Diabetes: The silent killer By Dr. Rabia Sabir

DVM, M.Phil Microbiology IOM-UAF

Diabetes (also known as diabetes mellitus, DM) is described as a metabolic disorder in which the body cannot properly store and use the energy found in food.

More specifically, diabetes is a condition that affects the body's ability to use glucose (a type of sugar) as fuel. Glucose is a form of carbohydrate that comes from foods such as breads, cereals, pasta, rice, potatoes, fruits and some vegetables. Glucose is also synthesized in the liver and is carried in the blood to the rest of the body to fuel cellular processes.

To use glucose as fuel, insulin is required to get the glucose into cells. Insulin is a hormone (a type of chemical messenger) made by specialized cells in the pancreas. Insulin regulates blood glucose by stimulating the removal of glucose from the blood and uptake into muscle, liver and fat cells where it can be stored for energy.

Sometimes body does not make enough insulin or the cells do not respond properly to insulin. Blood glucose levels can then become elevated while the cells are deprived of fuel. When blood glucose levels get too high (hyperglycemia) this can cause damage to the tiny blood vessels in the eyes, kidneys, heart and nervous system, which is why diabetes is associated with an increased risk of cardiovascular disease, kidney disease, loss of vision and neurological conditions.

Persistently elevated blood glucose may lead to a diagnosis of pre-diabetes or diabetes.

Pre-diabetes describes the condition where blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes.

There are three types of diabetes:

Type-1 diabetes

Type-2 diabetes

Gestational diabetes.

Type-1 diabetes used to be known as insulin-dependent diabetes (IDDM), or juvenile-onset diabetes as it often begins in childhood. Type-1 diabetes is an autoimmune condition where the immune system wrongly identifies and subsequently attacks the pancreatic cells that produce insulin, leading to little or no insulin production.

Type-2 diabetes used to be known as non-insulin dependent diabetes (NIDDM) and adult onset diabetes, but it is increasingly common in children, largely due to children being more likely to be obese or overweight. In this condition, body usually still produces some insulin, but this is not enough to meet demand and body's cells do not properly respond to the insulin. The latter effect is called insulin resistance, where persistently elevated blood glucose has caused cells to be overexposed to insulin, making them less responsive or unresponsive to the hormonal messenger.

Gestational diabetes occurs in pregnancy and typically resolves after childbirth. People who have experienced gestational diabetes do, however, have an increased risk of developing type-2 diabetes after pregnancy.

Signs and symptoms of diabetes 1 and 2

There are numerous medical consequences of persistently high levels of blood glucose. The most serious involvement is kidney failure, eye problems (blindness), neurological damage and increased risk of cardiovascular problems (including heart attack and stroke).

Some symptoms and warning signs are common in both type 1 and type 2 diabetes. These can be seen in the table below and include: being very thirsty, frequent urination, rapid weight loss, extreme hunger, weakness and fatigue, sickness and irritability.

Diabetes type-1 Diabetes type-2

Warning signs Very thirsty

Urinating frequently

Rapid weight loss

Feeling very hungry

Feeling extreme weakness and fatigue

Nausea, vomiting, irritability.

Very thirsty

Urinating frequently

Rapid weight loss

Feeling very hungry

Feeling extreme weakness and fatigue

Nausea, vomiting, irritability

Blurred vision

Excessive itching

Skin infections

Sores that heal slowly

Dry, itchy skin

Pins and needles or numbness in feet.

Common physical attributes found

Mostly normal or thin. Mostly overweight or obese.

Onset Rapid (in weeks) - often present acutely with keto-acidosis.

Slow (in years).

Complications Diabetic coma or keto-acidosis (from high blood sugar)

High blood pressure

Hypoglycemia (low blood sugar)

Diabetic coma or keto-acidosis (from high blood sugar)

High blood pressure

Hypoglycemia (low blood sugar)

Nephropathy

Blindness

Heart attack

Kidney disease

Stroke

Neuropathy

Amputation.

Nephropathy

Blindness

Heart attack

Kidney disease

Stroke

Neuropathy

Amputation.

Tests and Diagnosis of

diabetes type 1 and type 2

In the early stages of type-2 diabetes there may be few symptoms present. That is why blood tests are used to confirm the diagnosis of type 1 and 2 diabetes and pre-diabetes. Testing enables health care providers to find and treat diabetes and pre-diabetes before complications occur, and can delay or prevent type-2 diabetes from developing.

Any one of the following tests can be used for diagnosis of type-1 or type-2 diabetes, not all are recommended for diagnosing all types:

A1C test, also called the hemoglobin A1c, HbA1c, or glycohemoglobin test

Fasting plasma glucose (FPG) test

Oral glucose tolerance test (OGTT).

Another blood test, the random plasma glucose (RPG) test, is sometimes used to diagnose diabetes during a regular health checkup. If the RPG measures 200 micrograms per deciliter or above and the individual also shows symptoms of diabetes, then a health care provider may diagnose diabetes.

Blood test levels for diagnosis of diabetes and pre-diabetes are outlined below.

Comparison of tests and diagnosis for diabetes type-1 and diabetes type-2:

Diabetes type-1 Diabetes type-2

Possible cause factors

Genetic

Environmental

Autoimmune factors

Idiopathic.

Genetic

Obesity

Physical inactivity

High/low birth weight

Gestational diabetes mellitus (GDM)

Poor placental growth

Metabolic syndrome.

Commonly afflicted groups (but not exclusive to)

Children

Teens.

Adults

Elderly

Certain ethnic groups.

Prone ethnic groups

All. African-American

Latino/Hispanic

Native American

Asian

Pacific Islander.

Prevalence 5% 95%

Affected age group

Typically age 5 - 25 (can affect people of any age).

Most common in adults, but can also develop around puberty. Most children with type-2 diabetes have a family history of diabetes, are overweight, and are not very physically active. Until recently, only type-1 diabetes was commonly diagnosed in children.

Test A1C test A1C test

Random plasma glucose

Fasting plasma glucose

Genetic testing is conducted in cases where there is a family history of the disease.

Random plasma glucose

Fasting plasma glucose

Oral glucose tolerance test may also be conducted (rarely).

People with type-1 and sometimes type-2 diabetes are treated with insulin injections to control blood glucose levels.

Some facts and myths about diabetes:Many presumed "facts" are thrown about in the paper press, magazines and on the internet regarding diabetes. Some of them are, in fact, myths. It is important that people with diabetes, pre-diabetes, their loved ones, employers and schools have an accurate picture of the disease. Below are some diabetes myths:

People with diabetes should not exercise - NOT TRUE!! Exercise is important for people with diabetes, as it is for everybody else. Exercise helps manage body weight, improves cardiovascular health, improves mood, helps blood sugar control, and relieves stress. Patients should discuss exercise with their doctor first.

Fat people always develop type-2 diabetes eventually - this is not true. Being overweight or obese raises the risk of becoming diabetic, they are risk factors, but do not mean that an obese person will definitely become diabetic. Many people with type-2 diabetes were never overweight. The majority of overweight people do not develop type-2 diabetes.

Diabetes is a nuisance, but not serious - two thirds of diabetes patients die prematurely from stroke or heart disease. The life expectancy of a person with diabetes is from five to ten years shorter than other people's. Diabetes is a serious disease.

Children can outgrow diabetes - this is not true. Nearly all children with diabetes have type-1; insulin-producing beta cells in the pancreas have been destroyed. These never come back. Children with type-1 diabetes will need to take insulin for the rest of their lives, unless a cure is found one day.

Don't eat too much sugar, you will become diabetic - this is not true. A person with diabetes type-1 developed the disease because their immune system destroyed the insulin-producing beta cells. A diet high in calories, which can make people overweight/obese, raises the risk of developing type-2 diabetes, especially if there is a history of this disease in the family.

I know when my blood sugar levels are high or low - very high or low blood sugar levels may cause some symptoms, such as weakness, fatigue and extreme thirst. However, levels need to be fluctuating a lot for symptoms to be felt. The only way to be sure about your blood sugar levels is to test them regularly. Researchers from the University of Copenhagen, Denmark showed that even very slight rises in blood-glucose levels significantly raise the risk of ischemic heart disease.

Diabetes diets are different from other people's - the diet, doctors and specialized nutritionists recommend for diabetes patients are healthy ones; healthy for everybody, including people without the disease. Meals should contain plenty of vegetables, fruit, whole grains, and they should be low in salt and sugar and saturated or trans fat. Experts say that there is no need to buy special diabetic foods because they offer no special benefit, compared to the healthy things we can buy in most shops.

High blood sugar levels are fine for some, while for others they are a sign of diabetes - high blood-sugar levels are never normal for anybody. Some illnesses like mental stress and steroids can cause temporary hikes in blood sugar levels in people without diabetes. Anybody with higher than normal blood sugar levels or sugar in their urine should be checked for diabetes by a health care professional.

Diabetics cannot eat bread, potatoes or pasta - people with diabetes can eat starchy foods. However, they must keep an eye on the size of the portions. Whole grain starchy foods are better, as is the case for people without diabetes.

One person can transmit diabetes to another person - NOT TRUE. Just like a broken leg is not infectious or contagious. A parent may pass on, through their genes to their offspring, a higher susceptibility to developing the disease.

Only older people develop type-2 diabetes – Now things are changing. A growing number of children and teenagers are developing type-2 diabetes. Experts say that this linked to the explosion in childhood obesity rates, poor diet, and physical inactivity.

I have to go on insulin, this must mean my diabetes is severe - people take insulin when diet alone or diet with oral or non-insulin injectable diabetes drugs do not provide well-

enough diabetes control, that's all. Insulin helps diabetes control. It does not usually have anything to do with the severity of the disease.

If you have diabetes you cannot eat chocolates or sweets - people with diabetes can eat chocolates and sweets if they combine them with exercise or eat them as part of a healthy meal.

Diabetes patients are more susceptible to colds and illnesses in general - a person with good diabetes control is no more likely to become ill with a cold or something else than other people. However, when a diabetic catches a cold, their diabetes becomes harder to control, so they have a higher risk of complications.

Diabetes Treatment:

Type-2 diabetes has a number of drug treatment options to be taken by mouth known as oral anti-hyperglycemic drugs or oral hypoglycemic drugs.

Oral diabetes drugs are usually reserved for use only after lifestyle measures have been unsuccessful in lowering glucose levels to the target of an HbA1c below 7.0%, achieved through an average glucose reading of around 8.3-8.9 mmol/L (around 150-160 mg/dL).

The lifestyle measures that are critical to type-2 diabetes management are diet and exercise, and these remain an important part of treatment when pills are added.

People with type-1 diabetes cannot use oral pills for treatment, and must instead take insulin.

Oral anti-hyperglycemic drugs have three modes of action to reduce blood glucose levels:

Secretagogues enhance insulin secretion by the pancreas

Sensitizers increase the sensitivity of the peripheral tissues to insulin

Inhibitors impair gastrointestinal absorption of glucose.

Each class of anti-hyperglycemic drug has a different adverse event or safety profile, and side effects are the main consideration when it comes to choosing a medication.

Possible side effects range from weight gain, through gastrointestinal such as diarrhea, to pancreatitis and more serious problems. Hypoglycemia is also a possible adverse event.

No one particular choice of oral hypoglycemic is considered the most effective form of treatment. The decision over which drug to use is instead based on:

Consideration of the adverse side effects

Convenience and overall tolerability

Personal preference.

The use of a single drug can be escalated to combination therapy with a second drug in an effort to improve glycemic control.

Metformin is usually the first treatment offered, however, it is the most widely used oral anti-hyperglycemic. Metformin is a sensitizer in the class known as biguanides; it works by reducing the amount of glucose released by the liver into the bloodstream and increasing cellular response to insulin. A metformin pill is usually taken twice a day.

This drug is a low-cost anti-hyperglycemic with mild side effects that can include diarrhea and abdominal cramping. Metformin is not associated with weight gain or hypoglycemia.

Sulphonylureas are secretagogues that increase pancreatic insulin secretion. There are several drug names in this class, including:

Chlorpropamide

Glimepiride

Glipizide

Glyburide.

In case of sulphonylureas, the choice depends on daily dosing and the level of side effects. These drugs are associated with weight gain and hypoglycemia.

Glitazones (also known as thiazolidinediones) are sensitizers - they increase the effect of insulin in the muscle and fat and reduce glucose production by the liver.

Two glitazones are available:

Pioglitazone Rosiglitazone.

These drugs can have the side effects of weight gain or swelling and are associated with increased risks of heart disease and stroke, bladder cancer and fractures.

Alpha-glucosidase inhibitors are intestinal enzyme inhibitors that block the breakdown of carbohydrates into glucose, reducing the amount absorbed in the gut.

Available as

Acarbose Miglitol,

They are not usually tried as first-line drugs because of common side effects of flatulence, diarrhea and bloating, although these may reduce over time.

Dipeptidyl peptidase-4 (DPP4) inhibitors include

Alogliptin, Linagliptin, Saxagliptin, Sitagliptin.

Also known as gliptins, DPP4 inhibitors have a number of effects, including stimulating pancreatic insulin (by preventing the

breakdown of the hormone GLP-1). They may also help with weight loss through an effect on appetite.

These drugs do not increase the risk of hypoglycemia. Mild possible side effects are nausea and vomiting.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors include

Canagliflozin Dapagliflozin.

They work by inhibiting the reabsorption of glucose in the kidneys, causing glucose to be excreted in the urine (glycosuria).

SGLT2s may also cause modest weight loss. Side effects include urinary infection.

Meglitinides include

Repaglinide Nateglinide.

They stimulate the release of insulin by the pancreas. Meglitinides are associated with a higher chance of hypoglycemia and must be taken with meals three times a day. As a result, these drugs are less commonly used.

Treatment and prevention of diabetes type-1

and type-2:

Below are a list of the current methods used to treat diabetes type 1 and type 2.

Diabetes type-1 Diabetes type-2

Cure None. Some researchers are currently looking at the potential benefits of a

There is no cure for type-2 diabetes, although sometimes gastric surgery,

combination of immunosuppressant drugs and drugs that increase gastric production to encourage pancreatic regeneration that may allow people with type-1 diabetes to live insulin-free.

lifestyle and medication treatment can result in remission. Physical exercise, healthy loss of weight and diet control is advised.

Treatment Injections of insulin

Oral medications (less common)

Dietary modifications

Physically activity

Regular check-up of blood sugar levels

Controlling blood pressure

Monitoring cholesterol levels.

Using diabetes medicines

Sometimes insulin injections

Healthy food choices

Exercise

Self Monitoring of Blood Glucose (SMBG)

Controlling blood pressure

Monitoring cholesterol levels.

Prevention No known way to prevent the loss of pancreatic, insulin-producing cells.

Preventable and can be delayed with a healthy diet and exercise.

Diabetes is a slow killer with no known curable treatments. However, its complications can be reduced through proper awareness and timely treatment. Three major complications are related to diabetes are blindness, kidney damage and heart attack. It is important to keep the blood glucose levels of patients under strict control for avoiding the complications. One of the difficulties with tight control of glucose levels in the blood is that such attempts may lead to hypoglycemia that creates much severe complications than an increased level of blood glucose. , So, researchers now working on alternative methods for diabetes treatment in order to avoid this problem.