DIABETES ; RECENT ADVANCEMENT OF CONTROL & TREATMENT

DR.D.R.NAKIPURIA ,SENIOR GASTRO INTEST SPECIALIST & HIV/AIDS CONSULTANT
DR.MRS.RANJU NAKIPURIA,SENIOR GYNAECOLOGIST,OBST & INFERTILITY EXPERT
DR.MAYANK NAKIPURIA ,GENERAL PHYSICIAN.
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About 61.3 million people in India suffer from diabetes, and according to estimates,one in every 5 people in India will be diabetic by 2025. Similiary in China The number of Diabetic patients will increase like anything.Diabetes is a metabolic disease which is characterised by high blood sugar levels. It can be caused either due to the lack of insulin (type 1 diabetes) or because the body’s cells fail to respond to the insulin produced (type 2 diabetes). There’s another form of diabetes that afflicts pregnant women called gestational diabetes.
Symptoms:In diabetes,the body is unable to absorb glucose which leads to a host of problems. Here are some of the symptoms that could indicate diabetes:
1.Increase in appetite,Frequent urination,Feeling too thirsty,Loss of weight,Feeling fatigued all day long,Frequent infections,Poor wound healing,High irritability/Depression
,Blurred vision etc.
Our Digestive system breaks down whatever food we eat into glucose.This glucose is absorbed by the blood with the help of a hormone called insulin. Diabetes occurs when the body is not able to produce insulin or is not able to use it effectively. Here are some of the reasons why this happens.
1. Genes:Genes can be responsible for causing both Type 1 and Type 2 diabetes. Having certain combination of genes may increase or decrease the risk of diabetes. If your parents were diabetics, you should be extra careful about your lifestyle.So it runs in family,so if both mother and father diabetic child being diabetic is very high.
2. Autoimmune destruction of beta cells:Sometimes,our own immune system may recognise the beta cells that produce insulin as antigens, and create antibodies to destroy them.Often, diabetes is diagnosed after most of the cells are destroyed and the patient then needs a daily dose of insulin to survive.
3.Lack of physical activity/obesity:Lack of exercise and obesity can be major causes of Type 2 diabetes. An imbalance between calories consumed and calories burned renders our body incapable of absorbing insulin properly. Just 30 minutes of physical activity reduces the chances of you having diabetes by 30 per cent. So, make sure you include activities like walking and cycling in your daily timetable.
4.Age:As a person ages, several parts of his/her body stop functioning at their optimum best. This can lead to diabetes, along with several other ailments.
5. Certain drugs :Certain medicines like nicotinic acid, psychiatric drugs, diuretics, etc. can destroy the beta cells that produce insulin or disrupt insulin absorption.
6.Pancreatic disease or injury:Since the beta cells are present in the pancreas – any injury or diseases like cancer, pancreatitis, etc. can stop beta cells from functioning and ultimately lead to diabetes.
Diagnosis:Diabetes is diagnosed using blood tests, and the three tests used for diagnosing diabetes are:
1.A1C test or glycohaemoglobin test;This test is used for diagnosing Type 2 diabetes. It measures a person’s average blood glucose levels over the past three months.If a person’s A1C level is below 5.7%, it means that he/she is normal. If it is between 5.7 to 6.4%, it indicates prediabetes which may lead to diabetes if appropriate measures are not taken.A person is diagnosed with diabetes if he/she has an A1C level of 5.7% or above.
2.Fasting Plasma Glucose (FPG) test;The Fasting Plasma Glucose test is the most common test used for diagnosing diabetes. It is performed by measuring a person’s blood sugar level, after he/she has fasted for at least 8 hours.If a person has a fasting glucose level of 126 mg/dL or above, he or she has diabetes. It is advised to repeat the test on another day for confirmation.
3. Oral glucose tolerance test (OGTT);In an oral glucose tolerance test, a person has to fast for at least 8 hours. After that, he/she has to drink a glass of water mixed with 75g of glucose.If a person’s 2-hour blood glucose-level is between 140 to 180 mg/dL, the person has prediabetes which could lead to diabetes if appropriate measures are not taken. If the blood glucose-level is above 180 mg/dL, then the person is diagnosed with diabetes as this level kidney excerete sugar in urine and urine show sugar and patient is called diabetic below this level sugar not seen in urine of person.
Treatment:Beast way to treat Diabetic is first to control food avoid Glycemic food or food which produce more sugar as sugaar and its product or food under ground like potato,reddish,carrot,beet,sugar cane,rice,apples,grapes etc even hifh fat is changed in to sugar so high fat content or high starch food or high calorie diet lead to more load of high calorie to our gut and as aresult of less Insulin or This food being les utised so high bloodglucose or Diabetes occurs.So food having less gluscose,freen veteables and leafy food should be taken.
If we do excersie this excessive food is burnt so excercise is also good and is second step to control diabetes,mostly pre Diabetic condition is controlled by food and excercise only.If diabetes can’t be controlled with diet, xercise and weight control,ten we take anti-diabetic medications or insulin.Type I diabetes occur only in children and young s and there is lack of Insulin so treatment is only Insulin which is injected either three times or once or twice with long acting insulin.
Most people who have type 2 diabetes start with an oral medicine. Here are some of them:
Drugs that act on your pancreas ;
Sulfonylureas (DiaBeta, Glucotrol, Amaryl, etc.) lower blood glucose levels by increasing the release of insulin from the pancreas. These drugs decrease blood sugar rapidly but may cause abnormally low and dangerous levels of blood sugar (hypoglycaemia) leading to mental confusion and even coma. Meglitinides (Prandin, Starlix, etc.) also work on the pancreas to increase insulin secretion. Their effects depend on the level of glucose. Victoza (lyraglutide), an injectable medicine, helps the pancreas make more insulin after eating a meal. It improves blood sugar in people with type 2 diabetes when used with a diet and exercise programme.
Drugs that decrease the amount of glucose released from the liver:
Biguanides (Metformin) decrease glucose production by the liver, decrease the absorption of glucose in the intestines and improve the body’s resistance to insulin. It also suppresses hunger, which may be beneficial in diabetics who are overweight.
Drugs that increase the sensitivity (response) of cells to insulin :
Thiazolidinediones (Actos and Avandia) lower blood glucose by increasing the sensitivity of the muscle and fat cells to insulin. These drugs may be taken with metformin and/or a sulfonylurea. They can cause mild liver problems but are reversible with discontinuation of the drug.
Drugs that decrease the absorption of carbohydrates from the intestine:
Alpha glucosidase is an enzyme in the small intestine which breaks down carbohydrates into glucose. Acarbose is the drug that inhibits this enzyme. Carbohydrates are not broken down as efficiently and glucose absorption is delayed, thus preventing high glucose levels after eating in people with diabetes.
Drugs that slow emptying of the stomach:
Exenatide (Byetta) is a substance like gut hormone (GLP-1) that cannot be easily broken down. It slows stomach emptying, slows the release of glucose from the liver and controls hunger. Administered in the form of an injection, Byetta also causes weight reduction, thus making it particularly suitable for patients with type 2 diabetes who are also overweight. DPP-IV inhibitors (Januvia, Onglyza, Tradjenta), inhibit DPP-IV enzyme from breaking down gut hormone (GLP-1). This allows the hormone already in the blood to circulate longer. They also increase insulin secretion when blood sugars are high and signal the liver to stop producing excess sugar.
Insulin Injections – Insulin is the backbone of treatment for patients with Type 1 diabetes. Insulin is also important in Type 2 diabetes when blood glucose levels cannot be controlled by diet, weight loss, exercise and oral medicines. Different types of insulin are:
1. Rapid-acting insulin – starts working in about 15 minutes and lasts for 3 to 5 hours. There are 3 types of rapid-acting insulin: Insulin lispro, Insulin aspart and Insulin glulisine
2. Short-acting insulin (regular insulin) – starts working in 30 to 60 minutes and lasts 5 to 8 hours.
3. Intermediate-acting insulin (insulin NPH) – starts working in 1 to 3 hours and lasts 12 to 16 hours.
4. Long-acting insulin (insulin glargine and insulin detemir) – starts working in about 1 hour and lasts 20 to 26 hours.
5. Premixed insulin- combination of 2 types of insulin (usually a rapid-acting or short-acting insulin and an intermediate-acting insulin).
Various methods for administering insulin are:
Pre-filled Insulin Pens – This is similar to an ink cartridge in a fountain pen. An insulin cartridge is held by a small pen-sized device. The amount of insulin to be injected is dispensed by turning the bottom of the pen until the required number of units is seen in the dose-viewing window. The tip of the pen consists of a needle that is disposed off with each injection.
Insulin pump – This is the most recently available advance in insulin delivery. It is composed of a pump reservoir similar to that of an insulin cartridge, a battery-operated pump and a computer chip that allows the user to control the exact amount of insulin being delivered. The pump is used for continuous insulin delivery. The amount of insulin is programmed and is administered at a constant rate.
Insulin Inhalers – Inhaled form of insulin is not much in use these days. The insulin is packaged in dry packs which are inserted into an inhalation device. This device allows the insulin to enter a chamber that has a mouth piece. Through this mouth piece the user can inhale the insulin.
Newer injectable injections - Symlin (pramlintide) is an injectable medication for use in diabetes patients treated with insulin but unable to achieve adequate sugar control. Amylin is a hormone synthesised by pancreas and helps control glucose after meals. It is absent or deficient in patients with diabetes. Pramlintide, a synthetic form of human amylin, when used with insulin, can improve sugar control. Symlin reduces blood sugar peaks after meal, reduces glucose fluctuations throughout the day and increases the sensation of fullness (leading to weight loss).
Insulin pills: insulin has been synthesises in tablet form by nano particle and will be absorbed in intestine passing Gastic acid and it is succesful in mice.
Permanant : Either transpnting B-cells of langerhans in Pnacreas a or complete pancreatic transplant to control diabetic in patient undergoing idney replacement due to high diabetes.But process is expesive and and dosenot work well with so many immunosuppresants.
Bariatic Surgery/Obesity Surgery:bariatic surgery bypass food from stomach to intestines so less food absorption and weight loss so daibetes is controlled.
Prognosis/complications:
Diabetes, if uncontrolled can lead to deadly complications.
1. Effect on fat and metabolism (Diabetic ketoacidosis): Since the hormone insulin which breaks down glucose is lacking, in uncontrolled cases, the body starts using fat as the fuel source. While you might think it’s not such a bad idea to lose some fat, what this leads to is build up of by-products of fat digestion called ‘ketones’. If you’re not taking your insulin doses regularly, have fever/diarrhoea/vomiting and/or going through a lot of stress or are an alcoholic, you need to be extra careful about developing this condition called ‘ketoacidosis’. If you develop symptoms like deep gasping breathing, acute pain in the abdomen, bad dehydration leading to weakness and fainting, vomiting, it’s time you take it seriously and contact your doctor.
2. Effect on the eyes (Diabetic retinopathy): Retina (the innermost layer of your eye) is affected by ineffective blood glucose control. The small blood vessels in the retina are damaged and weakened. The early symptom of eye problems related to diabetes is blurred vision and double vision. It can also cause a severe, permanent loss of vision. Diabetes increases the risk of developing cataracts and glaucoma.
3. Effect on kidneys (Diabetic nephropathy): If you notice swelling in your feet and legs or around your eyes, your kidneys might get affected because of the uncontrolled blood sugar levels. If you have hypertension (or high BP), your chances of developing this is even higher.
4. Effect on nerves: Some of the nerves, especially around your peripheries like legs might get affected first leading to a loss of sensation. You might not be able to figure out if you’ve had an injury and it may end up getting infected. Diabetic gangrene (infection of the leg, leading to decay of flesh) can occur and the leg may have to be amputated. Uncontrolled diabetes can also affect nerves that control your heartbeat, blood pressure, digestion, blood flow to organs etc leading to diarrhoea, erectile dysfunction, loss of bladder control, vision changes, and dizziness.
5.Effect on heart: If you are a smoker, have high blood pressure, are grossly overweight and/or have a family history of diabetes and are diagnosed with diabetes, you have a greater risk of developing heart disease, strokes.