Management of Diabetes Mellitus

Controlling your blood sugar is very crucial to keep healthy and avoiding late complications of Diabetes Mellitus (DM). Some people are able to control their blood sugar with diet and exercise alone. Others may need to use insulin or other medications in addition to lifestyle changes. In either case, monitoring your blood sugar is a key part of your treatment program.

The development of long-term complications is influenced by hyperglycemia. Poor control of diabetes accelerates their progression. Thus, to prevent complications, good control of diabetes mellitus is essential and the management of diabetes should therefore aim to improve glycaemic control beyond that required to control its symptoms.

Medicine is an ever-changing science and advances and new developments in diabetes mellitus care and clinical practice will continue to take place. Thus revision of the guidelines will be necessary as new knowledge is gained.

General objectives of diabetes mellitus management:

• To correct associated health problems and to reduce morbidity, mortality and economic costs of diabetes
• To relieve symptoms
• To prevent as much as possible acute and long-term complications; to prevent the
• development of such complications and to provide timely intervention
• To improve the quality of life and productivity of the individual with diabetes

Assessment of Diabetes Mellitus :

• Family history of diabetes, cardiovascular disease, and stroke
• Height and weight measurements
• Thyroid examination
• Blood pressure measurements
• Blood tests for fasting blood sugar, A1c, and cholesterol
• Examination of hands, fingers, feet, and toes for circulatory abnormalities
• Prior infections and medical conditions
• A list of current medications, including: Over-the-counter medications, Prescription medications
• Smoking history, including encouragement to stop smoking (if applicable)
• Vitamin, mineral or herbal supplements
• Vision abnormalities, to check for eye health issues
• Signs of complications with pregnancy or trying to get pregnant for women patients
• Eating and exercise habits
• Urination abnormalities, which can indicate kidney disease

Glucose monitoring: Self-blood glucose monitoring allows you to know your blood glucose level at any time and helps prevent the consequences of very high or very low blood sugar. Monitoring diabetes mellitus also enables tighter blood sugar control, which decreases the long-term risks of diabetic complications.

Dietary Management and Physical Activity: In general, the more active you are, the lower your blood sugar. Physical activity causes sugar to be transported to your cells, where it's used for energy, thereby lowering the levels in your blood. Aerobic exercises such as brisk walking, jogging or biking are especially good. But gardening, housework and even just being on your feet all day also can lower your blood sugar. Diet and exercise are basic measures of treatment of diabetes mellitus.

To prevent the development and progression of atherosclerotic disease as well as microangiopathy, diet management of diabetes mellitus should be focused on the reductions of conventional risk factors for atherosclerosis such as hyperglycemia, dyslipidemia, and hypertension. To control the these risk factors, both total energy and fat intake should be reduced.

Exercise therapy is an effective measure for improving glycemic control in Type 2 diabetic patients. A diet designed to lose one to two pounds per week should be instituted in most type 2 diabetic patients and a eucaloric diet in most type 1 diabetic patients. As little as a 5% loss of body weight results in a significant and disproportionate decrease in insulin resistance and improved glycemic control. Every patient will benefit from dietary counseling, not only when diabetes mellitus is diagnosed, but also at regular intervals after diagnosis.

Oral Medications: Normally, people who are suffering from Type 1 diabetes mellitus don't use oral medications. These medications work best in people with Type 2 diabetes who have had high blood sugar for less than ten years and who have normal weight or obesity. It's not uncommon for oral medication to control blood sugar well for years and then stop working. Some people who begin treatment with oral medications eventually need to take insulin. Oral diabetes medications are sometimes taken in combination with insulin.

Insulin Therapy: Insulin is a hormone and is found in even single-celled organisms and has been around for several billion years. Insulin is also a protein just like many other hormones. The pancreas has a group of cells called islet cells. It is the islet cells that secrete insulin. Without insulin, the cells in our bodies would not be able to process the glucose and therefore have no energy for movement, growth, repair, or other functions. Insulin is key to unlocking the door of the cell to allow the glucose on the patient with diabets mellitus to be transferred from the bloodstream into the cell.

People with Type 1 diabetes mellitus produce inadequate amounts of insulin, so insulin replacement is their key treatment. The pancreas secretes little or no insulin (type 1 diabetes) or your body produces too little insulin or has become resistant to insulin's action (type 2 diabetes), the level of sugar in your bloodstream increases. This is because it's unable to enter cells. Left untreated, high blood sugar can lead to complications such as retinophaty, nerve damage (neuropathy) and nephropathy.

There are four major types of insulin:

• Rapid-acting
• Short-acting
• Intermediate-acting
• Long-acting

Managing Diabetes Mellitus is a balancing act between insulin and blood glucose. Finding the right amount of insulin to keep blood glucose levels as close to normal as possible is the key to good control.

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Dietary Management of Diabetes Mellitus

It is recommended that people with diabetes mellitus work with their diabetes management team (registered dietitian, nurse, physician and other health care professionals, as needed) to develop a nutrition care plan (diet) that fits their own metabolism, nutrition and lifestyle requirements.

Preferred food advice for diabetic patients has been a controversial issue for many years. There is much controversy regarding what diet to recommend to sufferers of diabetes mellitus. The diet most often recommended is high in dietary fiber, especially soluble fiber, but low in fat (especially saturated fat).

Making healthy food choices every day has both immediate and long-term effects. With education, practice, and assistance from a dietitian and/or a diabetes mellitus educator, it is possible to eat well and control diabetes. Those with diabetes need an understanding of diet to maintain reasonable weight and body composition, reduce blood glucose and lipid levels, and delay the chronic complications of diabetes.

Many factors affect how well diabetes is controlled. Many of these factors are controlled by the patient, including how much and what is eaten (about diet), how frequently the blood sugar is monitored, physical activity levels, and accuracy and consistency of medication dosing. Even small changes can affect blood sugar control.

Consistently eating at the same times every day is important for some people, especially those who take long-acting insulin (eg, NPH) and oral medications that decrease blood sugar levels (sulfonylureas or meglitinides). If a meal is skipped or delayed while on these regimens, you are at risk for developing low blood glucose.

Recommendations for diet:

Protein: Protein intake accounts for 15 to 20 percent of total daily calories consumed among the general population as well as those with diabetes.

Carbohydrate: The groups agree that a dietary pattern that includes carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk should be encouraged. The groups agree that a dietary pattern that includes carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk should be encouraged.

Fiber: Dietary fiber is defined as the complex carbohydrates from plants that humans lack the enzymes to digest. Fiber is divided into two categories: soluble and insoluble. Whereas insoluble fiber passes through the digestive tract relatively unchanged, soluble fiber dissolves to form a soft gel. Some familiar foods that contain soluble fiber are apricots, citrus, oats, lentils, and dried beans and peas.

Non-nutritive Sweeteners. Saccharin, aspartame, acesulfame potassium (K) and sucralose have been approved by the Food and Drug Administration (FDA) and can be used by people with diabetes, including pregnant women, within a balanced diet. Because saccharin can cross the placenta, other sweeteners are better choices during pregnancy.

Sugar: It was previously believed that simple sugars are more rapidly digested and absorbed than starches, and therefore are more likely to cause high blood sugar levels.

Food items likes green leafy vegetables, tomatoes, cucumber, soups, and radish can be eaten freely as they promote the overall health of the person.

Dietary Fat and Cholesterol: The total amount of fat you eat, whether high or low, isn't really linked with disease. What really matters is the type of fat you eat. Total fat should be 30 to 35 percent or total calories. Polyunsaturated fat is limited to 10 percent and monounsaturated fat to 20 percent of total calories. Dietary cholesterol should be less than 300 mg/day. Those individuals with LDL cholesterol greater than or equal to 100 mg/dl may benefit from lowering dietary cholesterol to less than 200 mg/day. Elevated levels of triglycerides (greater than 150 mg/dl) are also a risk factor for CVD.

The Basic Objective of Meal Planning :

• To provide relief from symptoms
• To achieve and maintain a desirable body weight
• To maintain near normal blood sugar level
• To achieve and maintain healthy and productive life
• To prevent, delay or minimise the onset of chronic degenerative complications.
• To maintain optimal nutrition for adequate growth, development and maintenance.

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Who are at Risks to Get Diabetes Mellitus?

To find out your risk for diabetes mellitus, check each item that applies to you.

Type I diabetic is more common among whites than Asian, Hispanic, Native and African Americans.

Family history: A close member of your family has Type 2 diabetes (parent or brother or sister).

People who have other clinical conditions associated with insulin resistance, such as a condition called acanthosis nigricans, characterized by a dark, velvety rash around my neck or armpits.

Sedentary Lifestyle: A lack of daily physical activity can lead to obesity, a major factor in developing type 2 diabetes. Persons with type 2 diabetes are at increased risk for stroke, eye complications, heart disease, kidney disease, and foot and skin problems.

People who have high blood pressure or a heart attack or a stroke.

Unhealthy Eating Habits: Ninety% of people who have been diagnosed with type 2 diabetes are overweight. Unhealthy eating contributes largely to obesity.

Obesity: The number one risk factor for type 2 diabetes is obesity.

History of Gestational Diabetes: Most of the women who experienced gestational diabetes late in pregnancy. Although this form of diabetes usually goes away after the baby is born, a woman who has had gestational diabetes is more likely to develop type 2 diabetes later in life. 40% to 60% of women who had gestational diabetes are diagnosed with type 2 diabetes within 15 years.

Age: The risk for type 2 diabetes increases with age, especially after 45 years Woman with polycystic ovary syndrome and you overweight.

People who experienced impaired glucose tolerance or impaired fasting glycaemia.

The more risk factors that apply to you, the greater your risk of having diabetes.

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Symptoms of Diabetes Mellitus

The classical symptoms of diabetes are polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger). Diabetes often goes undiagnosed because many of its symptoms seem so harmless.

Symptoms may develop rapidly (weeks or months) in type 1 diabetes while in type 2 diabetes they usually develop much more slowly and may be subtle or absent.

Symptoms of Type 1 Diabetes

• Frequent urination
• Excessive thirst
• Extreme hunger
• unexplained weight loss
• Increased fatigue
• Blurry vision that changes from day to day
• Irritability

Symptoms of Type 2 Diabetes

• Any of the type 1 symptoms
• Frequent infections
• Blurred vision
• Cuts/bruises that are slow to heal
• Tingling/numbness in the hands/feet
• Recurring skin, gum, or bladder infections
• Increased thirst
• Leg pain
• Dry mouth

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Complications of Diabetes Mellitus

Diabetes mellitus is a disease of metabolic disturbance, most notably abnormal glucose metabolism. Complications of diabetes mellitus can be acute or chronic, accompanied by characteristic late complications.

It is called acute (sudden in onset) when there is result from extreme fluctuations in blood glucose

Late Complications of Diabetes Mellitus: Chronic (long-term) complications occur over a long period of time and result from changes in the small (microvascular) and large (macrovascular) blood vessels of the body.

Micro-vascular complications as:

a. Diabetic Nephropathy: is clinically defined by persistent proteinuria greater than 500 mg/24 hours in a person with diabetic retinopathy without other renal disease. also known as Kimmelstiel-Wilson syndrome, or nodular diabetic glomerulosclerosis and intercapillary glomerulonephritis, is a progressive kidney disease caused by angiopathy of capillaries in the kidney glomeruli.

It is characterized by nephrotic syndrome and diffuse glomerulosclerosis. It is due to longstanding diabetes mellitus, and is a prime indication for dialysis. The causes diabetic nephropathy is the kidneys have many tiny blood vessels that filter waste from your blood. High blood sugar from diabetes can destroy these blood vessels. Over time, the kidney isn't able to do its job as well. Later it may stop working completely. This is called kidney/renal failure.

NEPHROPATHY IN TYPE 1 DIABETES:

Stage 1: Glomerular Hyperfiltration and Renal Enlargement. At onset of type 1 diabetes, approximately one third of individuals have an elevated GFR that is 20% to 40% higher than that of age-matched normal subjects.

Stage 2: Early Glomerular Lesions which has normal albumin level Those structural changes appear 18 to 36 months and may become prominent after 3.5 to 5 years after onset of type 1 diabetes mellitus.

Stage 3: Incipient Diabetic Nephropathy or Microalbuminuric Stage. The third stage, also called incipient diabetic nephropathy, is characterized by persistent and usually increasing microalbuminuria. Hypertension may also involved in this stage.

Stage 4: Clinical or Overt Diabetic Nephropathy: Proteinuria and Falling Glomerular Filtration Rate Albuminuria greater than 300 mg/24 hours, relentless decline of renal function, and hypertension define the fourth stage of diabetic nephropathy.

Stage 5: End-Stage Renal Disease After 20 to 30 years of type 1 diabetes, about 30% to 40% of patients progress to End-Stage Renal Disease (ESRD).

NEPHROPATHY IN TYPE 2 DIABETES

End-stage renal failure (ESRF) in diabetic patients, mostly type 2, has become the most frequent cause of renal replacement therapy in western Europe. Type 2 diabetes is characterized by insulin resistance, i.e., the failure to respond to normal concentrations of insulin, and this is accompanied by compensatory hyperinsulinemia, although the kinetics of insulin secretion are abnormal very early. In later stages, {beta} cell secretion fails to overcome insulin resistance. Increased lipolysis with fatty acid release and accumulation of fat in parenchymal organs further aggravate the metabolic disturbance.

b. Diabetic Neuropathy is neuropathic disorders that are associated with diabetes mellitus. These conditions are thought to result from diabetic microvascular injury involving small blood vessels that supply nerves (vasa nervorum) in addition to macrovascular conditions that can culminate in diabetic neuropathy. Diabetic neuropathy is a heterogeneous disorder that encompasses a wide range of abnormalities affecting proximal and distal peripheral sensory and motor nerves as well as the autonomic nervous system. The major morbidity associated with somatic neuropathy is foot ulceration, the precursor of gangrene and limb loss.

c. Diabetic Retinopathy is (damage to the retina) caused by complications of diabetes mellitus, which can eventually lead to blindness. It is an ocular manifestation of systemic disease which affects up to 80% of all patients who have had diabetes for 10 years or more. Typically, diabetic ESRD patients have serious co-morbid conditions, especially heart, eye, and peripheral vascular diseases. It is not surprising, therefore, that caring for afflicted individuals imposes a major financial burden on family members and governments.

Macro-vascular complications as: Atherosclerosis with MI, CVA, peripheral vascular disease.

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How is diabetes diagnosed?

Diagnosis of diabetes can be made based on any of the following test results, confirmed by retesting on a different day:

Normally, blood glucose levels stay within narrow limits throughout the day (4 to 8mmol/l). But they are higher after meals and usually lowest in the morning.

Fasting plasma glucose level ≥ 7.0 mmol/L (126 mg/dL). Fasting blood glucose level -- diabetes is diagnosed if higher than 126 mg/dL on two occasions. Levels between 100 and 126 mg/dL are referred to as impaired fasting glucose or prediabetes. These levels are considered to be risk factors for type 2 diabetes and its complications.

Oral glucose tolerance test -- diabetes is diagnosed if glucose level is higher than 200 mg/dL after 2 hours. (This test is used more for type 2 diabetes.)

Random (non-fasting) blood glucose level -- diabetes is suspected if higher than 200 mg/dL and accompanied by the classic diabetes symptoms of increased thirst, urination, and fatigue. (This test must be confirmed with a fasting blood glucose test).

Glycated hemoglobin (Hb A1C) ≥ 6.5%. this test has been used in the past to help patients monitor how well they are controlling their blood glucose levels. In 2010, the American Diabetes Association recommended that the test be used as another option for diagnosing diabetes and identifying pre-diabetes. Levels indicate:

• Normal: Less than 5.7%
• Pre-diabetes: Between 5.7% - 6.4%
• Diabetes: 6.5% or higher

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Causes of Diabetes Mellitus

Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused by too little insulin, resistance to insulin, or both. Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused by too little insulin, resistance to insulin, or both. The cause of diabetes depends on the type. For all types of diabetes, the metabolism of carbohydrates (including sugars such as glucose), proteins, and fats is altered.

Type 1 diabetes can occur at any age, but it usually starts in people younger than 30. Type 1 diabetes is an autoimmune disease. An autoimmune disease results when the body's system for fighting infection-the immune system-turns against a part of the body. In diabetes, the immune system attacks and destroys the insulin-producing beta cells in the pancreas. The pancreas then produces little or no insulin. A person who has type 1 diabetes must take insulin daily to live.

The exact cause of type 1 diabetes is not known. Genetics, viruses, and autoimmune problems may play a role.Symptoms are usually severe and occur rapidly. In type 1 diabetes, the beta cells of the pancreas produce little or no insulin, the hormone that allows glucose to enter body cells. Once glucose enters a cell, it is used as fuel. Without adequate insulin, glucose builds up in the bloodstream instead of going into the cells.

The body is unable to use this glucose for energy despite high levels in the bloodstream, leading to increased hunger. In addition, the high levels of glucose in the blood causes the patient to urinate more, which in turn causes excessive thirst. Within 5 to 10 years after diagnosis, the insulin-producing beta cells of the pancreas are completely destroyed, and no more insulin is produced.

Type 2 diabetes is due primarily to lifestyle factors and genetics. Family history and genetics play a large role in type 2 diabetes. Low activity level, poor diet, and excess body weight (especially around the waist) significantly increase your risk for type 2 diabetes.

In type 2 diabetes, there also is a steady decline of beta cells that adds to the process of elevated blood sugars. Essentially, if someone is resistant to insulin, the body can, to some degree, increase production of insulin and overcome the level of resistance. After time, if production decreases and insulin cannot be released as vigorously, hyperglycemia develops.

The pancreas does not make enough insulin to keep blood glucose levels normal, often because the body does not respond well to insulin.

Other risk factors of diabetes mellitus include:

• Gestational diabetes or delivering a baby weighing more than 9 pounds
• Age over 45 years
• A parent, brother, or sister with diabetes
• Infections: Cytomegalovirus infection and Coxsackievirus B
• Some ethnic groups (particularly African Americans, Native Americans, Asians, Pacific Islanders, and Hispanic Americans)Heart disease
• High blood cholesterol level
• Polycystic ovary disease (in women)Obesity
• Not getting enough exercise
• Drugs: β-adrenergic agonists, glucocorticoids and thyroid hormone
• Previous impaired glucose tolerance

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What is Diabetes Mellitus (DM)?

Diabetes Mellitus (DM) is a group of metabolic diseases in which a person has 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) and polyphagia (increased hunger).

There are two main types of diabetes mellitus :
Type 1 diabetes mellitus is a chronic medical condition that occurs when the pancreas, an organ in the abdomen, produces very little or no insulin your body does not make insulin.

Type 1 diabetes usually begins in childhood or young adulthood, but can develop at any age. In the United States, Canada, and Europe, type 1 diabetes accounts for 5 to 10 percent of all cases of diabetes.  Insulin is a hormone central to regulating carbohydrate and fat metabolism in the body. Insulin causes cells in the liver, muscle, and fat tissue to take up glucose from the blood, storing it as glycogen in the liver and muscle.

Type 2 diabetes mellitus comprises an array of dysfunctions resulting from the combination of resistance to insulin action and inadequate insulin secretion. It is disorders are characterized by hyperglycemia and associated with microvascular (ie, retinal, renal, possibly neuropathic), macrovascular (ie, coronary, peripheral vascular), and neuropathic (ie, autonomic, peripheral) complications.

Over time, having too much glucose in your blood can cause serious problems. It can damage your eyes, kidneys, and nerves. Diabetes mellitus can also cause heart disease, stroke and even the need to remove a limb. Pregnant women can also get diabetes, called gestational diabetes.

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