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How to Deal with Diabetes?

Diabetics can beat down the disease themselves if they take adequate well-informed measures, says Dr. Tony George Jacob, M.D.

This disease has many names: none of them ever express the gravity of the illness. Madhumeh in Sanskrit, prameham in Malayalam and Tamil--all have the element of sweet in it.

Diabetes is of various kinds, both of which have a characteristically increased urine output and hence the name. There is diabetes mellitus in which the regulation of the level of sugar in the body goes awry. The other is diabetes insipidus in which the concentrating ability of the kidney is lost and therefore a lot of dilute urine is excreted that may lead to dangerous dehydration and imbalance of salts in the body. 

Diabetes mellitus is due to problems with the production or action of a hormone called Insulin. Insulin is produced from a portion of the gland called pancreas, known as the Islets of Langerhan. They secrete insulin directly into the blood stream. This hormone helps to keep the level of blood sugar within normal limits i.e. 80 to 110g per 100 ml of blood. 

When a person eats food, it is converted into its basic elements of sugar, protein and other nutrients in the gut, which then pours it into the blood stream. Therefore after a meal there is a rise in the blood sugar levels. The blood sugar after a meal should not be more than 110-140mg per 100 ml of blood. Any further rise in the levels leads to it being excreted into urine and other bodily fluids. Sugar being an osmotic agent takes along with it water; this leads to increased urinary output.

Insulin has the action of making the cells of the body take up sugar from the blood stream and use it as a fuel or as a reserve. This signal to the cells brings down the blood sugar level. Therefore in diabetes this regulation of sugar level is not possible and the cells are also not able to draw their fuel from the blood. Consequently, the cells send out signals of starvation even in the presence of abundant sugar. This starts a vicious circle of increasing blood sugar levels by any means but the cells remain hungry because they cannot utilize the sugar in the blood stream in the absence of insulin.

Diabetes mellitus itself is of various kinds:

1) Adult diabetes mellitus- this has onset in the 4th to fifth decade of life. There is a burn out of the cells that produce Insulin. 

2) Maturity onset of diabetes mellitus in the young (MODY) - this has the same spectrum of symptoms and signs as adult diabetes, but occurs in a younger age group- usually the third or fourth decade of life.

3) Pregnancy induced diabetes mellitus: this occurs in women during pregnancy. The affected women are normal before and after pregnancy, however their insulin production is not commensurate to the needs of the stress of pregnancy.

4) Juvenile diabetes- this is a disease in which the body does not produce any insulin either because the cells in the pancreas that produce them have been destroyed or their cascade of signals have been interrupted somewhere. These people are dependent on Insulin injections for day to day survival.

The problem with diabetes is that it is a very insidious disease. It rarely produces any dramatic symptoms which warrant immediate attention. The person may have increased appetite (polyphagia), increased thirst (polydipsia) and increased urine output (polyuria; usually manifest as getting up more than the usual number of times during the night to urinate), and repeated minor infections, and more importantly they feel weak, tired and lose weight despite the increased food intake.

Such a person goes and gets his/her blood sugar tested and then they know that they may be diabetic, now what. Does life go on as usual? It shouldn’t.

Here are a few must dos…

Lifestyle modification

Diet: The diet should be rich in fibers (which prevent the rapid absorption of sugar) and meals should be small and more frequent (to prevent a rapid increase in blood sugar.) So whatever meal you take, divide it into two. If you are used to taking three to four meals a day, start eating half the quantity six to eight times a day. 

Refined sugar (refined flour-maida, polished rice, juices) and fried foods (pastries, samosas, creamy milk and biscuits) should be avoided--they are calorie bombs.

Exercise: Make it a point to build exercise into your daily routine. You may be washing clothes, sweeping the floor, but that is not exercise, they are your daily routine. Take time off for a brisk walk for half an hour or a jog (if your joints allow it). 

Medication: If your doctor has advised you to take a particular medication, please see to it that you know when you are supposed to take it and make it a regular habit. Keep a reminder near your refrigerator or on your work table or anywhere till it becomes a reflex. Next, it is important to monitor the drug’s effectiveness.

Testing: A random blood sugar value is of no use. A fasting blood sugar level is important especially for people on medication; it indicates the night control of sugar by the medication. If the level is high the dose may be increased or an added dose given during the night.

The post prandial blood sugar level is taken an hour after a regular meal. This indicates whether there is enough insulin produced or being taken by injections to control the blood sugar rise after a meal (which is a normal phenomenon up till a certain limit).

The HbA1c (glycosylated hemoglobin) test reveals the control of sugar in the previous three or four months. It is unmindful of the daily fluctuations of sugar levels and gives an overall idea if the current method of treatment is proving adequate for the patient or not. The Glucose tolerance test helps to detect diabetes in pregnant women. Here a loading dose of glucose is given and blood sugar levels measured every half hour for the next 2 to 2.5 hours.

Effects of diabetes

The high amount of sugar that goes around in the blood in a patient of poorly controlled diabetes has a tendency to stick to various structures in the cell of the body. This makes the cells sticky and prone to destruction and malfunction. It makes the walls of small blood vessels to thicken; this in turn decreases the amount of oxygen reaching the various tissues of the body and then finally the cells die. This process known as microangiopathy may take anything between 10 to 20 years. 

Therefore after one or two decades a patient of diabetes may have:
1) kidney failure
2) retinal failure and blindness
3) heart attacks, angina
4) nerve dysfunctions
5) repeated infections, which includes tuberculosis and skin infections
6) hypertension due to thickening of the blood vessels and renal failure
7) strokes

They may have one or many of the above spectrums. This is called end-organ damage. It is this that often kills the patient than the disease itself.

Immediate complications

In a person with uncontrolled diabetes or in a person with diabetes under control but facing an unaccounted stress (infections, travel, and undue exercise) the person may present with a florid picture of sugar loss or increase.

1) Hyperglycemia- there is an excess of sugar in the body. This has to be excreted in urine along with a lot of water. This leads to dehydration. But the cells of the body cannot take in sugar without insulin so give signs of starvation and therefore start producing ketone bodies and acids… this can lead to coma and death if not detected early and treated with insulin and fluids.

2) Hypoglycemia- there is a lack of sugar in the blood. This is usually due to an overdose of the drug that is being taken or due to an excess or unprecedented exercise. This usually responds well to a spoonful of sugar, but has to be confirmed with a blood sugar level taken before administering the sugar.

Both in hypo and hyperglycemia the patient feels faint, has a lot of sweating, palpitations, and may actually faint. But the treatment of both conditions is diametrically opposite. And therefore amateur advice to take sugar whenever you feel faint is inviting trouble.

Precautions

Regular monitoring of blood sugar levels, at least once a month. If you are starting with a new drug, then test every week. If you are on insulin, then everyday till you have stabilized on a dose on which your blood sugar is normal, thereafter blood levels of sugar may be tested weekly or biweekly. Diabetics on insulin need to adjust their doses according to daily need. If they decide that they are going to start regular jogging or aerobics, or are simply going to go the hills, they should either increase the amount of food that they eat or decrease the dose of insulin for that time period.

Diabetics are prone to infections and so any pedicure or should be done carefully and avoid cuts and bruises which may get secondarily infected, fester and eventually lead to amputation. They must also monitor the functions of their heart by regular measurements of their Blood pressure and ECGs.

Diabetes rarely kills by itself, but it leads an army of organ failures against you that eventually maims, tortures and takes lives. But if controlled properly, it can never raise its head against you. The ball is always in your court in the case of diabetes. You may take the upper hand if you wish it. It just takes an ounce of will power and sufficient knowledge about what you are up against.