• What is the Diabetes Mellitus?

  Diabetes Mellitus is a chronic progressive spectrum of diseases which involved almost every organ of the body. It's one of the most common causes of premature aging.

  In a natural course of the uncontrolled Diabetes the organs like Kidneys (Nephropathy/ Chronic Kidney Disease) , Eyes ( Retinopathy/ Early Cataract) , Nervous system (Neuropathy) , Cardiovascular system ( Coronary Artery Disease, Ischemic Heart Disease, Cardiomyopathy), Skin ( Acanthosis, pigmentation) , Nails ( fungal infections), Gastro-intestinal system (Gastroparesis, Altered bowel) , Sexual health (Erectile dysfunction , low libido, anorgasmia) and almost all other organs are involved.

  The current trends of managing Diabetes focuses on tight blood sugar control by medications, life style modification, exercise, dietary modification, sleep management and stress reduction.

  Now we have started to look in the other potential hormonal and metabolic implications of Diabetes and started focusing on fixing them.

  Once diagnosed with Diabetes one should not leave hope. The current medical world is working very hard to give array of hope to people living with diabetes.

• Tips for Management of Diabetes

  • Be vigilant about Blood sugar.(Fasting Blood Sugar, Post Prandial Blood Sugar, Glycosylated Haemoglobin).
  • Regular screening for Diabetes complications.(Blood Cholesterol, Kidney Function test, Liver Function test, Nerve testing, Complete eye check up, Complete Cardiac work up, Other hormones evaluation, SHBG)
  • Control of blood cholesterol.
  • Modify life style.
  • Healthy eating.
  • Yoga, meditation.
  • Sleep/Stress management.
  • Avoidance of Smoking/Alcohol.
  • Take medicines on time.
  • Follow up with your doctors very regularly.

  Diabetes can be prevented to some extent. Its complications can be delayed or prevented if the above points can be followed.

  Instituting Early Insulin Therapy in newly diagnosed diabetes patients is a proven measure to delay/prevent the complications of Diabetes. The Insulin therapy needs to be closely supervised and all the measures need to be taken to prevent any episode of hypoglycemia.

• Who are at Risk?

  • Diabetes Mellitus is a group of metabolic disorders leading to defects in Insulin Secretion and/or Insulin action leading to high blood sugar levels and other Systemic and Metabolic changes(Including Proteins and Fat metabolism).
  • Almost 370 million people worldwide have Diabetes Mellitus in various stages.
  • In India, there are approximately 65 million Diabetic patients (second only to China).
  • Almost every living being is at risk of contracting Diabetes Mellitus.
  • Family history of Diabetes (First degree relative) :

    1. No Diabetic parent : Risk is 14%

    2. One Diabetic Parent : Risk is 29.2%.

    3. Father having Diabetes : 20 times more risk than the General population.

    4. Mother having Diabetes : 7 times more risk than the General population.

    5. If both parents are Diabetic then the risk of acquiring Diabetes is about 40%.

  • Indian Ethnicity.
  • Urban more than rural.
  • Early exposure to cow's milk protein (Absence of Breast feeding in infancy).
  • Children kept away from socialization and mixing with other people.
  • Patients of Polycystic Ovarian Syndrome.
  • Low Birth weight babies.
  • Obesity.
  • Sedentary life style people.
  • Increased waist circumference.
  • Females on long term Oral Contraceptive Therapy.
  • Smokers
  • Alcoholics

• Symptoms of Diabetes Mellitus

  If you have one or more of the following symptoms then you should investigate yourself for Diabetes Mellitus :

  • Involuntary weight loss.
  • Loss of Muscle mass.
  • Excessive thirst (Polydypsia)
  • Excessive Hunger (Polyphagia)
  • Excessive urination (Polyuria)
  • Unexplained weight gain (Diabetes Mellitus type 2 ; Insulin Resistance Syndrome)
  • Sexual Dysfunction (Low Libido, Erectile Dysfunction , Anorgasmia)
  • Unexplained Infertility
  • Abortion, Miscarriage, Stillbirth
  • Polyhydramnios during pregnancy
  • Repeated Vaginal and Penile infections (Candida)
  • Repeated Urinary Infections
  • Skin Changes (Hyperpigmentation, Skin thickening/Thinning, Premature Greying of hairs, Dermatitis, Eczema, Repetitive fungal infections etc.)
  • Non Healing wounds/Ulcers
  • Unexplained Fatigue, Weakness, Lethargy
  • Unexplained Mood Changes
  • Unexplained Irritability
  • Unexplained Bowel Complains (Constipation/Diarrhoea)
  • Unexplained Abnormal Sweating pattern
  • Unexplained Giddiness while changing posture
  • High Blood Pressure OR Low Blood Pressure
  • Changes in Vision (Refractory Errors, Cataract , Glaucoma , Retinal Changes etc.)
  • Abnormal sensations like Tingling, Numbness, paresthesia, loss of sensations.
  • Repeated Dental and Gum infections

• Following Incidental Investigations/ Imaging Findings also call for Diabetes Evaluation

  • Hyperlipidemia (High Cholesterol, Triglycerides, LDL)
  • High Random Blood Sugar levels
  • Incidental finding of Abnormal ECG and Stress Test.
  • Abnormal findings in Fundoscopy and other ophthalmic examination
  • Abnormal findings in Audiometry
  • Abnormal Nerve Conduction studies and Electromyography
  • Abnormal Kidney function test (Including Creatinine)
  • Abnormal Urinary analysis (Sugar/Ketones/Proteins/Bacteria/Pus Cells in Urine)

• Causes of Diabetes Mellitus

  • Environmental
  • Genetic
  • Hereditary
  • Autoimmune
  • Pancreatitis
  • Obesity
  • Sedentary Life style/Lack of Physical Exercise
  • High Carbohydrate / Fat intake in diet
  • Refined Sugar Intake
  • Oxidative Damage
  • Inflammation
  • Infections like Rubella, CMV, Coxsachie Virus etc.
  • Other Endocrine diseases likePCOD, Cushing's disease,Acromegaly,Hyperthyroidism etc.
  • Stress
  • Medicines Induced like Niacin,Glucocorticoids, OCP, Growth hormone, Thiazides, Thyroid hormones, Phenytoin etc.
  • Addictions/Substance Abuse like Alcohol, Smoking, Neuroexciting drugs etc.
  • Tumours
  • Toxins

• Types of Diabetes Mellitus

  • Diabetes Mellitus Type 1
  • Diabetes Mellitus Type 2
  • Insulin Resistance Syndrome
  • Gestational Diabetes
  • Others (Genetic, Drug induced , Infections, Endocrinopathies etc)

• Complications of Diabetes

  "Once you are diagnosed to have Diabetes Mellitus, your risk of getting Cardio Vascular (Heart) complications are equal to any patient who has already had a heart attack"

  Almost all the systems of the body can be affected adversely by Diabetes Mellitus :

  • Atherosclerosis
  • Hypertension
  • Obesity (DM Type II)
  • Cachexia (DM Type I)
  • Ischemic Heart Disease
  • Cardiomyopathy
  • Pericarditis
  • Pericardial Effusion
  • Neuropathy
  • Myopathy
  • Non healing ulcers/ Diabetic Foot
  • Autonomic Dysfunction (Postural hypotension, Erectile Dysfunction, Premature Ejaculation, Bladder and Bowel disturbances, Abnormal sweating, Giddiness, Dizziness, Fainting, Syncope etc.)
  • Mood and Memory Disturbances
  • Hypoglycemia leading to convulsion/Coma.
  • Diabetes Keto acidosis
  • Hyper osmolar Coma
  • Electrolyte imbalances leading to Seizures, Convulsions, Unconsciousness.
  • Nephropathy leading to Kidney Failure/End Stage Renal Disease.
  • Ophthalmic Complications (Cataract, Glaucoma, Retinopathy)
  • Erectile Dysfunction , Impotence, Infertility
  • Abortion, Miscarriage, Stillbirth
  • Polycystic Ovarian Syndrome
  • Macrosomia and other birth defects in newborn
  • Premature Ovarian Failure
  • Dermatological Complications (Acantosis Nigricans, Hirsutism , Dermatitis, Eczema, Ulcers, Alopecia etc)
  • Repeated Infections
  • Low Immunity
  • Fatty Liver, Gall Stones
  • Bronchiectasis, Emphysema
  • Pancreatitis
  • Sleep Apnea
  • Multiple Endocrine disturbances
  • Others

• Association with other Endocrine Disturbances

  Diabetes Mellitus is associated bi-temporally with other Endocrine (Hormone) Disturbances and diseases including :

  • Hypothyroidism
  • Hyperthyroidism
  • Obesity
  • Acromegaly
  • Cushing's syndrome
  • Pheochromocytome
  • Polycystic Ovarian Syndrome (PCOS)
  • Hirsutism
  • Low Testosterone in Men
  • High Testosterone in women
  • High Estrogen in Men
  • Abnormally low/high Estrogen and Progesterone in women
  • Low Dopamine
  • High Prolactin
  • High counter-regulatory hormones like Growth Hormone , Glucagon , Glucocorticoids
  • Abnormal IGF-1
  • High Aldosterone
  • Low DHEA
  • Low Vit D
  • Inappropriate Incretins effects
  • Abnormal Adipokines (Leptin, Adiponectin) effects.
  • Others

  Diabetes Mellitus management should therefore not be limited to Insulin management. The associated Endocrine and Systemic imbalances need to be corrected simultaneously.

• Association with other Autoimmune Disorders

  • Grave's Disease
  • Hashimoto's Disease
  • Pernicious Anaemia
  • Addison's Disease
  • Vitiligo
  • Cystic Fibrosis
  • Celiac Disease
  • Polyglandular diseases
  • Others

• Association with Genetic Disorders

  • Down's Syndrome
  • Turner's Syndrome
  • Kleinfelter Syndrome
  • Prader Willi Syndrome
  • Myotonic Dystrophy
  • Others

• Gestational Diabetes

  What is Gestational diabetes?

  • There occurs some physiological alteration in the carbohydrate metabolism in pregnancy.
  • Human pregnancy is characterized by Increased Insulin Resistance which helps to ensure a steady glucose supply to the fetus.
  • The hormones like human placental lactogen, Estrogen and progesterone contribute to this state.
  • If these alterations are exaggerated then there is abnormal glucose tolerance leading to "Gestational Diabetes".
  • Alternatively pregnancy may unmask an underlying pre-diabetic state.
  • GDM can be diagnosed by Glucose Tolerance Test.This can be done during the first visit and then repeated on 24 weeks and then 32-34 weeks.
  • 2 hrs GTT of more than 140mg/dl or above indicates GDM.
  • Obesity, Over weight, Family history of Diabetes are risk factors of developing GDM.
  • High occurrence in Asians.

  How does it affect the mother and the baby?

  • Excessive Fetal growth (big baby)
  • Obstructed labour.
  • Increased chances of developing Gestational Hypertension.
  • Increased mortality rate of mother and fetus.
  • Increased chances of developing overt Diabetes in mother (almost 50%).
  • Chances of Respiratory distress Syndrome in baby.
  • Increased risk of abortions.

  Is there any way to avoid it?

  • Weight Control.
  • Maintaining the calorie intake.
  • Small frequent meals during pregnancy (Balanced diet).
  • Avoid Obesity/Over weight before conception.
  • Stay active through out pregnancy.
  • Pre-conception screening and counselling.

  How is it treated?

  • Calorie Control 30-35 Calories/Kg of present weight.
  • 50-55% Carbohydrate, 20-25% Proteins and rest in form of fat.
  • Split the daily meals in 5-6 portions.
  • Insulin Therapy, whenever needed.
  • Normal physical activity plus graduated daily exercise like walking.
  • Monitor Body weight, Blood Pressure, Haemoglobin, Glycosylated Haemoglobin, Blood Sugar and other parameters.
  • Fetal development assessment by Ultrasonography.
  • Educate the patient and the family about GDM.
  • It needs to be a team approach comprising of Gynecologist, Diabetologist, Neonatologist, Trained nurse and Educator.

  Is it a common occurrence?

  • In developed countries the rate is almost 7%.
  • In developing countries Including India the prevalence is almost 16-17%.
  • It seems to happen almost equally in rural and urban areas in India.

• Investigations in Diabetes Mellitus

  • Investigations in Diabetes Mellitus do not simply end in monitoring the Blood Sugar levels (Fasting Blood Sugar , Post Prandial Sugar, Glucose Tolerance Test , Glycosylated Hb etc.).
  • Being a multisystem , metabolic and Endocrine disease influenced by Genetics and Life Style , the cause and complications should be investigated/monitored simultaneously.
  • The whole series of Clinical Systemic examination , Biochemical laboratory evaluation and Imaging parameters (Diagnostics and Screening) are key for successful management of Diabetes Mellitus.
  • The Occupational , Psychological , Social evaluation is equally important.
  • Diabetes Mellitus being a multisystem disease calls for the evaluation of all the systems of the body.
  • Diabetes Mellitus being a Metabolic disease calls for evaluation of the Metabolic profile.
  • Diabetes Mellitus being an Endocrine Disease calls for evaluation of all the related hormones.

• Genetic Testing for Diabetes Mellitus

  Who should do Genetic Testing ?

  • Family history of Diabetes Mellitus.
  • Vague symptoms of Diabetes Mellitus but Laboratory reports normal.
  • High risk ethnicity with unhealthy life style.
  • Obesity with no signs of Diabetes Mellitus.
  • Low birth weight babies.
  • Down's Syndrome.
  • Turner's syndrome.
  • Klinefelter's syndrome.
  • Other Genetic disorders.
  • Pre Marriage Counselling.
  • Pre natal Counselling and risk assessment.
  • Risk assessment in an individual with genetic testing.

• Diabetes Management

  • BLOOD SUGAR CONTROL

  1. Life style management

  2. Weight management

  3. Dietary management

  4. Medical Management (Including Insulin and Incretins)

  • Identification of Risk Factors.
  • Management of Metabolic factors including Hyperlipidemia and hypoproteinemia
  • Prevention of Complications
  • Balancing other Hormonal and Systemic disturbances
  • Diabetic Foot Management
  • Management of Cardiac Complications
  • Management of Neuropathy, Nephropathy, Retinopathy, Myopathy
  • Psychological management
  • Occupational and Social management
  • Management of Sexual Dysfunction including Erectile Dysfunction
  • Surgical management

  1. Metabolic/Bariatric Surgery

Questionnaires

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Complicating Factors in Diabetes

Diabetes signs and symptoms