DIABETES MELLITUS

India has more diabetics than any other country in the world, according to the International Diabetes Foundation. More recent data suggest that China has even more. The disease affects more than 50 million Indians 7.1% of the nation's adults - and kills about 1 million Indians a year. The average age on onset is 42.5 years. The high incidence is attributed to a combination of genetic susceptibility plus adoption of a highcalorie, low-activity lifestyle by India's growing middle class

 Diabetes mellitus, or simply diabetes, is a group of metabolic diseases . Characterized by high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst) polyphagia (increased hunger).

 Under normal circumstances, food is consumed and digested to give glucose, amino acids and fatty acids which enter the blood stream. The glucose level in the blood rises after a meal and triggers the pancreas to secrete the hormone insulin and release it into the bloodstream. Glucose is carried to the target cells and enters the cell with the help of insulin. It is then utilized by the cell to give it energy thus the levels of glucose in the blood decrease

 There are three main types of diabetes mellitus Type 1 DM results from the body's failure to produce insulin, and presently requires the person to inject insulin or wear an insulin pump. This form was previously referred to as "insulin-dependent diabetes mellitus" (IDDM) or "juvenile diabetes".

Type I diabetes mellitus (IDDM)

Type I diabetes affects children or adults, was traditionally termed Juvenile diabetes Occurs due to loss of insulin-producing beta cells of the islets of Langerhans in the pancreas, leading to a deficiency of insulin Immune-mediated or idiopathic. The majority of type I diabetes is of the immune-mediated variety, where beta cell loss is a T-cell mediated autoimmune attack. Most affected people are otherwise healthy with normal weight during onset of diabetes. Sensitivity and responsiveness to insulin are usually normal in the early stages Later the child becomes underweight and develops acidosis

Type II diabetes mellitus (NIDDM)

Adult onset diabetes occurs due to obesity Milder or more stable Caused due to insulin resistance or reduced insulin sensitivity Also due to reduced insulin secretion The defective responsiveness of body tissues to insulin by the insulin receptor in cell membranes

Gestational diabetes mellitus

Gestational diabetes mellitus (GDM) resembles Type II diabetes, involving a combination of relatively inadequate insulin secretion and responsiveness It occurs in about 2-5% of all pregnancies and may improve or disappear after delivery. Gestational diabetes is fully treatable but requires careful medical supervision throughout the pregnancy About 20-50% of affected women develop type II diabetes later in life. They give birth to large babies.

Malnutrition Related Diabetes Mellitus (MRDM) Seen in young people (15-30 yrs) of tropical countries Pancreas fails to produce adequate amount of insulin Do not develop ketoacidosis

 Diabetes without proper treatments can cause many complications.

Acute complications include hypoglycemia, diabetic ketoacidosis, or nonketotic hyperosmolar coma. Serious long-term complications include cardiovascular disease, chronic renal failure, and diabetic retinopathy (retinal damage).neuropathy or nephropathy. Adequate treatment of diabetes is thus important, as well as blood pressure control and lifestyle factors such as smoking cessation and maintaining a healthy body weight. Globally, as of 2012, an estimated 346 million people have type 2 diabetes.

Diagnosis
Random blood sugar If the fasting plasma glucose is greater than 140 mg/ dl or the random plasma glucose is greater than 200 mg/dl indicates diabetes. Glucose tolerance test 75 g of glucose dissolved in 250-300 ml of water is given to the patient after testing the fasting glucose levels. Half an hour after administration of glucose, blood and urine specimens are collected seven times every 30 minutes .

Blood Glucose Level

Fasting Plasma mg% Normal <100 2 hrs after 75g. glucose (oral) Plasma mg%

< 140
Impaired glucose tolerance (IGT) Diabetes Mellitus ( DM) 100-140 >140 140 -200 > 200

Treatment
Clinical criteria
Relief from symptoms Reduction in obesity Prevention of acute and chronic complications Provision of adequate energy for normal work performance. To promote normal development in childhood diabetes During pregnancy, to deliver the normal baby without complications

Bio-chemical criteria
Urine and blood estimates for glucose levels Glycosylated Hb give the trend of glucose levels of the past 2-3 months (HbA1c) Maintaining normal serum lipid profile

Management of Diabetes
The main modes of treatment of diabetes are Diet Drugs Exercise Education

Diet
Carbohydrate: High carbohydrate and high fibre diet improves insulin receptor binding capacity. Therefore 60-65% of total calories should be from CHO Proteins: A diet high in protein (20% of Kcal) is suggested. Requirement for adults is 1gm/kg body weight and for children 1-1.5g/kg body weight Fat: 15-25% of total calories from PUFA should be provided.

Vitamins and minerals:

Vitamin C, Vitamin E, magnesium and zinc are needed to overcome oxidative stress and deficiency. Vitamin D deficiency contributes to Impaired Glucose Tolerance Chromium supplementation reduces insulin dose. All others are given in normal doses

Dietary fibre
: About 25-50g of dietary fibre and complex carbohydrate for type I and II diabetes. Decreases Insulin requirements Increases peripheral tissue insulin sensitivity Decreases serum cholesterol and triglycerides Aids in weight control Decreases blood pressure

Glycemic index
Ranking of the foods as per post prandial blood glucose response compared to reference diet gives the GI of foods Factors which influence the glycemic index The presence of nonabsorbable oligosaccharides and viscous dietary fibre such as pectins, glucans and gum found in fruits, vegetables and cereals reduce the efficiency of enzyme hydrolysis and slows down the rate at which glucose enters the blood stream.

 Starch encased in its seed coat or coarsely ground is not efficiently hydrolysed to glucose because digestive enzymes are prevented from reaching the starch. Starch granules subjected to moist heat and subsequent cooling become dense and less available to enzyme action. Retrograded starch has low glycemic index.

 Rice bran, which is rich in fibre and oil has low glycemic index. Chapathis, which need chewing have lower glycemic index compared to wheat 'kanjee'. Raw food has lower glycemic index than cooked food. Foods rich in fat and protein have low glycemic index. Phytic acid present in whole grains decrease glycemic index. Natural food has low glycemic index compared to processed foods.

Complications
Diabetic ketoacidosis: Elevated levels of ketone bodies in the blood decrease the bloods PH, leading to diabetic keto acidosis. Ketoacidosis can easily become severe enough to cause hypertension, shock, and death More common in type I diabetes than type II.

Hyperglycemia & hyperosmolar state

This results in loss of water and an increase in blood osmolarity. If fluid is not replaced (by mouth or intravenously), the osmotic effect of high glucose levels, combined with the loss of water, will eventually lead to dehydration. Lethargy may ultimately progress to coma, though this is more common in type II diabetes than type I.

Hypoglycemia
Hypoglycemia, is abnormally low blood glucose Severe hypoglycaemia may lead to loss of consciousness leading to coma, seizures, or even brain damage and death

Chronic complications
Chronic elevation of blood glucose level leads to damage of blood vessels (angiopathy). The damage to small blood vessels leads to a microangiopathy, which can cause one or more of the following: Diabetic retinopathy in retina leads to severe vision loss.

 Diabetic neuropathy - abnormal and decreased sensation, starting with the feet but potentially in other nerves, later often fingers and hands. When combined with damaged blood vessels this can lead to diabetic foot

 Diabetic nephropathy - damage to the kidney which can lead to chronic renal failure, eventually requiring dialysis. Diabetes mellitus is the most common cause of adult kidney failure worldwide in the developed world. Diabetic cardiomyopathy - damage to the heart, leading to diastolic dysfunction and eventually heart failure.

Dietary Guidelines
Energy intake is based on age, sex, actual weight in relation to desirable weight, activity and occupation For children Boys: basal requirements 1000kcal+125kcal x in no of years Boys: basal requirements 1000kcal+100kcal x no of years should maintain 10% of ideal body weight in Broka's index = Height in cm - 100 = Ideal body weight in kg Energy needs 20 kcal/kg- overweight, 30 kcal/kg- Normal 40 kcal/kg- underweight

 Distribution of calories for each meal if no insulin is given: Breakfast 33% Midmorning Lunch Tea Dinner Before going to bed 33%

33%

Avoid simple sugars and junk foods insulin based on need, calorie based on insulin Include low GI foods Mixture of oils High protein and water soluble fibre-hypoglycemic Timely intake in between meals to avoid hypoglycaemic stress Use food exchange lists Avoid fasting and feasting Include hypoglycemic foods like fenugreek Sodium 6g/day and 3 g/ day for hypertensive diabetics Include whole wheat instead of rice

 Diet should meet the needs of antioxidants, micronutrients, and phytochemicals Supplement vitamins and minerals if needed. Starch encased in its seed coat or coarsely ground is not efficiently hydrolysed to glucose because digestive enzymes are prevented from reaching the starch Starch granules subjected to moist heat and subsequent cooling become dense and less available to enzyme action. Retrograded starch has low glycemic index.

 Rice bran, which is rich in fibre and oil has low glycemic index. High amylase rice varieties which are slowly digested are potentially useful in low glycemic diets. Chapathis, which need chewing have lower glycaemic index compared to wheat kanjee. Raw food has lower glycemic index than cooked food. Foods rich in fat and protein have low glycemic index Phytic acid present in whole grains decrease GI Natural food has low glycemic index compared to processed foods The GI for fructose is low (23) compared to lactose (46), sucrose (65) or glucose (97). Fructose produces lower risk of blood sugar than glucose. In view of its effect on serum lipid, it can be taken only in moderation.

Foods to be avoided

Eaten in Moderation

Foods permitted

Simple sugars (glucose, honey, syrup, dried fruits, cake, candy, fried foods, alcohol, nuts Jaggery, sweetened juices.

Fats, cereals, pulses, meat, egg, nuts roots, fruits, artificial sweetener.

Green leafy vegetables, fruits except banana, lemon, clear soups, onion, mint, spices, salads plain coffee or tea, skimmed and butter milk, spices.