In this essay we will discuss about the Diabetes Mellitus:- 1. Meaning of Diabetes 2. Types of Diabetes 3. Clinical Features 4. Symptoms 5. Diagnosis 6. Management 7. Treatment 8. Choice of Therapeutics 9. Clinical Features of Ketoacidosis 10. Diseases Suffered 11. Problems in Management 12. Prognosis 13. Prevention.
Contents:
- Essay on the Meaning of Diabetes
- Essay on the Types of Diabetes
- Essay on the Clinical Features of Diabetes
- Essay on the Symptoms of Diabetes
- Essay on the Diagnosis of Diabetes
- Essay on the Management of Diabetes
- Essay on the Treatment of Diabetes
- Essay on the Choice of Therapeutics for Diabetes
- Essay on the Clinical Features of Ketoacidosis
- Essay on the Diseases Suffered by Diabetic Patients
- Essay on the Problems in Management of Diabetes
- Essay on the Prognosis of Diabetes
- Essay on the Prevention of Diabetes
Essay # 1. Meaning of Diabetes:
Diabetes mellitus is a syndrome due to different diseases characterized by a raised glucose concentration in the blood, due to diminished effectiveness of insulin. The disorder is chronic and also affects the metabolism of fat and protein. It has an increased risk of atherosclerotic diseases and of certain obstetrical difficulties.
It is the commonest endocrine disorder. There are two major types -Type 1 insulin dependent diabetes which was formerly known as juvenile onset diabetes occurring between 10 and 12 years of age. Type 2 non-insulin diabetes occur in middle age or later. Genetic and dietary factors, infections and possibly stress may increase the risk of developing diabetes.
Essay # 2. Types of Diabetes:
i. Primary Diabetes:
a. Genetic Factors:
Many separate genetic mechanisms increase the risk of diabetes and its various manifestations, and these differ in type 1 and type 2 diabetes.
b. Obesity:
Although most type 2 diabetics are obsese, only a minority of obese patients develop diabetes. In simple obesity there is insulin resistance, particularly in muscle, and hyper-insulinemia. There is impaired insulin uptake by receptors in target tissues.
In general, the more carbohydrate tolerance is impaired in obese diabetics, the more deficient the insulin secretory response to various stimuli. Obese people in general are less physically active than those whose weight is normal. It is possible that physical exercise may reduce the risk of diabetes in susceptible individuals.
c. Dietary Restrictions:
Restrictions on the food supply of community, affect diabetes. Rationing is beneficial to individuals susceptible to diabetes.
d. Sugar Intake:
A high intake of sugar is definitely associated with a high prevalence of obesity. Sucrose has a specific diabetogenic effect, though the very high intake may contribute to the high prevalence of diabetes.
e. Dietary Fibre:
The high fibre content of the diet causes the reduced prevalence of diabetes. Most diets now recommended for diabetics are high in fibre.
f. Infections:
Diabetes is frequently diagnosed by finding glucose in the urine with an acute staphylococcal or other infections. Infections cause a non-specific outpouring of catabolic hormones which antagonize insulin action and this may trigger the onset of the disorder.
More evidences show that type 1 diabetes especially in younger patients is caused by virus infection. The virus may trigger an autoimmune reaction in the pancreatic islets and this impairs insulin secretion and ultimately destroys the beta cells.
g. Stress:
Stress causes a sudden increase in secretion of catabolic hormones which may precipitate the disorder. It probably does not cause diabetes in people who would never have developed it. The impaired secretion by pancreatic islet cells may cause the disorder.
Many environmental factors may lead to such impairment. Genetic factors appear as the main determinant of susceptibility to such environmental factors, those leading to overweight and obesity being the most important in type 2 diabetes and viral infections in type 1.
ii. Secondary Diabetes:
A minor cases of diabetes occurs as a result of pancreatitis, haemochromatosis, carcinoma of the pancreas and pancreatectomy. Diabetes may also accompany endocrine disorders which increase concentrations of catabolic hormones or modify the regulation of insulin receptors.
Essay # 3. Clinical Features of Diabetes:
Type 1 Diabetes:
This usually appears in early age (between 10 to 12 years of age) in patients of normal or less than normal weight. Symptoms are usually severe and develop rapidly. Severe Ketoacidosis occurs and is often fatal without insulin treatment. Since insulin is required for their survival an alternative name for this patient is insulin dependent.
Type 2 Diabetes:
This usually appears in middle age or later in patients who are often obese and their hyperglycemia is controlled by dietary means alone or by an oral hypoglycemic drug. The patients are less prone to develop Ketosis. Therefore, type 2 is less severe disease than type 1.
Essay # 4. Symptoms of Diabetes:
(a) Some patients complain of some or all of the classical symptoms which are thirst, polyuria, nocturia, tiredness, loss of weight, reduced visual activity, white marks on clothing, polydipsia.
(b) Many patients are first found to have glycosuria in the course of some routine examination e.g., for insurance, for employment purposes. They may have few or no symptoms.
(c) Ketoacidosis may occur in diabetics in infection. Epigastric pain and vomiting may be the main complaints. These are usually type 1 diabetes.
(d) Patients may complain one of the symptoms like failing vision; parasthesia in the limbs or pain in the legs; impotence; infection of the skin, lungs or urinary tract.
Physical Signs:
There is dehydration, loose dry skin, dry furred tongue with cracked lips. The pulse is rapid and the blood pressure is low. Breathing may be deep and rapid. The sweet smell of acteone may be noticeable in the breath. There may be coma. Early signs of diabetic neuropathy are depression of the ankle jerks and impaired vibration sense in the legs. The presence of neuropathy may be indicated by proteinuria.
Essay # 5. Diagnosis of Diabetes:
Urine Testing:
(a) Glycosuria
(b) Ketonuria.
Random Blood Sugar:
The oral glucose tolerance test.
Essay # 6. Management of Diabetes:
Diabetic patients no longer die in Ketoacidosis in any number as they once did. The increased death rate of treated diabetic patients is due to coronary heart disease. Many of those whose duration of life has been extended are chronic invalids. They may live for many years with cerebral, coronary, or peripheral vascular disease, or with renal disease or serious visual impairment.
Essay # 7. Treatment of Diabetes:
i. Diet alone.
ii. Diet and oral hypoglycemic drugs.
iii. Diet and insulin.
About 40 per cent of new case of diabetes can be controlled adequately by diet alone, about 30 per cent require insulin and another 30 per cent need an oral hypoglycemic drug. Insulin is needed for juvenile diabetes; older patients do not require insulin except when control of their diabetes by an illness, infection or operation.
i. Diet:
(a) In all diabetics the amount and time of food intake, especially the carbohydrate, should be controlled to prevent the fluctuations of blood glucose beyond the normal range.
(b) Intake of refined sugars should be low because their consumptions is followed by absorption and a high peak of blood glucose.
(c) Patients should avoid fasting or feasting; their intake from day to day should be maintained with adjustments for exercise and appetite; they should not miss a meal or over-indulge.
(d) Type 1 patients require insulin and their food, particularly carbohydrate, should be adjusted to match the time of action of their insulin. This depends on the type of insulin being used and whether the patient is having a single injection or more than one each day.
The balance between insulin and meals has to be adjusted from time to time. They usually want to take moderate and sometimes strenuous exercise. They, therefore, require a generous amount of dietary energy.
(e) Type 2 patients are usually obese. Being middle aged or elderly they may not take much exercise. For these reasons the daily energy intake should be restricted to about 1,000 k cal. The flying career of airline pilots depends on avoiding insulin or drugs.
(f) The nature of carbohydrate is important. Sucrose should be eliminated or greatly reduced. Starchy foods rich in dietary fibre are beneficial to diabetics. There are two essential points about a diabetic diet. First, energy intake should be adjusted to maintain ideal body weight. Secondly, all patients taking insulin should follow a regular pattern of meals, matched to the injected insulin.
(I) Carbohydrate:
(a) A minimum of 100 grams is needed to prevent ketonuria.
(b) Foods rich in sucrose and other sugars should be kept to a minimum.
(c) 60 grams of fructose should be taken a day; obese diabetics should not use fructose and sorbitol as they have the same energy value as other sugars. Although fructose may not raise blood glucose as much as sucrose or glucose, it may raise plasma triglycerides more.
(II) Protein:
Amino acids stimulate insulin secretion in both normal subjects and in those with type 2 diabetes. A smaller rise in blood glucose also occurs when carbohydrate is consumed along with protein. A minimum amount of about 50 grams of protein should be specified in all diabetic diets unless the patient is obese.
(III) Fat:
As diabetic patients have an increased risk of death from coronary heart disease and as this may be related to the amount of saturated fat in the diet, the total amount of fat should be restricted even in those who are not obese.
ii. Types of Diet:
There are two types of diet:
(a) Measured diet:
The amount of food to be eaten at each time of the day is specified.
(b) Unmeasured diet:
The patient is supplied with a list of foods grouped in three categories – foods with a high concentrated carbohydrate content which are to be avoided altogether, foods with a relatively stable un-concentrated carbohydrate content which are to be eaten in moderation only, and non-carbohydrate foods which may be eaten as desired.
iii. Alcohol:
Patients may take alcohol if they need to have energy value and carbohydrate content. Beer may contain 10 to 30 grams of carbohydrate per half litre and this provides 150 to 400 kcal depending on the strength of the beer.
iv. Sweetening Agents:
Saccharin and aspartate may be used but have no energy value.
v. Drugs:
A good number of compounds reduce hyperglycemia in patients who would require insulin. The sulphonylurea compounds, tolbutamide, chlorpropamide, glibenclamide, glipizide, gliquidone, metformin have a place in the management of 30 per cent of diabetic patients. It is dangerous to attempt to control juvenile-onset diabetes with these compounds.
vi. Insulin:
Most diabetics now manage with two injections daily, one before breakfast and one before the evening meal, each containing soluble and depot insulin.
(a) Soluble insulin:
This is a clear solution whereas depot insulin’s are cloudy. It begins to lower the blood glucose in 30 minutes: the effect is maximal in 4 to 6 hours and ends after 6 to 10 hours.
Soluble insulin is essential in the following circumstances:
1. For new cases with severe dehydration or Ketoacidosis.
2. For emergencies associated with ketosis, such as acute infection, gastroenteritis or some surgical operations.
3. For the treatment of nearly all young patients.
(b) Depot Insulin’s:
Depot insulin’s do not lower blood sugar before 5 to 6 hours; the effect is maximal at 8 to 14 hours and ends only after 20 to 30 hours.
Essay # 8. Choice of Therapeutics for Diabetes:
(a) All young patients who develop diabetes before the age of 40 years require treatment with insulin. The majority are best controlled by a combination of short-acting and intermediate-acting (depot) insulin injected twice daily, before breakfast and before the evening meal.
(b) Most patients developing the disease over the age of 40 years can be controlled by diet alone. Obese patients should be treated by dietary restriction and weight reduction but others may do well on dietary therapy alone. Insulin and the sulphonylureas increase the appetite and thus may increase weight and intensify disability.
(c) Those over the age of 40 who are not controlled by dietary measures alone usually respond well to sulphonylureas. If adequate control is not achieved by one drug, a combination of sulphonylurea and biguanide may be tried. If this fails, insulin is needed.
(d) Elderly patients who require insulin often do well with a small dose (20 units) of a depot insulin alone. But those who require more than 40 units a day should be given soluble insulin in addition.
Essay # 9. Clinical Features of Ketoacidosis:
The most common cause of Ketoacidosis is neglect of treatment due to carelessness, misunderstanding or illness. There is intense thirst and polyuria. Constipation, muscle cramps and altered visions are common. Sometimes, there is abdominal pain with or without vomiting. Weakness and drowsiness are commonly present.
The signs include dry tongue, soft eyeballs due to dehydration, hyperventilation indicated by rapid, deep, sighing respirations and rapid, weak pulse, with low blood pressure and acetone may be smelt in the breath. Sometimes there is abdominal rigidity and tenderness.
Ultimately, coma appears. Laboratory tests show heavy glycosuria and ketonuria, blood glucose usually between (360 and 720 mg/100 ml), and low plasma bicarbonate and blood pH.
Treatment of Ketoacidosis:
This condition should be treated with the utmost urgency in hospital. Intravenous therapy is required although the patient is able to swallow. Extracellular fluid is repleted first with sodium chloride infusions. It is better to give low dose insulin starting with 6 to 9 units per hour and halving the dose when the blood glucose has returned to normal.
In the majority of cases potassium therapy should be started from the outset. Intracellular fluid is replaced once the blood glucose has fallen below 250 mg/ 100 ml by infusing glucose solution. Intensive medical care is needed and the blood glucose, pH, electrolytes and ketones have to be monitored, hourly at first.
Essay # 10. Diseases Suffered by Diabetic Patients:
i. Vascular Disorders:
Atherosclerosis occurs commonly and extensively in diabetics. Diabetics are more prone to myocardial infarction and gangrene of the toes and feet at an earlier age than other people. The peripheral pulses in the legs are often diminished, ischaemic changes in the feet are frequently apparent.
Defective circulation in the legs results in the dangerous complication of gangrene. Diabetic gangrene usually starts in one foot. Toxic absorption from necrotic tissue and secondary infection may kill the patient unless the limb is amputated. Amputation of a toe, a foot or even a whole leg is sometimes necessary to save life.
ii. Cataract:
Cataract is more prevalent in old people having diabetes. Rarely a specific type of opacity of the lens occurs in diabetic children whose disease has not been adequately controlled.
iii. Infections:
Poor control of diabetes has lowered resistance to infection.
The following forms are especially important:
(a) Carbuncle:
The development of a carbuncle may unmask diabetes and may even precipitate ketosis and coma. Cleanliness is very important in the prevention of skin infection in diabetes. Once infection has occurred a suitable antibiotic is needed.
(b) Urinary Tract Infections:
The presence of glucose in the urine provides a favourable medium for the growth of bacteria. Intractable infections of the urinary tract frequently occur and for this reason catheterisation should be avoided. Once infection has been started treatment consists of controlling the glycosuria and the administration of suitable antibiotics.
(c) Pulmonary Tuberculosis:
In countries where this is prevalent all new diabetic patients should have a chest radiograph.
(d) Vulvitis:
Candida albicans is nearly always present in diabetic women. In the majority, the treatment is abolition of glycosuria which brings rapid relief.
Essay # 11. Problems in Management of Diabetes:
i. Children:
(a) Diabetes is not common in childhood, but when it occurs it is relatively severe and always requires treatment with insulin. The problem of matching the dose of insulin to the food intake raises practical difficulties.
(b) As the children should be growing, their energy requirements are large and difficulties arise in meeting them. It is important to make sure that the child does not become too fat because too much insulin can lead to excessive appetite and hence to obesity. It is better to encourage them to take responsibility of their own care. They should be trained to swim under supervised pools.
(c) Children are not expected to lead a steady life and their activities fluctuate unexpectedly. Excessive activity may result in hypoglycemia, and lethargy in hyperglycemia. Hyperglycemia may be caused by infectious disease. A combination of one of the depot insulin’s and soluble insulin before breakfast and a second dose of soluble insulin before supper.
ii. Pregnancy:
(a) Pregnancy in a diabetic woman carries certain risks. In the later stages, she may develop an excessive accumulation of amniotic fluid; in addition the fetus is sometimes unusually large leading to difficulty in labour. There is also an increased risk of her baby having a neural tube defect or other error in development. A planned pregnancy reduces the risk.
(b) A pregnant diabetic patient requires close supervision by a team consisting of physician, obstetrician, anesthetist, nurse and dietician. After the diagnosis of pregnancy, the patient should be seen at first fortnightly and later at weekly intervals. In the later stages of pregnancy, lactosuria occurs and may lead to confusion. Therefore, blood glucose estimation should be done by finger-prick.
(c) Nowadays, many pregnancies are allowed to go on to full term with improved glycemic control and caesarian section is less used.
iii. Diabetes and Surgery:
Any surgical operation causes a metabolic stress which the diabetic is less able to meet. The position is worse if there is tissue wasting with much breakdown of fat and protein. It is to be kept in mind that there is the need to provide an adequate supply of energy for the tissues and the need to be on the alert for acidosis. Diabetes is to be first diagnosed before operation.
Essay # 12. Prognosis of Diabetes:
The prognosis of diabetes has improved steadily since the introduction of insulin. It is difficult to estimate the prognosis of an individual patient because so many variable factors have to be considered. The incidence of the complications of diabetes is mainly related to the duration of the disease but probably also to the precision with which it has been controlled.
Essay # 13. Prevention of Diabetes:
Diabetes is a disease of the prosperous and in wealthy countries. It is one of the major health problems. Sufficient exercise and avoidance of excess diet have repeatedly been stated. Diabetes, like obesity and atherosclerosis, is likely to occur in persons who eat too much and exercise too little.