A Family Doctor's Tale - DIABETES MELLITUS

DOC I HAVE DIABETES


Of all the chronic diseases such as hypertension, heart disease, high cholesterol, diabetes is probably the hardest disease to control because it is very dependent on the patient's ability to control his or her diet, A simple food indulgence may cause the blood sugar level to go up very high and the diabetes to become uncontrolled with consequence to his or her kidney, skin problems or gangrene of his lower limbs. When I have patients with multiple diseases like hypertension, diabetes and high cholesterol, it is usually the diabetes which are not well controlled. You will have to instil discipline in the patient to control their diet.


Diabetes mellitus literally means sweet urine. 
It is a common chronic disease which happens when the hormone insulin produced by the pancreas is missing, lacking or not working well.
Insulin unlocks the cell to allow glucose from the bloodstream to enter the body cells for usage or storage. When this mechanism fail, the high amount of glucose in the blood leads to the glucose being spilled over into the urine, causing diabetes.


The main types of diabetes are
1.Type 1
2.Type 2.


Type 1 occurs commonly in children and young adults although it may occur at any age.
It is more serious because there is practically no insulin produced due to damaged pancreatic cells and therefore insulin injections is needed for treatment.
The cause is unknown. 
Complications are more sudden and life-threatening.


Type 2 is more common. 
It is found in
1.adults over 40 years old, 
2.overweight and
3.physically inactive.
The insulin produced is not enough or may not be working effectively.
Type 2 diabetes can be controlled by proper dieting and exercise.
Most Type 2 diabetics will also need oral medication.


Gestational diabetes occurs only in pregnancy but may be an indicator of diabetes later in life


Diabetes is more likely to occur if you have:
1.Obesity (body mass index > 23)
2.family history of diabetes
3.hypertension (>140/90 mmHg)
4.previous gestational diabetes
5.Coronary heart disease
6.polycystic ovary disease
7.Hyperlipidemia(high blood cholesterol of 4.17 mmol or 200mg/dl and tryglycerides of 200)
8.Inadequate regular exercise
9.age above 40 years,more common in males than females
10.smoking habit


The following symptoms are typical of diabetes:

1.frequent thirst even after drinking lots of water
2.passing more frequent urine during day and night
3.weight loss while having good appetite
4.constant tiredness
5.poor healing of skin wounds
6.itchy skin particularly around the genital area
7.constant hunger
8.blurred vision


Note that some diabetics may not experience any symptoms at all.


Diagnosis is confirmed if:
1.Random blood glucose (anytime) is 11.1mmol/l or higher
2.Fasting blood glucose (after 8 hours of overnight fast) is 7.0mmol/l or higher.
3.Oral 75g Glucose Tolerance Test show presence of diabetes


The high blood glucose concentration in diabetes reduces the blood flow to many organs and nerves resulting in many organ damage especially the kidney, heart, brain, eyes and nerves.
The high blood glucose allows germs to proliferate because the glucose provides nutrition to the germs.
All these lead to many serious complications:
1.high blood pressure,
2.heart attack,
3.stroke,
4.kidney failure,
5.blindness, 
6.impotence,
7.numbness of hands and feet,
8.infections with poor healing,
9.wounds on feet that do not heal
10.coma,


Control of Diabetes

Diabetes is a chronic disease which cannot be cured.
It can be controlled to prevent the development of the above serious complications by :
Living a healthy lifestyle

1.diet -
reduce your intake of sugar and sweet food
Increase intake of more high fiber and wholegrain food like brown rice, wholemeal bread and oats
Take food with less fat content like lean meat,fish,skinless poultry and low fat milk
Have at least 2 servings of vegetables and 2 servings of fruits a day
Use healthier methods of cooking such as grilling and steaming rather than deep frying and use less salt and sauces
Take multiple (4-6) small meals a day that contains enough complex carbohydrates (e.g. rice), some lean meat or fish and vegetables.
Have regular meals and avoid skipping meals
Do not overeat


2.regular exercise-
this helps your body to use glucose more efficiently
Frequency: 3-5 days per week(daily if low intensity)
intensity: 60-85% of maximum heart rate till the patient feels warm or sweats and breathes deeply but easily
Time: 20-60 mins each time
Type: aerobic exercises like walking, jogging, swimming, cycling


For those who have not been active for some time start with walking first, then increase to more active exercises


3.weight control -
lose extra body weight by proper dieting and exercise
Aim for half kg loss per week
Aim for a BMI of 18.5-22.9kg/m2
Insulin works better in a lean healthy body.


4.Avoid smoking-
smoking increases all the risks associated with diabetes


5.Avoid stress by meditation, yoga, deep breathing exercises


Medication

1.oral tablets:
a. Insulin secretagogues - drugs that increase insulin release from pancreas
eg. glibenclamide, repaglinide
Side effects: low blood sugar


b.Insulin sensitizers- drugs that make insulin work better especially in muscles and liver
eg.metformin
side effects:gastric discomfort, metallic taste in mouth
eg. rosiglitazone
side effect:water retention


c. Alpha-glucosidase blocker -slows digestion of carbohydrates in the intestine
eg. acarbose
side effect: stomach discomfort,bloating,diarrhea


If the oral medicines even in combination cannot bring down the blood sugar, the insulin injection may be required either alone or together with oral medication.


2.insulin injections as prescribed by your doctor.
Insulin is destroyed in the stomach so it has to be given as an injection.
Best place to inject the insulin is in the abdominal area where the is a lot of subcutaneous fat.
Avoid 2 fingers around the navel and below the rib cage which is rich in nerve supply and therefore more painful.
Injection is usually done in the morning and evening.
Night injection controls the glucose when the patient sleep and avoid early morning high glucose.


a.Rapid and short acting insulin
eg. regular soluble insulin
onset 30-60min, peak 2-4 hrs, duration 6-8 hrs


b.intermediate and long acting insulin
eg. NPH insulin
onset 1-4 hrs,peak 8-12 hrs, duration 12-20hr


c.premixed or biphasic insulin
eg. NPH/regular 70/30
more convenient and less injections


Important hygiene tips:
use needles once only
mix well by shaking bottle or injection pen 20 times
store all unused insulin in fridge(will keep until expiry date). Do not freeze insulin.
Insulin in use can be kept at room temperature away from sunlight and direct heat and must be discarded 4-6 weeks after use


Follow the instructions very carefully and keep detailed records of your treatment.


If you can, monitor your progress with the help of your daily home blood glucose records.
Monitor;
a.before and after meals
b.before and after exercise
c. when feeling giddy to confirm low blood glucose
d. when sick and not eating well
e.Type 1 diabetes should be monitor 3-4 times a day
f. Type 2 non-insulin diabetes 1-2 times a day  followed by 1 every 2-3 days
g. Type 2 insulin diabetes 2-3 times a day followed by 2-3 days a week.
h. pregnant patient should also monitor their blood glucose daily


Aim for a Fasting Blood glucose 4.0 -7.0mmol/l
          Blood HbA1c 4.5 -7.0


This will check if your diabetes is under control.
If not, you need more medicines or further change in diet.


Reducing high blood and high cholesterol help to keep diabetes under control and protect against its complications.
Aim for a blood pressure of 130/80 or less
          LDL cholesterol of 2.6mmol/l     


Regular checkups are essential:

1. Regular monthly checkups for diabetes.
2. Check for hypertension and heart disease  at the same time
3. Check for high blood cholesterol once a year.
4. Check eyes once a year.
5. Check for kidney problems at least once a year.
6. Check teeth once a year
7. Check you feet for signs of infection, gangrene and neuropathy.


Foot care is particularly important in diabetes::

1. wash feet daily with soap and water
2. After washing ,dry thoroughly especially between the toes
3. keep your toe nails short,trimming them straight across to avoid ingrowing toenails
4. moisturize feet daily to prevent dryness and cracking of skin
5. examine feet daily for scratches, cuts, blisters and corn
6. use a mirror to check the sole of your feet
7. wear shoes that fit well and wear clean cotton socks which has loose fitting elastic tops
8.Avoid going barefoot
9.Seek prompt treatment for cuts and sores
10.annual review for foot ulcers,risk of neuropathy (poor sensation), blood circulation( palpable pulses)