With an aim to create awareness about the escalating health threat that diabetes now poses, World Diabetes Day is celebrated every year on November 14 worldwide, led by the International Diabetes Federation (IDF) and its member associations.
In an exclusive interview with Salome Phelamei of Zeenews.com, Dr Rekha V Bhat MD (Internal Medicine) DM (Endocrinology), conversed on diabetes, the care required, risks involved, treatment and prevention measures.
Dr Rekha V Bhat did her DM in Endocrinology from the prestigious institute "PGIMER", Chandigarh. She is currently working as consultant endocrinologist in Columbiaasia group of hospitals, Mysore, Karnataka.
1. What is diabetes mellitus? What are the Types?
Diabetes Mellitus is a metabolic syndrome caused by defective action of insulin. This can be due to inadequate secretion of insulin or resistance to the action of insulin.
When insulin secretion is nearly absent it results in what is called Type 1 diabetes mellitus. Type 1 diabetes mellitus is usually diagnosed in childhood. Daily insulin injections are mandatory for survival.
Type 2 diabetes mellitus results from a combination of insulin resistance and insulin deficiency. Its prevalence is rapidly increasing and the age of onset is progressively decreasing, largely fuelled by lack of exercise and obesity.
A third Type, gestational diabetes mellitus, appears during pregnancy in women who did not have diabetes. These women are at high risk of developing Type 2 diabetes and cardiovascular disease later in life.
2. History of diabetes mellitus..........
The earliest case of diabetes mellitus can be traced back to 1552 BC. A physician of Egyptian descent noted a patient who urinated all the time. Subsequently, it was observed that these patients passed urine that was sweet to taste. Diabetes means "flow through" and mellitus means "sweet". Several decades later, autopsy findings revealed unhealthy pancreas in a patient with diabetes mellitus. The symptoms and signs of diabetes mellitus were noticed when pancreas was removed from healthy dogs.
In 1922, Canadian surgeon Frederick Banting and his assistant Charles Best isolated insulin from pancreas extract and revolutionised the world of medicine. Patients with diabetes mellitus who, until then, were destined to die a slow death, now got a new lease of life. Since then the management of diabetes mellitus has come a long way to include insulin and insulin analogues of a high degree of purity, nearly painless injections and orally active drugs effective in Type 2 diabetes mellitus. Diagnostic methods have also evolved considerably to such an extent that it is possible for patients with diabetes mellitus of any Type to have a normal lifespan.
3. Who are at risk?
There are many risk factors for Type 2 diabetes, including:
a) Age greater than 45 years
b) A parent or sibling with diabetes
c) Gestational diabetes or delivering a baby weighing more than 3.5 kg
d) Cardiac disease
e) High blood cholesterol levels
g) Lack of physical activity
h) Women with polystic ovary disease
i) Past history of impaired glucose tolerance (impaired glucose tolerance means plasma glucose above the normal range, but below levels classified as diabetes mellitus)
j) Some ethnic groups (for example African Americans, Native Americans and Asians)
4. What is the prevalence of it in the country?
The prevalence rate of diabetes is higher in urban areas compared to rural population. It is around 12% in urban areas, whereas the prevalence is 4 to 6 times lower in rural areas. India is currently harbouring around 40 million people with diabetes. By 2025 it is anticipated that India will contain the largest number of patients with diabetes mellitus in the world.
5. What is the burden of disease on family, health care system and on economy of the country?
Diabetes being a chronic illness is expensive for the majority of patients. A study published in the journal of association of physicians of India has thrown light on the economic burden imposed by diabetes mellitus. It has been estimated that the annual cost could be Rs.90,200/- million (USD 2.2 billion) for diabetes health care. Patients spent an average of 7.7% of their income for outpatient care and 17.5% of their income when inpatient management was necessary. Patients with complications like foot ulcers, retinopathy, involvement of the kidneys, etc. face additional expenditure for specialised care. Complications like amputations and kidney failure, and complications compromising vision can reduce productivity and increase dependency on the family.
6. How to detect or identify diabetes at initial stage and when to go to doctor?
The classical symptoms of diabetes mellitus are excessive thirst, excessive urination, and weight loss despite a good appetite. Anyone with these symptoms should be screened for diabetes mellitus immediately. However, since Type 2 diabetes mellitus can be asymptomatic in many individuals for several years, routine screening should be done at regular intervals.
Screening for Type 2 diabetes in people with no symptoms is recommended for:
a) Overweight children who have other risk factors for diabetes starting at age 10 and repeating every 2 years
b) Overweight adults who have other risk factors
c) Adults over 45, every 3 years
7. What are the tests available to diagnose diabetes?
The following blood tests are used to diagnose diabetes -
a) Fasting plasma glucose level- diabetes is diagnosed if plasma glucose is greater than 126 mg/dL on two separate occasions.
b) Hemoglobin A1c test- 6.5% or higher indicates diabetes mellitus.
c) Oral glucose tolerance test- diabetes is diagnosed if plasma glucose levels are greater than 200 mg/dL after 2 hours.
8. How is diabetes related with obesity, heart disease and hypertension?
Diabetes mellitus is not an individual entity. It is part of a wider spectrum. The same factors that predispose to diabetes confer a risk for development of obesity, cardiovascular disease, hypertension and abnormal cholesterol levels. Presence of any one of these metabolic abnormalities predisposes to the others. They also have a role to play in the development and progression of the complications of diabetes mellitus.
In other words, if one has to control diabetes mellitus and its potential complications, it is equally important to keep in control body weight, blood pressure and cholesterol levels. A person with diabetes mellitus is prone to develop cardiovascular problems. In fact, heart attacks can be "silent or painless" in these individuals. This makes it mandatory that patients with diabetes mellitus have a regular heart check even if they do not have any symptoms of cardiac involvement.
9. Suggest some roles of- diet, exercises and drugs for diabetes.
A diabetic diet is actually a healthy diet meant to be followed by normal people. High calorie and junk foods like carbonated drinks, pizza, cake, ice-cream, chips, etc. should be avoided. The intake of sweets, oil, butter, ghee, should be minimised. Milk without cream, buttermilk, fresh fruits, green vegetables should be consumed regularly. The patient must eat on time and avoid skipping meals. A dietician will be able to give a personalised diet chart with appropriate exchange proportions.
People with diabetes mellitus should exercise regularly equivalent to daily walks for 30 to 45 minutes, at least 5 days in a week.
This includes insulin and tablets. Tablets are also called oral hypoglycemic drugs. People with Type 1 diabetes cannot produce insulin. They need daily insulin injections. Unlike Type 1 diabetes, Type 2 diabetes may be treated with exercise, diet, and oral drugs.
The oral hypoglycemic drugs act by manipulating the endogenous insulin secretion from the pancreas or by reducing insulin resistance.
10. If my parents have diabetes what are the chances of me developing it?
Genetic inheritance is stronger for Type 2 than Type 1 diabetes mellitus. If an identical twin has Type 2 diabetes mellitus, the chances of the normal twin developing it is about 90%. If one parent has diabetes, the child has a 2-fold higher risk; if both the parents have diabetes mellitus, the risk is 6 times greater; if a sibling is affected, the risk is 4 times greater.
11. What are Hypoglycemia and Hyperglycemia? What are symptoms, treatment and prevention for it?
Hypoglycemia means low blood glucose. The threshold for experiencing the symptoms of hypoglycemia differs from person to person. Generally a person first experiences symptoms of sympathetic over activity like tremors, palpitation, sweating, etc. before progressing onto symptoms of brain involvement like drowsiness, confusion, coma. However with repeated hypoglycemic episodes, a person may directly slip into drowsiness, confusion or coma without going through the warning signs of tremors, etc.
Hypoglycemia is likely to occur if the patient has taken medications and skipped food intake, if there was unaccustomed physical activity, if there is renal impairment or if there has been an over dosage of medication. When hypoglycemia occurs, the patient should immediately consume some food, for example fruit juice. The factors that caused this should be analysed and addressed.
Hyperglycemia simply means elevated blood glucose levels. The classic symptoms are excessive thirst, excessive urination and weight-loss despite a good appetite. Often, hyperglycemia is asymptomatic. The treatment consists of disciplined diet, regular exercise, oral hypoglycemic agents and insulin.
12. What about oral hypoglycemic drugs, will it cure the disease?
There is no cure for diabetes mellitus. It can be controlled with combination of diet, exercise, oral hypoglycemic agents and insulin. The complications can be prevented or at least detected at an early stage when they are reversible, if the treatment regimens and follow up schedules are strictly adhered to as advised by the medical practitioner.
13. How insulin is used medically to treat some forms of diabetes mellitus?
Insulin is administered to patients who do not secrete insulin endogenously. This holds true for Type 1 diabetes mellitus and long-standing Type 2 diabetes patients, when they have exhausted their insulin reserves. Pregnant and breast-feeding women cannot be given oral hypoglycemic agents. They too require insulin injections. Taking insulin injections is simple and cane be learned in less than 5 minutes from a doctor or nurse. The injections are best taken in the abdomen. Many insulin preparations have to be taken in relation to meals and this has to be followed for smoother control. The storage methods as advised by the manufacturer must be followed.
14. Please tell us about prevention of complications arising from diabetes mellitus.
Maintaining an ideal body weight and an active lifestyle may prevent Type 2 diabetes.
To prevent complications of diabetes, patients with diabetes mellitus should visit their medical practitioner periodically, as per their advice.
They must regularly have the following tests-
a) Blood pressure (130/80 mmHg or lower).
b) Glycosylated hemoglobin (HbA1c) every 3 months
c) Cholesterol and triglyceride levels yearly (aim for LDL levels below 100 mg/dL, less than 70 mg/dL in high-risk patients).
d) Yearly tests for the kidneys (microalbuminuria and serum creatinine).
e) Review with ophthalmologist (eye specialist) at least once a year, or more often if there are signs of diabetic retinopathy.
f) Dental check up every 6 months.
g) Daily foot examination to look for callosities, ulcers, redness, etc. The nails should be clipped straight. The feet should be kept as clean as the face.
15. What are the long-term goals of treatment from diabetes mellitus?
The long-term goals of treatment are-
a) Prolong life
b) Reduce symptoms
c) Prevent diabetes-related complications such as blindness, heart disease, kidney failure, and amputation of limbs
These goals are accomplished through-
a) Blood pressure and cholesterol control
b) Careful self testing of blood glucose levels
e) Foot care
f) Meal planning and weight control
g) Medication or insulin use