Management of Diabetes Mellitus
Diabetes Mellitus is a chronic clinical syndrome characterised by Hyperglycaemia which is difficult to cure. Management is done for keeping blood sugar levels as close to normal (Euglycemia) as possible without giving undue complications to the patient. This can usually be done by close dietary management, exercise, & use of proper medications.
Aims of treatment :
Diabetes mellitus patients no longer die due to Ketoacidosis, but the major problem arises is invalidism of many of those whose duration of life has been extended. They live for several years with all forms of vascular disease like cerebral atherosclerosis, coronary insufficiency, peripheral vascular disease, renal disease, and serious visual impairment.
The ideal treatment for diabetes mellitus is to allow the patient-
• To lead a fully normal life
• To remain not only symptom-free but in positive good health
• To achieve a normal metabolic state, and
• To escape the complications with long-term diabetes.
Though the relation between the degree of control & the development of serious complications is not a simple task, it may give rise to vascular abnormalities secondary to the metabolic abnormalities occurring in diabetes, in both primary and secondary diabetes. Good health and sense of wellbeing are usually associated with a normal blood glucose level, combined with adequate nutrition of the patient.
Aims of treatment are therefore:
• The abolition of symptoms of diabetes while avoiding hypoglycaemia.
• The correction of hyperglycaemia and glycosuria.
• The achievement and maintenance of an appropriate body weight.
The success and failure of treatment depends upon the patient's realisation as early as possible & the doctor can only advise. Time must be given to educate the individual patient, and the doctor must take care of ensuring that his diabetic patients are educated to the limit of their abilities and that as for as possible they have adjusted fully to their condition & have sufficient knowledge to perform the day –to-day management of their diabetes completely.
As soon as the diagnosis is established the patient is asked that he has developed diabetes, he should be reassured, instructed and treatment starts. The average patient suffers from an acute reaction on being told that he has diabetes. If he realises what is wrong with him, why he has certain symptoms, and what he must do to correct the abnormalities present, it will be found that he is less afraid and more co-operative in following the regime of treatment.
Regimes of treatment :
There are three types of treatment and patient has to follow a dietary regimen for the whole of his life.
1. Diet alone.
2. Diet and oral hypoglycaemic drugs.
3. Diet and insulin.
• Approximately 40% of new cases of diabetes can be controlled by diet alone.
• About 30% require insulin.
• Another 30% will need an oral hypoglycaemic drug.
• A patient may pass from one group to another temporarily or permanently.
Diet in Diabetes mellitus :
In general the principles of treatment of all diabetic patients, especially those with insulin regimen, require some dietary restrictions if control is to be satisfactory. By regulating the times and amount of food intake particularly the carbohydrate intake, the dose of insulin, or oral hypoglycaemic drug, an attempt is made to achieve a flat profile of glycaemia throughout day and night. It is evident that if the intake of food varies from day to day it is rather impossible to work out steady insulin or other regime to cover it. So it is extremely important that patient must understand that this is the main region for dietary restriction. Often people have mistaken idea that the main purpose of dietary restrictions in their treatment is the avoidance of certain types of food which are bad.
To achieve affixed daily intake and avoid the monotony of a static diet sheet, some kind of exchange of food is necessary, and this is the basis of nearly all diets in use today.
The first step in making a dietary regimen is to map out a time table of the patient's day including a description of his usual meals. This is an essential step and is often omitted. The total daily requirement of calories must next be decided. The diet must be nutritionally adequate for the patient's needs, and it must be estimated for each and every patient after considering factors like age, sex, actual weight in relation to required weight, activity, occupation, and financial conditions. An average range for the different groups might be:
1. An obese, middle aged or elderly patient with mild diabetes requires 1,000- 1,600Kcal daily.
2. An elderly diabetic but not overweight, 1,400-1,800kcal daily.
3. A young, active diabetic, 1,800-3,000kcal daily.
It is important to maintain the body weight at or slightly below the ideal for the patient's height cannot be over-emphasised. So the calorie range of group 2 may be extended if it is not sufficient to maintain the body weight, and young patients in group 3 who are overweight may have to reduce their daily intake to below 1800kcal, temporarily only.
The proportion of calorie obtained from carbohydrate, protein and fat must be identified. The ratio in diets is protein 12%, fat 38% and carbohydrate 50%. The % of calories from carbohydrate may be reduced and those from protein increased if possible. In most diabetic diets, percentage of calories derived from carbohydrate should be roughly 40%, from protein about 15% and remaining 45% from the fat.
The daily carbohydrate intake advised ranges from the minimum sufficient to prevent ketonuria are 100gm daily, to a maximum 240-260gm. It is difficult to achieve satisfactory blood glucose level throughout the 24 hours with a daily carbohydrate intake more than maximum limit. A simple method of calculating the carbohydrate content of the diet is to know a figure equivalent to 1/10th of the total calories to carbohydrate, i.e. if the diet of 1800 kcal, about 180 gm carbohydrate provide 720kcal or 40% of the total.
The protein intake is accessed by socio-economic condition and often lowers than desired. The daily consumption of protein will often lie in the range of 60-110 g daily.
The fat intake to bring the total calories desired amount to 50-150 gm daily. The diet sheet & exchanges must be discussed with diabetic patient at regular interval.
Types of Diet :
Mainly there are two types of diet:
1. Measured diet: in which the amount of food to be eaten each time of the day is specified.
2. Unmeasured diet: in which a list of food is given to the patient which grouped in three types:
• Foods with a high carbohydrate are avoided altogether.
• Foods with relatively low carbohydrate content are eaten immoderate form only.
• Non carbohydrate foods may be eaten as desired.
• Alcohol: There is no medical objection to take alcoholic drinks in moderate quantity provided the patient realises that he must take account of their calorie value and sometimes of their carbohydrate content.
• Sweetening agents: are advised and they are so-called diabetic foods & drinks. Saccharin is a sweetening agent for many years having no calorie value. Sorbilol, a glucose derivative, and fructose are added to diabetic foods & drinks for sweetening purposes. In moderate quantities neither the action nor demands of insulin. If a patient has difficulty in reducing weight or in maintaining a normal weight, then the use of substitutes for sugar is discontinued. Diabetic chocolate has a high fat content and this must be taken into account.
Medical treatment of diabetes mellitus :
Diabetes mellitus is a chronic disease with no cure. Management of disease is done by close dietary management, exercise and use of proper medications. Insulin only in case of Juvenile-onset or type1 diabetes mellitus while oral anti-diabetic drugs may be used in maturity-onset or type2 diabetes as well as insulin.
Oral hypo-glycaemic drugs :
Sulphonylureas : stimulate pancreas to make more insulin.
Biguanides : decrease the amount of glucose produced by liver.
Thiazolidinediones : increases the sensitivity to insulin.
Alpha-glucosidase inhibitors-slows the absorption of starches consumed and slow down glucose production.
Meglitinides: stimulate pancreas to make more insulin.
D-phenylalanine derivatives : These agents stimulate the pancreas to secrete more insulin more quickly.
Amylin synthetic derivatives : Amylin is a naturally secreted hormone by pancreas along with insulin. Pramlintide (Symlin), a derivative of Amylin, is prescribed when blood sugar control is not achieved by optimal insulin therapy. Pramlintide is given sub-cutaneously along with insulin which to achieve lower blood sugar levels after meals, helps to reduce fluctuation of blood sugar levels throughout the day and improve haemoglobin A1c levels.
Incretin mimetics: enhance the insulin secretion by the pancreas and mimic other blood sugar level lowering that naturally occurs in the body. Exenatide (Byetta) is the first incretin mimetic agent which is indicated for diabetes mellitus type2 in addition to metformin or sulphonylurea, when these not control blood sugar level alone.
There is no method of giving insulin has been found which maintain the blood glucose within the normal range throughout the 24 hours without some risk of hypoglycaemia. It is usually possible to maintain the blood glucose within the required limit throughout the day & night without undue risk of hypoglycaemia, with one or more preparation of insulin. Different types of insulin are available and categorised according to times of action, onset and duration.
Rapid- acting insulin :
• Humulin R, Novolin R
• Insulin lispro (Humalog)
• Insulin aspart (Novolog)
• Insulin glulisine(Apidra)
• Prompt Insulin Zinc(semilente, slightly slower acting)
Intermediate-acting Insulin :
• Isophane insulin, Nentral protamine
• Hagidorn (NPH) Humulin N, Novolin N
• Insulin zinc(Lente)
Long-acting Insulin :
• Extended insulin zinc insulin(Ultra lente)
• Insulin glargine(Lantus)
• Insulin detemir (Levemir).