Diabetes mellitus- various aspects- The diabetes which we speak generally in common language refers to diabetes mellitus
Symptoms of diabetes mellitus –
1 Usually there may be no symptoms at all.. So instead of waiting for the day to come when the problem comes and it is necessary to take treatment ,it is always better to get done. Random blood sugar and other investigations once you cross the age of 40 yrs. Other investigations include ECG, Blood pressure measurement from qualified experienced MD General Medicine doctor.
2 Patient of diabetes frequently feels thirsty (polydipsia), so he frequently drinks water. People working in his office,any other profession start commenting on him. Initial comments may be such that this individual is very hard working ,so he feels thirsty frequently. But as we know people speak something and something else is going on in their mind. But when the problem exceeds the certain limit the individual is asked to consult a doctor as the suspicion of diabetes mellitus arises in mind.
3 Polyphagia – In this the diet of the individual is increased. Usually we have our own judgement ,but when even without doing much work we feel more hungry than usual this should alert us and we should consult a qualified and experienced MD General Medicine specialist doctor .
The reason of polyphagia is that in Diabetes mellitus either there is low production of insulin or inability of the body cells to utilize blood glucose as the cells become resistant to insulin. Insulin is necessary for the uptake of the glucose by the body cells. So in both the cases the uptake of glucose into the cells is decreased ,so the individual individual feels much hungry.
4-Polyuria –As the intake of water is increased, due to increasing thirst, the urine output naturally increases. So when all these 3 things are increased it should alarm the concerned individual. Whenever such an individual consults an MD General Medicine doctor initially only Random blood sugar is advised. If it turns high then only fasting blood sugar and Post prandial (PP) blood sugar is advised to rule out diabetes mellitus.
Such individual should seek advice from an experienced and qualified MD General Medicine doctor as early diagnosis and treatment prevents further complications.
5 In a normal individual whenever a wound occurs ,after some days a scab formation followed by skin formation is there, but in case of diabetes patient the wound remains raw for quite long periods of time, however high antibiotics are taken and however well dressings are given -these things go in favour of diabetes mellitus, but treatment is not started unless blood sugar level crosses 200 mg/dl.
6 Fatigue– An individual of diabetes easily gets exhausted. He finds it difficult to do too much hard work.
7-Blurrring of vision When a person has blurring of vision along with ophthalmic check up, testing random blood sugar also becomes essential.
8 Giddiness -All the above mentioned symptoms may not be there ,but even if giddiness is there alone or combined along with any of these above mentioned symptoms random blood sugar, ECG, blood pressure evaluation, and neurologist consultation is required. Types of diabetes mellitus –
Following are the different types of diabetes mellitus –
1-Type 1 diabetes.-It is also called juvenile diabetes.
Treatment can help in this case but it cannot be cured. It is a chronic condition in which the pancreas produce little or no insulin. It is a kind of autoimmune disorder in which autoantibodies develop which destroy the beta cells of islets of Langerhans that produce insulin. This occurs at a very early age and insulin has to be administered to such patients.
2-Type 2 diabetes.- In this there is impairment in the way which our body regulates and uses glucose as a fuel.
For details of symptoms of diabetes pl click on the link given below
The symptoms of diabetes mellitus given in the link mentioned above are only the general symptoms of diabetes, but diabetes has effects on various body systems like nervous system, gastrointestinal system, skin wounds and infections, blood vessels, vision ,kidney -the description for which is given in the links mentioned below –
All the following effects discussed in articles of the above links are part of symptoms of diabetes mellitus
As they are very lengthy ,they are in form of seperate blogs -as-
Effects of diabetes on gastrointestinal system
Effects of diabetes on nervous system
Effects of diabetes of skin
Effects of diabetes on wounds and infections
Effects of diabetes on blood vessels
3-Gestational diabetes.It is also called as diabetes mellitus in pregnancy.
In this the placenta produces certain hormones that block the effects of insulin. In such pregnant women the pancreas does not produce enough insulin. After delivery and in later part of life there is possibility that such women can develop Type -2 diabetes mellitus.
There may be no symptoms at all, but as routinely ANC check up is done in that the diagnosis of gestational diabetes comes ahead.
4-Maturity onset diabetes of the young (MODY)
Maturity-onset diabetes of the young (MODY) is a group of several conditions characterized by abnormally high blood sugar levels. These forms of diabetes typically begin before the individual reaches the age of 30, although they can occur at later age in life.
5-Neonatal diabetes-
What Is Neonatal Diabetes? Neonatal diabetes mellitus is a rare form of diabetes that occurs in individuals within the age of first 6 months of life. Humans need insulin to help the various cells of the body to produce energy. Infants with this condition do not produce enough insulin, as a result of which the blood glucose levels increase.
6-Wolfram Syndrome.
7-Alström Syndrome.
8-Latent Autoimmune diabetes in Adults (LADA)
Wolfram Syndrome.
6-Wolfram syndrome is a genetically inherited condition that is typically associated with childhood-onset insulin-dependent diabetes mellitus and progressive optic atrophy. In addition, many individuals with Wolfram syndrome also develop diabetes insipidus and sensorineural hearing loss.
What are the four most common features of Wolfram syndrome?
Wolfram Syndrome is a rare genetic disorder which is also known as DIDMOAD syndrome after its four most common features (Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness).
7-Alström Syndrome.
Alström syndrome is characterized by a progressive loss of vision and hearing, a form of heart disease that enlarges and weakens the heart muscle (dilated cardiomyopathy ), obesity, type 2 diabetes (the most common form of diabetes), and short stature.
Alström syndrome is a rare condition that affects various body systems. Many of the clinical features of this condition begin in infancy or early childhood, but some appear later in life.
8-Latent Autoimmune diabetes in Adults (LADA)-
Latent autoimmune diabetes mellitus in adults (LADA) is a slow-progressing form of autoimmune diabetes. Like the autoimmune disease type 1 diabetes, LADA occurs because your pancreas stops producing adequate insulin, mostly due to the autoantibodied which slowly damage the Beta cell of islets of Langerhans which produce insulin . But it is not as severe as type 1 diabetes as these affected individuals often do not require insulin for several months up to years after being diagnosed.
Investigations in diabetes mellitus-
Random blood sugar
If random blood sugar is at higher levels then Fasting and post prandial blood sugar levels need to be done.
In cases of chronic diabetes mellitus Hb 1 AC need to be done, which is described in detail below in this article.
As diabetes is usually associated with hypertension and elevated levels of serum cholesterol, it is necessary to do –
Lipid profile
Assessment of blood pressure from physican (MD-General Medicine)
HbA1c-
HbA1c is the average period of blood sugar levels in your blood over a period of 2-3 months .You must have ‘ heard about mean median and mode. These are measures of central tendency. If there are 25 people travelling through a bus and we want to find their average height, then what we do is that we add up their heights and divide by 25 ,this gives us an idea of their average height.
Similarly HbA1c is the average level of blood sugar over a period of 2-3 months.
It is necessary in those individuals with diabetes mellitus who have fluctuating levels of blood sugar, those who are at the risk of developing type 2 diabetes.
Normal level of HbA1c in a diabetic individual is about 48mmol/molecular and ideally it should be below 42 mmol/mol .
Explanation -In a diabetic individual the level of blood sugar is high as the body cells are not able to utilize the glucose in blood due to inability of glucose to get transported into the body cells. Haemoglobin is a molecule in the RBCs((Red blood corpuscles) that is necessary for transport of oxygen. The excess of glucose combines with haemoglobin to form glycated Haemoglobin.
So more the levels of glycated haemoglobin more is the hb 1 ac levels in case of diabetes mellitus.
Normal levels of Hb1 AC are below 5.7 percent. In pre-diabetes it is between 5.7 percent to 6.4 percent. In diabetes it is more than 6.5 percent.
Factors affecting the levels of Hb1ac.
1 -Anaemia -In anaemia the Haemoglobin percentage is very low so glycosylated Hb is also low and so leads to false low levels.
2- In liver and kidney disease false values are obtained .
3-When Vitamin C and Vitamin E are given then the values of He 1 AC obtained are misleading
4- When the cholesterol level is high in untreated cases the values of GB 1 AC are not correct.
In all these situations whenever you consult your qualified and experienced MD Medicine doctor for diabetes mellitus you have to let him know all these details, as it is quite possible that being busy in heavy OPD, he may not get time to ask you all these things. So awareness is quite important. If we know certain things we are definitely benefitted.
How frequently this test of Hb 1 ac should be done. -An individual with diabetes should do this test at least once in 3 months period. If satisfactory blood sugar levels are maintained then this test can be done less frequently .A minimum two times per year should be done in diabetic individuals.
Diet required by diabetes mellitus individuals is bit different from non diabetics. Below here we mention the details of diet required by a person who has diabetes mellitus –
Diabetic diet -Part -1
An individual with diabetes should avoid eating processed foods, deserts, outside snacks. Homemade food should be preferred.
Foods with high caloric value, too much sweets, ghee, fried foods should be avoided..
Diet rich in fruits, vegetables ,and proteins is helpful in diabetic individuals.
Sugary and starchy carbohydrates in high amounts can increase the blood sugar levels. They should be given in the right amount as per the instructions of balanced diet. For this advice should be taken from dietician.
It depends on what type of occupation the individual is doing ,the level of hard physical work in it -from this the dietician will decide the type of carbohydrate in diet and the amount of carbohydrate in diet for patients of diabetes mellitus.
It also depends on the fact that what medication is going on to the diabetes patient whether it is insulin or oral hypoglycemic agent and the dosage of these.
Regards diet consultation should be done from your dietician and MD General Medicine doctor only.
Following are the guidelines –
Fruits and vegetables should be taken in diet.
Lean protein should be included in diet.
Green leafy vegetables are rich in minerals vitamins, nutrients.
They do not have much great impact on blood sugar levels of diabetes mellitus patients. Green leafy vegetables like spinach and kale are rich in potassium, calcium ,vitamin A .Proteins and fiber are also present in it.
Green leafy vegetables have antioxidants and starch digesting enzymes which are of advantage to diabetic individuals.
List of green leafy vegetables that should be taken by diabetic individuals are –
Spinach
Kale
Cabbage
Broccoli
Collard greens
Bok choy
Foods should be such that sugar should not be added into it.
Juice should be made from kale and given to diabetes mellitus patients -it helps to reduce blood sugar levels. It doesn’t help to lower Blood pressure in individuals with high levels of blood pressure but it helps to lower blood pressure in individuals with subclinical hypertension.
300 ml of kale juice should be drunk by these individuals per day for a duration of 6 weeks.
If you are doing this you need to inform your regular MD Medicine doctor so that whatever you do is with his permission.
All this list of vegetables should be taken in salads, side dish ,soups, dinners. A source of lean protein like chicken should be combined with it.
Whole grains are preferable in comparison to refined grains as they contain more nutrients and more fiber material.
More amount of fiber will increase the time required for digestive process .This will reduce the rate of absorption of nutrients and in this way it will help to stabilize the blood sugar levels of diabetes mellitus patients.
Examples of whole grains are-
Whole grain bread
Brown rice
Buckwheat
Quinoa
Rye,
Bulgur
Millet
Decision regarding Artificial sweeteners available in the market should be taken only after consultation with your MD General Medicine doctor as some of these artificial sweeteners are attributed to be carcinogenic.
If you are a diabetes mellitus patient on oral hypoglycemic and you have got operated in some hospital for some surgery, before doing surgery you should inform the concerned operating surgeon about the ongoing medications.
Immediately after post -operative period there is a period of 6 hrs. NBM. In this period patient is not allowed to eat or drink anything. Iv fluids are allowed in this period. Even after this period and the next day the appetite of the patient is very low and so either oral hypoglycemic drugs should not be taken as per the consultation of your operating surgeon and your regular MD General Medicine doctor.
Dangerous hypoglycemia can result as already the food intake is low ,so blood sugar is low, on the top of that if oral hypoglycemic agents are taken then the blood sugar can drop to too much low levels and it can cause fainting .
To some extent hyperglycemia is ok, but hypoglycemia is too much dangerous in patients of diabetes mellitus.
Diabetic diet -Part -2
Fatty fish contain omega -3 Fatty acids.These are also known as EPA and DHA.
If diet contains monounsaturated and polyunsaturated fatty acids then it can achieve better diabetic control .Also if the diabetic individual has elevated lipid profile then control can be achieved over it also. Fish that have good level of monounsaturated and polyunsaturated fatty acids are
Salmon
Herring
Trout .
Prawns should be avoided by diabetic individuals and those with elevated levels lipid profile .
Baked roasted grilled fish should be consumed.
Fried fish should be avoided as it will cause intake of oil in diet and we always try to avoid oil in diabetic individuals and in individuals with elevated lipid profile .
Beans are good for diabetes mellitus individuals as they have a lower side glycaemic index. They have high content of protein and low content of carbohydrate so they help in better regulation of blood sugar as compared to the starchy foods.They also contain iron, potassium and magnesium.
Also appetite of the individual is satisfied. So it can help in weight loss, control of blood pressure and cholesterol levels.
Avoid taking beans from outside which are canned ,so salted
Make them at home to avoid this.
Walnuts -These are also rich in omega 3 fatty acids .Theses are good for heart and as diabetes mellitus patients have tendency to develop heart disease, so those should be utilized by diabetic individuals.
Omega -3 fatty acids can achieve better diabetic control and also control over elevated lipid profile. Walnuts also contain Magnesium, Vitamin B 6,iron ,proteins .
Citrus fruits contain bioflavonoid antioxidants -naringin and hesperidin and these are responsible for the antidiabetic effects of oranges.
Citrus foods also contain minerals like potassium ,folate and Vitamin C
Berries -There is lot of oxidative stress in patients of diabetes mellitus. Berries help to decrease it as they contain lot of antioxidants .Oxidative stress is a condition that occurs when there is imbalance between free radicals and antioxidants in our body.
Berries that should be consumed are blueberries
blackberries
Strawberries 
raspberries
Besides being helpful in diabetes they also contain fibre, minerals like potassium ,manganese, Vitamin K, vitamin C.
As due to busy schedule we may forget to consume them we should make a practice to include it in out breakfast.
Sweet potatoes are beneficial for patients with diabetes mellitus as they release blood sugar slowly and besides they also provide us vitamin A, vitamin C, fibre ,potassium .
Probiotic Yogurt -These reduce inflammation and oxidative stress .If a patient of diabetes has elevated blood cholesterol levels then this pro biotic yogurt will help to decrease it. It has been found that diabetes ,elevated cholesterol and hypertension are associated with each other. Pro biotic yogurt contains cultures of Lactobacillus of Bifidobacterium.If a diabetic patient is purchasing pro biotic yogurt from the market then he should make it sure that it doesn’t contain any added sugar.
Chia seeds -These contain high levels of antioxidants and omega3 fatty acids are thus reduce the oxidative stress in diabetes mellitus patient.People do not like to consume it directly so they should be added to salads and desserts.
Treatment of diabetes mellitus-
Treatment of diabetes is with a few different medications. Some are taken orally , while others are available as injections.
Type 1 diabetes mellitus
Insulin is the main treatment for type 1 diabetes. It replaces the hormone your body isn’t able to produce.
Various types of insulin are commonly used by people with type 1 diabetes. They differ in how quickly they start to work and how long their effects last:
Rapid-acting insulin: starts to work within 15 minutes and its effects last for 2 to 4 hours
Short-acting insulin: starts to work within 30 minutes and lasts 3 to 6 hours
Intermediate-acting insulin: starts to work within 2 to 4 hours and lasts 12 to 18 hours
Long-acting insulin: starts to work 2 hours after injection and lasts up to 24 hours
Ultra-long acting insulin: starts to work 6 hours after injection and lasts 36 hours or more
Premixed insulin: starts working within 5 to 60 minutes and lasts 10 to 16 hours
Type 2 diabetes mellitus
Diet and exercise can help some people manage type 2 diabetes. If lifestyle changes aren’t enough to lower your blood sugar, you’ll need to take medication.
These drugs lower your blood sugar in a variety of ways:
Drugs- Mechanisms of action -Examples-
alpha-glucosidase inhibitors slow your body’s breakdown of sugars and starchy foods
acarbose (Precose) and miglitol
biguanides reduce the amount of glucose your liver makes.
alogliptin (Nesina), linagliptin (Tradjenta), saxagliptin (Onglyza), and sitagliptin (Januvia)
glucagon-like peptide stimulate your pancreas to produce more insulin; slow stomach emptying
semaglutide (Ozempic), dulaglutide (Trulicity), exenatide (Byetta), and liraglutide (Victoza)
meglitinides stimulate pancreas of diabetes mellitus patient to release more insulin .
nateglinide and repaglinide
SGLT2 inhibitors release more glucose into the urine
canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance)
sulfonylureasstimulate your pancreas to release more insulin
glyburide (Glynase), glipizide (Glucotrol), and glimepiride (Amaryl)
thiazolidinedione help insulin work better.
You may need to take more than one of these medications. Some people with type 2 diabetes also take insulin.
Insulin-
What is Insulin ?
Insulin is a hormone that is secreted by the beta cells of the pancreas. It helps to regulate blood sugar levels and it has been found to effectively treat diabetes mellitus. Insulin is a hormone. It is mainly produced in the body by the islets of Langerhans.
Islets of Langerhans are a group of cells in the pancreas -they produce insulin. They not only do the production of insulin but also decide how much amount should be produced. The amount produced depends on the blood glucose levels. If the amount of blood glucose is increased then the amount of insulin produced is also increased.
Pancreas is endocrine gland. It secretes insulin directly into blood. This is in contrast to other glands that are exocrine-like salivary glands which have ducts.
As endocrine glands do not have ducts their secretion is directly added to blood.Insulin needs to be administered externally to some diabetes mellitus patients.
Introduction to hormones –
Hormones are chemo messengers that influence the target organs or cells. Hormones do the work of giving specific instructions to cells due to which the body cells can act in a specific way. Similarly insulin helps to transfer glucose from blood into cells and so the cells get energy .Thus it helps the cells to utilize glucose.
Indirectly insulin is required by humans to remain alive. If the levels of insulin are less (Insulin dependent diabetes mellitus. )/IDDM or if the cells are less responsive to insulin (Non -insulin dependent diabetes mellitus ) then the levels of glucose in blood will increase.
In IDDM there is malfunctioning of system due to which the immune system attacks the islets of Langerhans so that insulin production is affected and it becomes necessary to administer insulin to the individual .
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Insulin is given to those diabetes patients who do not respond to oral hypoglycemic agents .
The type of insulin that should be given to diabetes mellitus patient by MD Medicine doctor is decided by the following factors –
The time of onset of action after insulin is given
The time required to achieve the peak effect of action
The duration till when the action of insulin will persist(the time interval till when the hypoglycemic action of insulin will last)
The route of administration of insulin
Subcutaneous
Intravenous
Nasal spray
The most common route for administering insulin which is preferred all over the world is by subcutaneous method. This is easy method. Patient can do it himself and there is no need every time to visit doctor ‘s clinic.
Rapid acting insulin -This type of insulin is absorbed very fast into blood from the subcutaneous fat. So it is the insulin of choice if we have to correct hyperglycemia in a very short duration.The type of insulin to be given to diabetes mellitus patient is decided by physician- MD General Medicine doctor
In this type we have rapid acting insulin analogs. This takes on average 5-15 minutes to have effect. It lasts for duration of 4 hrs.
Regular human insulin -For this the time of onset of action is 30 minutes to one hr. The duration of action is 8 hrs.
Intermediate acting insulin. -In this type the time for onset of action is slow but it’s effects last for a longer time. So it’ll is always in a better position to control the blood sugar of diabetes mellitus patients overnight or in between meals.
Examples of intermediate acting insulin are-
NPH human insulin -For this onset of action is 1-2 hrs. and the peak level is achieved in 4-6 hrs. In some Case duration of action is 12 hrs.
Premixed insulin-This is a mixture of rapid acting insulin and intermediate acting insulin.
Long acting insulin -This is slow reach blood stream .It has a stabilizing effect on blood sugar and it lasts through out the day. Time of onset of action of insulin is 1.5-2 hrs. .
For actual treatment a diabetic patient should consult a qualified and experienced MD General Medicine doctor. Our website doesn’t mention the dose of medicines as it has been found that some people make diagnosis and treatment just by going to google and catastrophic consequences result. So the treatment for diabetes mellitus should be taken only after taking consultation with qualified and experienced MD Medicine doctor.
Side effects of insulin therapy –
In type 1 diabetes mellitus following side effects are seen due to insulin therapy –
Weight gain -Initially before insulin therapy cells are not able to utilize glucose as there is difficulty in transfer of glucose into the cells.
When insulin is started it helps in the transfer of glucose through the cell membrane from the blood into the cells. So now cells can utilize glucose. Our body has mechanism which helps to transfer glucose into fats and glucose into proteins. Insulin also helps in the breakdown of proteins and fats.
Due to all these mechanisms the body weight increases in case of diabetes mellitus patients.
Hypoglycemia -If more than the required dose of insulin is given, or if insulin is given at the wrong time then the blood glucose levels fall below the normal range ,brain does not get sufficient supply of glucose and the person faints. Following are the effects seen in hypoglycemia-
Dizziness
Trouble in speaking
Fatigue
The individual can become unconscious
Confusion
The skin becomes pale
Sweating
Seizures
Twitching of muscles
Fat necrosis -As the individual takes subcutaneous insulin it is actually delivered into the subcutaneous fat and there is a possibility that a painful lump can form in the subcutaneous plane.
So a person with diabetes mellitus should always keep packets of sugar or chocolate with him and these should be consumed as early as possible. Family members must be aware of all these things as hypoglycemia is always much more dangerous than hyperglycemia.
If this hypoglycemia(falling of blood glucose below the normal range ) occurs in a hospital then it is much more safe condition as immediately iv glucose can be given by the hospital staff and situation can be brought under control.
Sweating and palpitations can occur to the patient during hypoglycemia.
Rash or swelling -This can occur at the site of injection.
Anxiety and depression -These things can occur in a patient of diabetes mellitus taking insulin as he starts thinking that something has happened to him, he is definitely dependent on injections and things have not remained the same as before. In this case the family members should boost the morale of this patient.
Complications due to insulin therapy –
Heart attack (Myocardial infarction)
Stroke
Ophthalmic problems
Complications related to kidney.
