestational diabetes or have delivered a baby weighing more than 4 kg
- High-risk ethnic population (Indians, Hispanic, native American, African-American)
- Cardiovascular diseases and stroke
- People on some medications (e.g. cardiac drugs, hormones, anti-inflammatory drugs, anti-depressants, adrenergic agonists drugs etc.) that can impair body's use of insulin, impair glucose absorption, etc.
Screening methods and Diagnosis
- Glucose measurement in blood plasma
- Venous plasma glucose measured one hour later
- In pregnant women on their 24th and 28th week - administering 50g oral glucose load - identify glucose intolerance at week 24
- A value of >= 140 mg/dL (7.8 mmol/L) in venous blood glucose - do GTT (Glucose Tolerance Test) Diagnosis
- Fasting overnight for at least 8 hours but not more than 14 hours
- Administer 100g oral glucose
- Plasma glucose is measured while fasting and at 1, 2 and 3 hours after oral glucose load
- Meeting the following venous glucose concentrations for positive diagnosis:
- Hemoglobin A1C (HBA1C) - This is based on the level of glycosylated hemoglobin, a substance that accumulates over time in the blood. In poorly controlled diabetics, the figure is usually high. Because it is a test on an accumulated substance rather than an indicator of momentary blood glucose level, the HBA1C indicates the level of glucose control in the last two to three months.
Acceptable refers to goals for conventional therapy, while ideal indicates goals for intensive insulin therapy.Adapted from: Harrison's Principles of Internal Medicine -13th Edition
What is the goal of the glycosylated hemoglobin test?
Every person, whether or not he or she has diabetes, has a certain amount of glycosylation present. Because of more glucose in their blood, people with diabetes have a greater amount of glycosylation present. A low result on the glycosylated hemoglobin test is a good result. If your test is in the good control category, you can be satisfied that your diabetes management plan is working well. If the results are in the marginal category, some fine tuning of your treatment plan may be needed. A poor result can be improved. This test gives you valuable feedback on how well you are controlling your diabetes. Ask your doctor to help you in improving your diabetes management. Your physician will help you determine your goal range for glycosylated hemoglobin. If you are a Type 1 or Type 2 diabetic, you should be having this test done every 90 days (3 months); there is no reason that you should not.
Preventing diabetic complications*
Glucose control - Clinical studies carried out in various parts of the world have shown that
improved glycemic control benefits people with either type 1 or type 2 diabetes. It has been
found that for every 1% reduction in the results of HBA1C blood tests, the risk of developing
micro-vascular diabetic complications such as retinopathy (eye diseases), nephropathy
(kidney diseases) and neuropathy (nerve diseases) is reduced by 40%.
Blood pressure control - Blood pressure control reduces cardiovascular disease (heart disease and stroke) by approximately 33-50% and also reduces micro-vascular disease (eye, kidney and nerve disease) by approximately 33%.
For every 10 millimeter drop of mercury (mm Hg) in systolic pressure, the risk for any complication related to diabetes is reduced by 12%.
Blood lipids control - Improved control of cholesterol and lipids (such as HDL, LDL and triglycerides) can reduce cardiovascular complication by 20 to 50%.
Eye diseases - Detecting and treating diabetic eye disease early can reduce the development of vision loss by 50 to 60%.
Foot care - Comprehensive foot care can reduce amputation rate by 45 to 85%.
Kidney disease - Detecting and treating early kidney disease can reduce development of kidney failure by 30 to 70%.
*Source: Center for Disease Control and Prevention - Diabetes Fact Sheet
Treatment for diabetes - allopathic drugs
Traditionally, type 2 diabetes mellitus has been controlled with dietary restriction, exercise,
oral hypoglycemic drugs such as insulin sensitizers, a-glucosidase inhibitors, glucagons-like
peptide 1, sulphonylureas and biguanides. They have remained the main stay of oral
hypoglycemic treatment for more than 30 years. However, maintaining glucose control in
these patients remains a difficult task. Most of the modern diabetic drugs have succeeded
in treating symptoms of diabetes but have failed to suppress the progression of diabetes
and diabetic complications.
In the last decade, with increasing morbidity and mortality and severe side effects attributed to drugs and drug interactions, there has been a growing trend among diabetics to seek alternative remedy for their ailing conditions.
The ultimate aim of treatment would be to find a way to increase insulin sensitivity and to help get the glucose out of the blood and into the cells for metabolism, and convert it into energy. One ancient field of medicine that has been successful in providing alternative drugs and addresses the main issues in diabetes is Ayurveda.