Action Diabetes - The need of the hour

As per WHO's estimates, over 170 million people have diabetes mellitus worldwide, and this number may double by the year 2025. Much of this increase will occur in developing countries. Aging, unhealthy diets, obesity and sedentary lifestyles are causes for this increase. In Kuwait it is estimated that 1 out of every 5 adults has diabetes. Unfortunately many of these diabetics do not know they have the disease. Even in a developed country like USA, it is estimated that there are about 6 million undiagnosed diabetics. World over, WHO estimates that upto 50% are undiagnosed. Diabetes is associated with long-term complications that affect almost every part of the body. The disease often leads to blindness, heart and blood vessel disease, strokes, kidney failure, amputations, and nerve damage. Uncontrolled diabetes can complicate pregnancy, and birth defects are more common in babies born to women with diabetes.

Diabetes is not a new disease and it is not confined to any region or race. Arataeus of Cappadocia in Asia Minor is usually credited to its first description in the first century AD. He gave the disease its name. Diabetes refers to water passing through a siphon. However centuries earlier the ancient Indian Physicans Charak and Susrutha, had described a disease 'Madhumeha' (honey like urine) .The ancient Indians noticed ants congregating around the urine of diabetics. The seventeenth century Oxford physician, Thomas Willis is credited with the discovery of the sweet taste of the urine. Avicenna ( Ibn Sina), an Arab physician of the eleventh century, described many of the clinical features. Similar observations were also made in China in the seventh century AD by Chen Chhuan, who gave a good description of the main features, including the sweet urine.

What Is Diabetes?
Diabetes is a disorder of metabolism--the way our bodies use digested food for growth and energy. Most of the food we eat is broken down into glucose, the blood sugar. Glucose is the main source of energy for the body. After digestion, glucose passes into the bloodstream, where it is used by cells for growth and energy. For glucose to get into cells, insulin must be present. Insulin is a hormone produced by the pancreas, a gland in the abdomen. When normal people eat, the pancreas automatically produces the right amount of insulin to move glucose from blood into our cells. In people with diabetes, however, the pancreas either produces little or no insulin, or the cells do not respond appropriately to the insulin that is produced. Thus, the cells of the body are starved for energy even though the blood contains large amounts of glucose. Glucose builds up in the blood, overflows into the urine, and passes out of the body.
There are three main types of diabetes
• Type 1 diabetes
• Type 2 diabetes
• Gestational diabetes
Some rare conditions also lead to elevation of blood sugar and diabetes.


Type 1 diabetes
In this type of diabetes, there is destruction of the insulin-producing beta cells in the pancreas. The pancreas then produces little or no insulin. People with type 1 diabetes need to take insulin daily to live. Autoimmune, genetic, and environmental factors, possibly viruses, may be involved in the destruction of the beta cells of pancreas leading to insulin deficiency. Type 1 diabetes accounts for about 5 to 10 percent of diagnosed diabetes in the Caucasians and to a lesser extend in the other races.
Type 1 diabetes develops most often in children and young adults, but the disorder can appear at any age. Symptoms of type 1 diabetes usually develop over a short period, although beta cell destruction can begin years earlier as in LADA( Latent Autoimmune Diabetes in Adults) . Symptoms include increased thirst and urination, constant hunger, weight loss, blurred vision, and extreme fatigue. If not diagnosed and treated with insulin, a person can lapse into a life-threatening diabetic coma, also known as diabetic ketoacidosis.


Type 2 diabetes
The most common form of diabetes is type 2 diabetes. About 90 to 95 percent of people with diabetes have type 2. This form of diabetes usually develops in adults and the risk increases as one gets older. About 80 percent of people with type 2 diabetes are overweight. Type 2 diabetes is often part of a metabolic syndrome that includes obesity, elevated blood pressure, and high levels of blood lipids. Unfortunately, as more children and adolescents become overweight, type 2 diabetes is becoming more common in young people.

Type 2 diabetes develops gradually and derangement may be present in other metabolic parameters like the blood lipids before the blood sugar becomes high. Clinical diabetes is only like the tip of the iceberg as in the illustration above. When type 2 diabetes is diagnosed, the pancreas is usually producing enough insulin, but the body cannot use the insulin effectively, a condition called insulin resistance. After several years, insulin production decreases also. Some people have no symptoms. Others may have fatigue, frequent urination, unusual thirst, weight loss, blurred vision, frequent infections, and slow healing of wounds. Certain races including the Indians and Arabs are more at risk for this type of diabetes

People with prediabetes, a state between "normal" and "diabetes," are at risk for developing diabetes, heart attacks, and strokes. There are two forms of prediabetes, Impaired Fasting Glucose (IFG) and Impaired Glucose Tolerance(IGT) as per the values shown above.
It has been shown that majority of prediabetics can be prevented from developing diabetes by life style changes involving consumption of proper diet, losing weight, exercise and avoiding stress and certain medicines that adversely effect blood sugar. Medicines that augment the action of Insulin present in the body also have been shown to be helpful.

Management of Diabetes
Before the discovery of insulin in 1921, everyone with type 1 diabetes died within a few years after diagnosis. Although insulin is not considered a cure, its discovery was the first major breakthrough in diabetes treatment.
Today, healthy eating, physical activity, and insulin are the basic therapies for type 1 diabetes. The amount of insulin must be balanced with food intake and daily activities. Blood glucose levels must be closely monitored through frequent blood glucose checking.
Healthy eating, physical activity, and blood glucose testing are the basic management tools for type 2 diabetes. In addition, many people with type 2 diabetes require oral medication or/and insulin to control their blood glucose levels.
People with diabetes must take responsibility for their day-to-day care. Much of the daily care involves keeping blood glucose levels in the normal range. When blood glucose levels drop too low a condition known as hypoglycemia--a person can become nervous, shaky, and confused. Judgment can be impaired. If blood glucose falls too low, a person can become unconscious. A person can also become ill if blood glucose levels rise too high.
The goal of diabetes management is to keep blood glucose levels as close to the normal range as safely possible. A major study in USA, the Diabetes Control and Complications Trial (DCCT), showed that keeping blood glucose levels as close to normal as safely possible reduces the risk of developing major complications of type 1 diabetes.
The United Kingdom Prospective Diabetes Study (UKPDS) showed that intensive control of blood glucose and blood pressure reduced the risk of blindness, kidney disease, stroke, and heart attack in people with type 2 diabetes. For each 1% reduction in updated mean HbA1c (indicator of blood sugar level over the past 3 months) there was reduction of 21% for deaths related to diabetes 14% for myocardial infarction and 37% for microvascular complications. Treatment of co-existing conditions like high blood pressure and cholesterol are also very important. Each 10 mm Hg decrease in systolic blood pressure was associated with reductions of 15% for deaths related to diabetes, 11% for myocardial infarction and 13% for microvascular complications.
It is dangerous for diabetics to smoke as the vascular complications and amputations are more in them.

Can diabetes be prevented?
Researchers continue to search for the cause or causes of diabetes and ways to prevent and cure the disorder. Scientists are looking for genes that may be involved in type 1 or type 2 diabetes. Some genetic markers for type 1 diabetes have been identified, and it is now possible to screen relatives of people with type 1 diabetes to see if they are at risk.
Type 2 diabetes is preventable to a large extent. The incidence of diabetes is much more in the offspring, if both the parents are diabetic or prediabetic than if only one parent is diabetic. So marriage between two diabetics should be avoided.
It has been shown in several studies that weight reduction decreases the incidence of diabetes.
In a large prospective study involving more than 200,000 overweight subjects, overweight but otherwise healthy people who lost weight intentionally reduced their diabetes risk by nearly one-fourth. There was a 21 % reduction in rates of diabetes in men and a 28% reduction in women. Men who gained weight unintentionally had a 33 % increased rate of diabetes, and women had a 56 % increase. In case of men for every 20 lbs or 9-kg that they lost they reduced the rate of diabetes by 11 %. In the case of women for every 20 lbs or 9-kg that they lost there was a 17 % fall in the rate of diabetes.
Smoking may have a role in the development of type 2 diabetes and is also related to the premature development of morbidity and premature death associated with the development of macrovascular complications and microvascular complications of diabetes.
Some of the medicines used for other diseases may precipitate diabetes. The Finnish Diabetes Study showed that life style modification in people who have IGT produced a 58% reduction in incidence of the disease.
The cumulative incidence of diabetes after four years of participation in the study was 22% in the control group and only 10% in the intervention group. There are also medicines like Metformin, which reduced the incidence of diabetes by over 30%, in those with IGT.



Recent Advances
Transplantation of the pancreas or insulin-producing beta cells offers the best hope of cure for people with type 1 diabetes. Recently, researchers at the University of Alberta in Edmonton, Canada, announced promising results with islet transplantation in patients with type 1 diabetes.
Other advances in diabetes research have led to better ways to manage diabetes and treat its complications. Some of these are
• The development of insulin analogs.
• Better ways to monitor blood glucose and for people with diabetes to check their own blood glucose levels.
• Laser treatment for diabetic eye disease, reducing the risk of blindness.
• Successful transplantation of kidneys and pancreas in people whose own kidneys fail because of diabetes.
• Better ways of managing diabetes in pregnant women, improving chances of successful outcomes.
• New drugs to treat type 2 diabetes and better ways to manage this form of diabetes through weight control.
• Evidence that intensive management of blood glucose reduces and may prevent development of diabetes complications
• Demonstration that drugs called ACE (angiotensin-converting enzyme) inhibitors prevent or delay kidney failure in people with diabetes.
Medical Nutrition Therapy based on Glycemic Index ( GI), Glycemic Load ( GL) and Glycemic response of the different foods have enabled diabetics eat wholesome food and at the same time maintain better blood glucose control. Research is required to determine these values of the common foods consumed in Kuwait and to modify foods to decrease these values.
In the future, it may be possible to administer insulin through inhalers, a pill, or a patch. Devices are also being developed that can monitor blood glucose levels without having to prick a finger to get a blood sample.

Since diabetes is a common disease that can produce devastating complications every effort should be made to detect it early and treat adequately.
It is possible to detect the disease in the pre-diabetic stages (IFG and IGT). "A stitch in time saves nine"
Those above the age of 40years, are obese, lead a sedentary life or are stressed or have a family history of diabetes or have high blood pressure or high cholesterol are at risk of developing diabetes. It is better that pregnant women are screened as the incidence is higher in our community and it increases with the age. Screening for pre-diabetics and diabetics and research into the different aspects of the disease including diet, prevention and a possible cure are indeed a need of the hour.