Diabetes: the Silent Killer

Diabetes mellitus or simply known as DM refers to a group of common metabolic disorders that have a common presentation of hyperglycemia or high blood sugar level. There are several distinct types of diabetes mellitus that are caused by complex interaction between genetical and environmental factors. Some of the factors which can cause hyperglycemia are reduced insulin secretion (due to destruction of insulin producing cells in pancreas), insulin resistance, decreased glucose utilization, and increased glucose production.

It is estimated that in the year 2000 there were more than 175 million individuals with diabetes worldwide a significant rise of total number of approximately 30 millions in 1985. And it is estimated by using present trend of diabetes worldwide that by 2030 there will be more than 350 diabetes patients in the world and India will be leading in the total number of diabetes cases in the world (some people use the word “diabetes capital of the world”).

Diabetes can affect practically all the systems in our body as well as increase the risk of infection and delay healing/recovery after infection/injury. Diabetes commonly affects eyes (diabetic retinopathy is one of the leading cause of blindness throughout the world), kidneys, central nervous system, gastrointestinal and genitourinary system, cardiovascular system, lower extremities. All the systems are affected slowly and if the diabetic individual ignores (or in many cases complications of diabetes appear before diabetes is diagnosed and treatment commenced) the seriousness of the problem of diabetes, as it does not usually cause acute symptoms, it can slowly but steadily lead towards death of the diabetes patients without the patient realizing the outcome. That is the reason diabetes can be called a silent killer.

To prevent or delay the complications of diabetes and delay the fatal outcome of diabetes the most important is control of blood sugar level within normal limit 24 hours a day and to achieve the normal level of diabetes it is very important to follow the instructions and advice of treating physician or diabetologist properly. With the number of drugs available at present to treat diabetes, it is not difficult to maintain blood glucose level within normal limit and prevent/delay complications (both acute and chronic complication).

Prevent Exercise Problems in Diabetics

There may be high blood sugar or low blood sugar during and after exercise by diabetic patient, especially in type 1 diabetes. In patients with type 2 diabetes, exercise-related hypoglycemia is less common but can occur in individuals taking insulin.

A good diabetes and diabetic diet plan can help to reduce exercise related problem in diabetics. To prevent and avoid exercise-related hyperglycemia or hypoglycemia the following preventive precautions should be taken by the diabetic patients, especially by type1 diabetics while preparing for exercise:

1. Blood glucose should be monitored before, during, and after exercise and continue with exercise if blog glucose is within normal limit.
2. If the blood glucose is less than 100 mg per 100 ml of blood (5.6 mmol/liter), take carbohydrate (glucose, sucrose or other carbohydrates) before exercising.
3. Delay exercise if blood glucose is more than 250 mg per 100 ml of blood (14 mmol/liter) and ketones are present.
4. Reduce the doses of insulin, which should be based on previous experience, before exercise. The insulin should be injected into a non-exercising area like abdominal fat.
5. Every diabetic patient will have different exercise tolerance and should learn to adjust the requirement of glucose and insulin.

The asymptomatic cardiovascular disease generally appears at a younger age in type 1 as well as type 2 diabetes, there should be exercise tolerance testing for every patient with diabetes (both type 1 and type 2diabetes). Diabetic diet weight loss plan can help in delaying cardiovascular disease risk to a great extent.This exercise tolerance testing should be done with any of the following:

1. If the age of diabetic more than 35 years.
2. The duration of diabetes more than 15 years for type 1 diabetes and more than 10 years for type 2 diabetes.
3. Presence of micro vascular complications of diabetes like retinopathy, microalbuminuria, or nephropathy.
4. PAD (peripheral artery disease)
5. Other risk factors of coronary artery disease (CAD), or autonomic neuropathy.

N.B.: Untreated proliferative retinopathy is a relative contraindication to vigorous exercise, as this may lead to hemorrhage inside the eye or retinal detachment.

Emergency Loans & Health Care

Health care will be a tough task if there were no health insurance or medical insurance. In many countries health insurance is compulsory and in many countries it is not compulsory (or we can say health insurance is optional). Ideally health insurance should be compulsory due to the high cost of the health care these days. Health care is costly at present, especially in many developed countries and it is becoming dearer day by day. The high numbers of lawsuits (against medical professionals, hospitals, clinics and nursing homes) are also making the healthcare to skyrocket. Very few people can pay the high cost of health care from their own pockets. So health insurance is the only answer for the high cost of health care.

But health insurances unfortunately do not cover many non-health related expenses that have to be incurred by the person getting sick or the family or friends. The simple looking after of a sick person also need some expenditures, and these type of unexpected and unrelated (to health care) expenditures can be covered by emergency loans like Elastic. The emergency loans like Elastic are reliable and one can get it delivered at the doorstep within a day or two. You can get the emergency loans online and receive the cash (the emergency loans) at the comfort of your home. The emergency loans like Elastic can be of great value in time of emergency like medical emergency.

The emergency loans can also be used for other purposes other than emergency health care like repairing auto, repairing homes, pay bills and also to avid bouncing of checks (which can be a serious offence in some countries). In one simple term the emergency loans can be regarded as a way to stretch your paychecks. A simple drawback of emergency loans is the amount of the loan, which varies from a few hundred bucks to at the most few thousand bucks ($).

Importance of Exercise in Diabetes

For proper management of diabetes educating the patient about the disease (diabetes) is very important. The importance of patient education and proper understanding of the disease by the patient is essential part of management of diabetes. Understanding the diabetes and taking right steps is very important for long term management of diabetes. In the patient education the most important aspects are about the role of exercise and nutrition is very important, as well as little bit of understanding the disease itself and the mechanism of the development of the disease.

Role of exercise in diabetes management:

Exercise, especially regular aerobic exercise plays an important role in long term and proper management of diabetes. Exercise has multiple positive benefits in diabetes including reduction in risk of cardiovascular diseases or complications, in reducing blood pressure, maintenance of muscle mass, reduction in body fat, as well as weight loss.

Exercise also reduces blood sugar level (during and following exercise) in patients with type 1 or type 2 diabetes and in increasing insulin sensitivity. The ADA (American Diabetic Association) recommends 150 minute per week (which should be distributed over at least 3 days) of aerobic physical exercise. If patient is having type 2 diabetes, the exercise regimen should also include resistance training.

Caution during exercise:

Although there are several benefits of exercise, there may be problem of high or low plasma glucose (normally, insulin falls and glucagon rises during exercise) level during and after exercise, especially in type1 diabetes. This exercise induced hyperglycemia or hypoglycemia, depends on the pre-exercise plasma glucose, the circulating insulin level, and the level of exercise-induced catecholamines (mainly adrenalin and nor adrenalin). These are due to increased muscle activity during vigorous, aerobic exercise which greatly increases fuel requirements.

N.B.: If the circulating insulin level is excessive, this (relative hyper-insulinemia) may reduce glucose production in liver by decreased breakdown of glycogen to glucose, by decreased gluconeogenesis (production of glucose from non carbohydrate sources in liver) and by increased glucose entry into muscle, which may lead to hypoglycemia. Conversely if the insulin level is too low, there will be rise in catecholamines, which may increase the plasma glucose excessively, promote ketone body formation, and can lead to ketoacidosis.

Importance of Health Insurance

The importance of health insurance is known to all. You may live without life insurance, but it is difficult to live (even impossible if you are not rich) without health insurance. You can not find a person who does not suffer or who will not suffer from health problems in his/her life. Healthcare is becoming costlier day by day, especially in developed countries and it is difficult to afford health related expenses from own pocket and here is the need of health insurance or medical insurance.

Every individual (including myself) should have health insurance which covers most of the diseases. Choosing a right health insurance plan may be difficult due to the presence of numerous health insurance plans of many different health insurance companies and also due to large number of health or medical insurance plans of any single company. To choose a right health insurance plan you should find out about health insurance quotes of different plans and of different companies before you decide the right plan for you. It is prudent to do some research on different health insurance plans of different companies. We try to find out details for repairing out car, than why we should not find out details about health insurance plans, which will repair out body in future if need arises.

The importance of health insurance can be realized when any of your family member becomes sick and you don’t have a penny in your pocket, as I have experienced few months back. I dint have enough money when my father has to undergo operation, although not a major operation. But because of my health insurance plan I could overcome the difficulty easily. The same can be true to anybody. I would like to emphasize again that health insurance is more important than other insurance (but due respect to other insurances which also are very important in their own way).

Skin Manifestations of Diabetes

The commonest skin manifestation of diabetes mellitus is prolonged (protracted) wound healing time and skin ulcerations. The wound healing in diabetes is prolonged than usual is because of the high blood sugar level and also due to lower cell mediated immunity which makes it difficult for the body to fight organisms that may be present in the wound. Skin manifestations of diabetes, sometimes termed as “diabetic skin spots,” which begins as an erythematous area and evolves into an area of circular hyper pigmentation.

These lesions (diabetic skin spots) result from minor mechanical trauma in the pretibial (in the shin bone area) region and they are more common in elderly men with diabetes. Sometimes bullous diseases known as bullosa diabeticorum (shallow ulcerations or erosions in the pretibial region), are also seen.

Vitiligo also occur more frequency in patients with type 1 diabetes. Acanthosis nigricans which is hyper pigmented velvety plaques seen on the neck, axilla, or extensor surfaces of arms is sometimes a feature of severe insulin resistance and accompanying diabetes (type-1 diabetes). Generalized or localized erythematous plaques on the extremities or trunk and scleredema (areas of skin thickening on the back or neck at the site of previous superficial infections) are more common in the patients with diabetes. Lipoatrophy and lipohypertrophy can occur at insulin injection sites but are unusual with the use of human insulin. Xerosis and pruritus (itching) are common and both of these problems are relieved by skin moisturizers.

A rare skin manifestation of diabetes known as ‘Necrobiosis lipoidica diabeticorum’ is a rare disorder of diabetes generally predominantly affects young women with type 1 diabetes, neuropathy, and retinopathy. ‘Necrobiosis lipoidica diabeticorum’ usually begins in the shin bone area as an erythematous plaque or papules and gradually enlarges, darkened, and develop irregular margins, with atrophic centers and central ulceration. These lesions may be painful.

Infection in Diabetes Patients

Patients with diabetes have a greater frequency as well as greater severity of infection. The reasons for this greater frequency and severity of infection include abnormalities in cell-mediated immunity (although incompletely defined) and phagocyte function associated with hyperglycemia (high blood sugar level), as well as diminished vascularization. High blood sugar also aid colonization and growth of a variety of organisms (Candida and other fungal species are more common), by providing them with readily available food source.

Common infections are more frequent and severe in the diabetic patients. There are many rare infections seen almost exclusively in the diabetic patents. Examples of this (rare infections which are exclusive to diabetic patients) include rhinocerebral mucormycosis, emphysematous infections of the gall bladder and urinary tract, and “malignant” or invasive otitis externa. Invasive otitis externa (external ear) is generally secondary to Pseudomonus aeruginosa infection in the soft tissue surrounding the external auditory canal. This usually begins with pain and discharge, and which may rapidly progress to osteomyelitis and meningitis (both are very serious infection of bones and brain respectively). These infections should be investigated, in patients presenting with hypertropic hyperosmolar state of diabetes complication.

Pneumonia, urinary tract infections, and skin and soft tissue infections are more common in the diabetic patients. Urinary tract infections (UTI), either lower urinary tract or pyelonephritis, are generally the result of common bacterial agents such as Escherichia coli. But sometimes several yeast species (Candida and Torulopsis glabrata) may also cause UTI.

Complications of urinary tract infections are pyelonephritis and cystitis, both of which are emphysematous. Bacteriuria (bacteria in urine) occurs frequently in individuals with diabetic cystopathy. Susceptibility to furunculosis, superficial candidal infections, and vulvovaginitis are more in diabetes patients. Poor glycemic control is a common cause in individuals with these infections. Diabetic individuals have an increased rate of colonization of S. aureus in the skin folds. Diabetic patients also have a higher risk of postoperative wound infections. Strict glycemic control reduces postoperative infections in diabetic individuals undergoing coronary artery bypass grafting (CABG) and should be the goal in all diabetic patients with an infection.

Generally the organisms that cause pulmonary infections are similar to those found in the non-diabetic population.

Effective Weight Loss

In obese individuals weight loss may be a big problem. If you are obese, you may have tried many formulae for weight loss, but may not have succeeded in reducing body weight to normal or regained lost body weight after sometime. You may have tried many herbal and other natural formulae to reduce weight, but without desired result. Maintaining body weight to normal after loosing it is a big challenge for all the weight loss treatment regimens.

If you are in the above mentioned category you should try trusted, proven and approved (by competent government authority) medication for weight loss. Diet pills like orlistat or Alli (trade name of orlistat are alli, xenical etc.) is USFDA (United States Food & Drug Administration) approved for treatment of obesity. It is proven in many clinical trials to reduce body weight in obese individuals. Alli is prescribed by many doctors as part of weight loss management along with a good diet plan and regular physical exercise. Combination of diet and exercise can make weight loss faster and sustainable after losing it. If only alli is taken without diet and exercise the result of weight loss may not be up to what is desired and may take much longer time to reduce weight. The dose of orlistat may also be more than what will be required if combined with exercise and diet. If dose of Alli is highr the side effects will also be higher.

The common side effects of Alli are nausea, flatulence (air in stomach and intestine) or bloating, pain and discomfort in abdomen, fatty diarrhea etc. Another side effect of Alli is deficiency of fat soluble vitamins (vitamin A, D, E and K are fat soluble), which is due to reduced absorption fats during treatment with orlistat (alli). The side effects of alli are generally mild and adjusted easily or may go away if continued for sometime.

Lower Extremity Complications in Diabetes

Diabetic complications of lower extremities are a major problem among chronic long duration sufferers of diabetes. Diabetes is the leading cause of non traumatic amputation of lower extremities in United States as well as in many other countries. Other than amputation foot ulcer and infections are also major problems in diabetes and cause of morbidity.

Causes of lower extremity problems in diabetes:

There are several factors which are responsible for the development of lower extremity complications in diabetes such as neuropathy, abnormal foot biomechanics, PAD (peripheral artery diseases), and poor wound healing. Due to peripheral sensory neuropathy there is interference of normal protective mechanisms which allows the patient to sustain major or repeated minor trauma to the foot, often without knowledge of the injury, similar to the injuries sustained in leprosy.

There is abnormal weight bearing while walking which subsequently leads to formation of callus or ulceration. Motor and sensory neuropathy lead to abnormal foot muscle mechanics and to structural changes in the foot like hammer toe, claw toe deformity, prominent metatarsal heads, Charcot joint etc. Autonomic neuropathy results in altered superficial blood flow in the foot, which causes drying of the skin and fissure formation. Peripheral artery diseases and poor wound healing prevent resolution of minor breaks or wounds in the skin which allows them to enlarge and to become infected.

Approximately 15% of diabetic patients develop a foot ulcer (great toe area is most common), and a significant percentage of them will ultimately undergo amputation (up to 25% of the diabetics who develop foot ulcer will ultimately undergo amputation).

Risk factors for foot ulcers or amputation are as follows:

Male sex, diabetes of more than 10 years duration, peripheral neuropathy, and abnormal structure of foot (bony abnormalities, callus, thickened nails etc.), peripheral arterial disease and smoking, history of previous ulcer or amputation, and poor glycemic control are the risk factors for development of foot ulcer. Large callouses are often precursors to ulcerations.

Screening of Diabetes

The prevalence of diabetes mellitus is increasing as well as incidence of diabetes throughout the world; especially in some countries it is becoming alarming. The incidence of diabetes is increasing throughout the world, in some countries it is fast becoming sort of endemic and in some countries the increase in incidence is not much. Within a country also the rate of increase and prevalence is not same; in some regions it is highly prevalent whereas in some regions its prevalence is less. Because of the high prevalence of diabetes, the screening of diabetes is recommended.

The following are the reason why diabetes screening should be conducted routinely:

1. A large percentage of individuals who meet the current criteria for DM (diabetes mellitus) are not symptomatic and they are unaware that they have diabetes.

2. Many epidemiologic studies suggest that type 2 diabetes may be present for up to a decade before diagnosis is made and till that time they are asymptomatic and slowly develop complication without their knowledge.

3. Up to 50% of individuals with type 2 diabetes have one or more diabetes-specific complications at the time of diagnosis of diabetes.

4. With appropriate treatment of type 2 diabetes it is possible to favorably alter the natural history of diabetes. So screening is helpful.

Fasting plasma glucose (FPG) level should be strongly recommended if an individual has any of the following factors:

1. Family history of diabetes, especially any first degree relative (parents or sibling) with type 2 diabetes.

2. Obesity with a BMI (body mass index) of more than 25.

3. Previously identified IFG (impaired fasting glucose) or IGT (impaired glucose tolerance).

4. Race/ethnicity like African American, Latino, Native American, Asian American, Pacific Islander etc. are more prone to develop diabetes.

5. Habitual physical inactivity.

6. If individual is hypertensive and have high HDL cholesterol and/or a triglyceride level.

7. Birth weight more than 4 kg or 9 lb.