Diabetes is a lifestyle disease and its treatment involves medication, weight loss and exercise and DIABCARE is involved in management of disease at all these levels.
What is diabetes?
Diabetes is a condition in which body cannot use or does not produce enough insulin and alters blood glucose levels as a result. Insulin is a hormone secreted by pancreas that is responsible for transporting glucose from the blood into the cells, where the glucose is metabolized for energy. Without insulin bloody cannot metabolize blood glucose.
What are types of Diabetes?
- Type 1 – occurs usually in children and young adults. In TYPE 1 DIABETES body fails to produce insulin and therefore INSULIN is required for controlling Diabetes.
- Type 2 – It may occur at any age in young adults as well as older adults. Insulin insensitivity or insulin resistance and low insulin production is observed in this condition. Oral Hypoglycemic agents (OHA) or Insulin can be used to manage this condition.
- Gestational Diabetes Mellitus (GDM)– GDM is a condition in which women who were not previously diagnosed with Diabetes exhibit high blood glucose levels during or in later stages of pregnancy. Pregnancy puts an extra stress on women’s body that causes some women to develop Diabetes. Blood sugar levels often return to normal after child birth but usually there is an increased risk of developing diabetes at later stages of life if care not taken.
What are causes of diabetes?
- Genetics- Person having family history of diabetes
- Being overweight (Abdominal obesity- huge belly)
- Age ( Chances increase with age)
How does one know if He/ She have Diabetes?
Getting your blood tested to see if you have Diabetes. Normal fasting blood sugar levels are between 70-100 mg/dl. The standard diagnosis of Diabetes is made when a person has 2 readings of Blood sugar levels that are higher than this value i.e Fasting blood sugar level ( empty stomach) > 126 and Post Prandial PP (2hrs post meal) and >200.
Glycosylated hemoglobin test (HbA1c) – Sugar builds up in your blood and combines with your hemoglobin, becoming “Glycosylated”. Therefore, the average amount of sugar in your blood can be determined by measuring a hemoglobin A1c level. If your glucose levels have been high over recent weeks, your hemoglobin A1c test will be higher. The amount of hemoglobin A1c will reflect the last 3 months of blood sugar levels.
- Normal: Less than 5.7%
- Pre-diabetes: 5.7% to 6.4%
- Diabetes: 6.5% or higher
What are symptoms of Diabetes?
- Excessive thirst.
- Frequent urination.
- Fatigue ( feeling tired)
- Unusual weightloss.
- Blurred vision.
- Sexual Dysfunction.
- Slow healing of wounds.
What are complications of Diabetes?
Poor control of diabetes may lead to further complications of Diabetes which involves-
1. Diabetic Retinopathy
Uncontrolled blood sugar can cause minute vessels in eye to become fragile or blocked, resulting in damage to retina of the eye which can cause Blurred or Impaired vision, Blindness and Cataract. If u are Diabetic it is extremely important to get your eye checkup done annually.
Nerve Damage is called Neuropathy. Uncontrolled blood sugars can cause damage and scaring of nerves which affects their ability to perform their function of sending nerve signals. This leads to-
- Numbness, Burning Or Tingling sensation in hands and feet ( Peripheral Neuropathy)
- Loss of Sensation and Pain
- Changes in Stomach and bowel function.
- Sexual dysfunction.
3. Nephropathy (Kidney Disease)
Uncontrolled blood sugars can also damage blood vessels in the Kidney Leading to Kidney Disease.
4. Diabetic Foot Disease
Uncontrolled Diabetes can lead to Peripheral neuropathy which leads to diabetic foot.
- Poor sensation
- Poor recovery of cuts and wounds
- Dry scaly skin
- Gangrene- delayed healing of wound can cause infection in the diseased area which can lead to surgical amputation of whole or part of leg.
5. Heart Disease
There is an increased risk of Heart Disease in people with Diabetes compared to people who are not diabetic. Controlling your blood sugars and blood pressure is the key to prevent Heart Disease.
EXCELLENT CONTROL OF DIABETES SINCE THE TIME OF DIAGNOSIS CAN PREVENT FURTHUR COMPLICATIONS OF DIABETES.
DIABETES AND HYPOGLYCEMIA
Hypoglycemia, also called low blood glucose or low blood sugar, occurs when blood glucose drops below normal levels. Glucose, an important source of energy for body and Brain comes from food. Carbohydrates are the main dietary source of glucose. Cereals, Milk, Fruits, Sweets, Sugar are all sources of carbohydrate rich foods.
SYMPTOMS OF HYPOGLYCEMIA
* DIZZINESS OR LIGHT HEADEDNESS
* DIFFICULTY SPEAKING
Hypoglycemia can also occur during sleep. Some signs of Hypoglycemia during sleep include
* Crying out or having nightmares
* Finding clothes or sheets damp from perspiration
* Feeling tired, irritable, or confused after waking up.
CAUSES OF HYPOGLYCEMIA IN PEOPLE WITH DIABETES
Hypoglycemia can occur as a side effect of some diabetes medications, including insulin and oral diabetes medications- pills that increase insulin.
In people on insulin or pills that increase insulin production , low blood glucose can be due to
* Meals or snacks that are too small, delayed or skipped
* Increased physical activity
* Alcoholic Beverages
At what level of blood glucose is a person considered hypoglycemic?
For people with diabetes, a blood glucose level below 70 mg/dL is considered hypoglycemia.
|Normal and Target Blood Glucose Ranges
|Normal Blood Glucose Levels in People Who Do Not Have Diabetes
|70 to 99 mg/dL
|70 to 140 mg/dL
|Target Blood Glucose Levels in People Who Have Diabetes
|70 to 130 mg/dL
|1 to 2 hours after the start of a meal
|below 180 mg/dL
Diabetes treatment plans are designed to match the dose and timing of medication to a person’s usual schedule of meals and activities. Mismatches could result in hypoglycemia. For example, taking a dose of insulin—or other medication that increases insulin levels—but then skipping a meal could result in hypoglycemia.
To help prevent hypoglycemia, people with diabetes should always consider the following:
• Their diabetes medications. A health care provider can explain which diabetes medications can cause hypoglycemia and explain how and when to take medications. For good diabetes management, people with diabetes should take diabetes medications in the recommended doses at the recommended times. In some cases, health care providers may suggest that patients learn how to adjust medications to match changes in their schedule or routine.
• Their meal plan. A registered dietitian can help design a meal plan that fits one’s personal preferences and lifestyle. Following one’s meal plan is important for managing diabetes. People with diabetes should eat regular meals, have enough food at each meal, and try not to skip meals or snacks. Snacks are particularly important for some people before going to sleep or exercising. Some snacks may be more effective than others in preventing hypoglycemia overnight. The dietitian can make recommendations for snacks.
• Their daily activity. To help prevent hypoglycemia caused by physical activity, health care providers may advise
• Checking blood glucose before sports, exercise, or other physical activity and having a snack if the level is below 100 milligrams per deciliter (mg/dL)
•adjusting medication before physical activity.
•Checking blood glucose at regular intervals during extended periods of physical activity and having snacks as needed.
•Checking blood glucose periodically after physical activity.
Their use of alcoholic beverages. Drinking alcoholic beverages, especially on an empty stomach, can cause hypoglycemia, even a day or two later. Heavy drinking can be particularly dangerous for people taking insulin or medications that increase insulin production. Alcoholic beverages should always be consumed with a snack or meal at the same time. A health care provider can suggest how to safely include alcohol in a meal plan.
• Their diabetes management plan. Intensive diabetes management—keeping blood glucose as close to the normal range as possible to prevent long-term complications—can increase the risk of hypoglycemia. Those whose goal is tight control should talk with a health care provider about ways to prevent hypoglycemia and how best to treat it if it occurs.
When people think their blood glucose is too low, they should check the blood glucose level of a blood sample using a meter. If the level is below 70 mg/dL, one of these quick-fix foods should be consumed right away to raise blood glucose:
Prompt Treatment for Hypoglycemia : “The Rule of 15”
The rule of 15 is a helpful way to remember the treatment regimen for mild-to-moderate hypoglycemia. For example,
► 15 gms of quickly absorbed carbohydrate such as 1 tablespoon of sugar or honey,
1/2 cup, or 4 ounces, of any fruit juice
1/2 cup, or 4 ounces, of a regular (not diet) soft drink
1 cup, or 8 ounces, of milk
5 or 6 pieces of hard candy
► Wait 15 minutes.
► If not better, or blood glucose is not above 60 mg/dl, treat with another 15 gms of quickly absorbed carbohydrate.
► As this quickly absorbed carbohydrate will not last long in the body, it is important that the person is given something to eat within a short time.
► If the next meal is more than 1 hour away, the person should be given some food rich in carbohydrate and protein, such as sandwich with sprouts, a fruit with milk or a small chapatti (Indian bread) with dal (lentils) or a fistful of murmura (puffed rice) and roasted chana (whole Bengal gram). This will ensure that the blood sugar will not drop again before the next meal.
• 3 or 4 glucose tablets
• 2 tbsp of sugar—the amount equal to 15 grams of carbohydrate
• 1/2 cup, or 4 ounces, of any fruit juice
• 1/2 cup, or 4 ounces, of a regular—not diet—soft drink
• 1 cup, or 8 ounces, of milk
• 5 or 6 pieces of hard candy
• 1 tablespoon of sugar or honey
Recommended amounts may be less for small children. The child’s doctor can advise about the right amount to give a child.
The next step is to recheck blood glucose in 15 minutes to make sure it is 70 mg/dL or above. If it’s still too low, another serving of a quick-fix food should be eaten. These steps should be repeated until the blood glucose level is 70 mg/dL or above. If the next meal is an hour or more away, a snack should be eaten once the quick-fix foods have raised the blood glucose level to 70 mg/dL or above.
Prolonged high blood sugar in a diabetic patient produces changes in the blood vessels all over the body. The damage to the blood vessels of the retina is called Diabetic Retinopathy. The blood vessels in the retina can be examined directly and non invasively and so even the earliest changes can be diagnosed.
Highlights of Diabetic Retinopathy
- Diabetic retinopathy can be assessed only by retinal examination.
- Retinal test is different from glasses testing.
- Beware! Early stages of diabetic retinopathy will not produce any sight loss.
- Hence only by retinal examination diabetic retinopathy can be diagnosed.
- Retinal examination should be done once a year.
Types of Diabetic Retinopathy
- Non-Proliferative Diabetic Retinopathy (NPDR).
- Proliferative Diabetic Retinopathy (PDR).
In early diabetic retinopathy there are small dialations of the capillary walls in the retina which is called as microaneurysms. At this stage good control of diabetes and regular follow up examination of the retina is necessary.
In the next stage, small haemorrhages, accumulation of fluid, cells and fat can occur. This is the warning stage and there is no specific treatment even in this stage.
The point to be noted here is that sight will not decrease in these stages and so retinopathy can be detected only by routine examination.
In severe cases fluid can collect in the critical “seeing area” of the retina called Macula. Mild to moderate disturbances in the vision may be present. Laser photocoagulation can be done to bring down the fluid accumulation and prevent permanent damage to macula.
In proliferative diabetic retinopathy, abnormal blood vessels develop in the retina, which are very weak and have a tendency to bleed. Once there is a bleed there will be sudden and sometimes total loss of sight. Once there is sight threatening retinopathy, a test called Fundus Fluorescein Angiography (FFA) and laser treatment should be done.
Common queries regarding Diabetic Retinopathy
1. Is a laser treatment for Diabetic Retinopathy harmful to eyes?
Laser treatment prevents progression of diabetic retinopathy and deterioration of sight.
2. How is (Cataract) lens opacification treated?
Cataract surgery is done by a technique called Phako emulsification which is-mistaken for laser.
3. Is glass test and retinal test are same?
No, Retinal test is entirely different from the glasses testing. Retinal test should be performed every year after dilatation with eye drops.
4. What is the normal prevalence of Diabetic Retinopathy?
In a population based study done by using retinal photography, the prevalence of Diabetic Retinopathy was 19%.
5. How often retinal examination has to be done?
For Type 1 Diabetes – every year after 5 years of onset of diabetes.
For Type 2 Diabetes – at the onset of diabetes and every year thereafter.
What Is Diabetic Neuropathy?
Diabetic neuropathy, a common complication of diabetes, is damage to the nerves that allow you to feel things such as pain. There are several ways that diabetes damages the nerves, but they all seem related to blood sugar being too high for a long period of time.
Diabetes-related nerve damage can be painful, but it isn’t severe pain in most cases.
There are four types of diabetic neuropathy: peripheral, autonomic, proximal, and focal.
PERIPHERAL VS AUTONOMIC NEUROPATHY
- What is the difference between peripheral Neuropathy and Autonomic Neuropathy?
Neuropathy is a disorder of the human nervous system. The Central nervous system consists of the sensory nervous system and the autonomic nervous system. The sensory nervous system is responsible for sensing and managing the external environment of the body like the feet, the hands. The autonomic nervous system (a part of the body that is little understood, even by medical practitioners) is responsible for functioning of the internal environment of the body like the heart, the kidneys, the lungs. The autonomic nervous system functions voluntarily. It cannot be controlled by us it does its work silently and in the background.
Complications of diabetes lead to disorders of these systems. A disorder of the sensory nervous system leads to issues with limbs like the feet, the hands. This is called peripheral neuropathy.
Disorders of the autonomic nervous system lead to issues with internal organs like the heart, the kidneys, the lungs. This is called autonomic neuropathy .Many Diabetes suffer from silent heart attacks when they sleep at night. Dysfunction of the autonomic nervous system is at bottom of this.
Autonomic neuropathy is by far, the most serious of the complications. Some Doctors say “With peripheral neuropathy, you can lose a limb, with autonomic neuropathy u can lose a LIFE”.
Clinical Signs Of Autonomic Dysfunction.
e.g. Decreased diameter of dark adapted pupil.
e.g. unawareness and unresponsiveness of low blood sugars
e.g. Exercise intolerance, orthostatic hypotension.
(e.g. giddiness on getting up from supine to standing position )
e.g. Increased sweating
e.g. Constipation, Diarrhea.
e.g. Cystopathy, Erectile dysfunction.
MEASUREMENT OF AUTONOMIC NEUROPATHY
The ANSiscope is currently the only device that makes it possible to screen and measure for autonomic neuropathy.
The results of autonomic function testing can contribute to good patient management in the following ways.
- § To confirm diagnosis of diabetic autonomic neuropathy.
e.g. in case of patient presenting clinical signs which may be attributed to autonomic dysfunction.
- § To assist in the establishment of tight Glycemic control Diabetes control and complications trail (DCCT) documented that intensive therapy can slow the progression and the development of abnormal autonomic function.
- § To facilitate the decision to start the treatment for cardiovascular autonomic dysfunction
e.g. use of beta blockers may modulate the effects of autonomic dysfunction.
- § To accentuate the importance of adherence to diet, this helps to maintain tight Glycemic control and physical training which improves autonomic function.
- § To observe deterioration extent of patient’s health.
- § To adapt treatment according to the evolution of the measurements
e.g. studies using antioxidants have shown promising results
- § To provide diabetic patients with a concrete measure of the effects of their efforts on their health.
Diabetic Proximal Neuropathy
Diabetic proximal neuropathy causes pain (usually on one side) in the thighs, hips, or buttocks. It can also lead to weakness in the legs. Treatment for weakness or pain is usually needed and may include medication and physical therapy. The recovery varies, depending on the type of nerve damage. Prevention consists of keeping blood sugar under tight control.
Diabetic Focal Neuropathy
Diabetic focal neuropathy can also appear suddenly and affect specific nerves, most often in the head, torso, or leg, causing muscle weakness or pain. Symptoms of diabetic focal neuropathy may include:
- Double vision
- Eye pain
- Paralysis on one side of the face (Bell’s palsy)
- Severe pain in a certain area, such as the lower back or leg(s)
- Chest or abdominal pain that is sometimes mistaken for another condition such as heart attack or appendicitis
Diabetic focal neuropathy is painful and unpredictable; however, it tends to improve by itself over weeks or months and does not tend to cause long-term damage.
Other Nerve Damage Seen With Diabetes
People with diabetes can also develop other nerve-related conditions, such as nerve compressions (entrapment syndromes).
Carpal tunnel syndrome is a very common type of entrapment syndrome and causes numbness and tingling of the hand and sometimes muscle weakness or pain.
Prevention of Diabetic Neuropathy
Keeping tight control of your blood sugar levels will help prevent many of these diabetes-related nerve conditions. Talk to your doctor about optimizing your individual diabetes treatment plan.
Diabetes is one of the most common systemic disease to affect the KIDNEY
Why Kidney damage?
Small blood vessels in the kidney filter out the waste products from the body. High blood pressure and high blood sugar can damage these vessels thereby they will not be able to do their functions effectively.
Stages of diabetic kidney damage
In the beginning stages of kidney damage, traces of protein also called ‘albumin‘ begins to appear in the urine. This stage is called MICROALBUMINURIA. Early kidney damage has no symptoms and can be treated with diet and medicines and is reversable.
As the kidney damage gets worse, large amounts of protein can be detected in the urine which is called as the stage ofPROTEINURIA or overt nephropathy. By this stage, the damage is often irreversable in most cases. Finally the stage of renal failure sets which can rapidly progress to End stage Renal Disease which requires either Dialysis or Transplantation to sustain life.
If albuminuria is detected the following investigations are recommended :-
- Check for the history of other renal diseases in the family.
- Check for urinary tract infection through urine and culture sensitivity test.
- Ultrasound examination of the kidneys.
- Measurement of urea and serum creatinine and comparison with previous levels.
- 24 hr urine collection for protein excretion.
- Blood pressure measurement.
- Check ECG and Chest X-ray.
- Retinal examination.
RISK FACTORS LEADING TO KIDNEY DISEASE
- Poor control of diabetes.
- Long duration of diabetes.
- Uncontrolled blood pressure.
- Genetic Factors (Family History of kidney disease).
How to prevent kidney disease
- Diagnosing diabetes at an early stage by regular screening.
- Once diabetes is diagnosed, it should be kept under very good control.
- Tight control of blood pressure (130/80mm/Hg) helps to prevent kidney damage.
- Regular screening for microalbuminuria to identify early stages of kidney damage.
- Use of ACE inhibitors or other drugs, which have very good effect in early stages of kidney disease.
- Regular check up at diabetes centre.
- Strict diet as advised. If there is proteinuria, the protein intake in the diet may have to be reduced.
- Diabetic kidney disease is one of the commonest causes of kidney failure.
- Kidney disease is asymptomatic till late stages.
- Kidney disease is preventable by early detection of diabetes and good control of diabetes and blood pressure.
- Screening for diabetic kidney disease should be done at least annually.