Diabetes - A Wake up Call for the 21st Century

The 6th Edition of the IDF Diabetes Atlas reports that the number of people living with diabetes rose to 382 million in 2013 and evidence shows that diabetes prevalence by 2035 will be nearly 600 million with diabetes and approximately 470 million will have impaired glucose tolerance. 1 in 8 people in the world, 1 billion people,will live with or be at risk of diabetes. 

                              
Bionic Pancreas to Control Blood Glucose

A recently published paper on a study by Boston University and Massachusetts General Hospital provides a boost to the global fight against diabetes. The Bionic Pancreas is a wearable experimental device that has passed the test of constantly monitoring blood glucose and automatically giving insulin or a sugar boosting drug as needed.

The device controls blood glucose in people with Type 1 Diabetes mellitus using doses of both insulin and  the blood glucose raising hormone, glucagon.

Unlike other artificial pancreas in the process of being developed that just correct high blood glucose, this one can also fix low blood glucose thereby imitating what a natural pancreas does.

The device has three parts, 2 cell phone sized pumps for insulin and sugar- raising glucagon and an IPhone wired to a Continuous Glucose Monitor. Three small needles go under the skin usually in the belly, to connect patients to the components which can be kept in the pocket.

The study results were published in the New England Journal of Medicine.

                                      New Causes of Neonatal Diabetes

Neonatal diabetes is diagnosed when a child is less than 6 months old and has added complications such as muscle weakness, learning difficulties and, at times, epilepsy.

A study from Exeter (UK) has revealed 2 new genetic causes of neonatal diabetes which affects  approximately 1 in 100,000 births and provides further insight into the formation of insulin producing beta cells in the pancreas.

Exeter is a leading centre for neonatal diabetes. Subjects were screened for mutations in genes important for human pancreatic development . Mutations were found which increase the number of known genetic causes of neo natal diabetes to 20. 

As well as shedding light on the genetic causes of the disease and providing answers for parents of children with this rare condition, this work helps to understand how the pancreas develops.

 Many people with diabetes can no longer make insulin and would benefit from therapies that replace insulin producing beta cells of the pancreas.

(Diabetes Update Spring 2014)

                                                 Islet Cell Transplant

The first successful islet cell transplant in the UK took place in 2005. Today it can be a life- saving therapy for those experiencing more than one severe hypo each year.

People who use insulin to control their blood glucose levels sometimes experience episodes of very low glucose or hypoglycaemia.Most people with Type 1 diabetes mellitus are able to manage these hypos because of the characteristic symptoms that tell them when their blood glucose is low such as feeling shaky, sweaty or anxious. 

These symptoms are very important because they urge people to manage each hypo thereby preventing their blood glucose levels from falling further which could have potential serious consequences.

Severe hypos can occur in anyone taking insulin but it is more likely to happen in people who have had diabetes for more than 15 years, and thosewho are unable to recognize the low blood glucose level – hypo unawareness.

There are several different medical approaches to help reduce the risk of having a severe hypo.

These include 

• The use of multiple injections of modern insulin  or
• The use of DAFNE(Dose Adjustment For Normal Eating) style education that help people match their insulin dose to the amount of carbs in each meal.
• Insulin pump therapy sometimes combined with continuous blood glucose monitoring can be helpful. 

For people who continue to experience more than one severe hypo each year, an islet celltransplant can be very beneficial and might help them regain control of diabetes. It can be life changing and at times life- saving. They are also suitable for kidney transplant patients who have Type 1 diabetes mellitus and poor blood glucose control.

Islet cell transplantation involves extracting the insulin producing islet cells from the pancreas of a deceased donor and implanting them in the liver of someone with Type 1diabetes mellitus. This minor procedure is usually done twice for each transplant patient and can be performed with minimal risk using a needle under local anaesthestic.

Most people who receive islet cell transplantation continue to take low dose insulin therapy so this is not seen as a cure for diabetes.

Benefits

• Reduces risk of severe hypos
• Leads to improved awareness of hypos
• Less variability in blood glucose levels
• Improved quality of life and reduced fear of hypos.

Risks include a small but increased risk of certain cancers, severe infections and other side effects related to medication needed to prevent the islet cells from being rejected by the body.

The following people might be suitable for an islet transplant:

• Those who have experienced two or more severe hypos within the last two years and have impaired awareness of hypos
• Those with a functioning kidney transplant who experience severe hypos and impaired hypo awareness or poor blood glucose control despite best medical therapy.

The following people are not suitable for an islet transplant:

• Those who need a lot of insulin a day – e.g more than 50 units a day for a 70 kg body weight.
• Who weigh over 85 kg
• Those with poor kidney function.

(balance – May – June 2013)

What is Type 2 diabetes?

India has been designated the ‘Diabetes Capital’ of the world with the maximum number of cases of diabetes and an equally large number of undetected cases. 

What is Type 2 diabetes?

Diabetes is a disease in which sugar builds up in the blood.


Type 2 diabetes is the most common type of diabetes. In Type 2 diabetes, your body makes insulin, but the insulin is either not enough or the body cannot use it, so glucose from the blood which is very necessary for energy cannot be used by the cells.

Why does Type 2 diabetes occur?

Type 2 diabetes can occur due to excess weight, low levels of activity, carbohydrate rich diet, or genes that run in the family - the familial tendency for diabetes is passed on from one generation to the next through genes. This is transmitted to the offspring even if they were born before the parents developed diabetes.

Why do Indians have a tendency for  insulin resistance?
It could be

• Genetic,  

• Due to  physical inactivity, 

• Consuming excess calories, 

• Obesity, especially around the waist,  

• Use of large amounts of saturated fats  

• Low intake of fruit and vegetable in the Indian diet 

What are the symptoms of diabetes?

Frequent urination, increased thirst, increased appetite, loss of weight, frequent infections, blurred vision, feeling of tiredness or fatigue , a burning sensation in the feet, losing feeling in your feet or getting a tingling sensation in the feet… are all symptoms of diabetes. 

However, many people with diabetes do not show any of these signs. So don’t wait for them. Consult your doctor for screening for diabetes, if you are at risk.

Am I at risk for diabetes?

The following are some of the risk factors for Type 2 diabetes:

• Being overweight or obese.  

• Age — being older than 45 

• Inactivity — exercising less than 3 times a week  

• Family history — having a mother, father, brother, or sister with diabetes 

• Race— It is more common among people of African, Asian or Latin American origin 

• Having a baby with a birth weight more than 9 pounds
• High blood pressure
• High cholesterol
• Abnormal results in an earlier diabetes test
• Having a history of heart disease or stroke

Many people show no symptoms before they are diagnosed with diabetes. So, if you are in the high risk group, you should get yourself tested routinely.

What is pre- diabetes?

Pre-diabetes is a condition where your blood glucose is higher than normal but is lower than the diabetes range. This puts you at risk of getting Type 2 diabetes and heart disease. 

However, you can reduce the risk of getting diabetes and even return to normal blood glucose levels with reasonable weight loss and moderate physical activity.

• If you are diagnosed with pre- diabetes, lose weight (5-10 percent of total body weight) through diet and through moderate exercise, such as walking 30 minutes a day, 5 days a week. 

• Pre-diabetes increases your risk for heart disease or stroke by 50 percent; so stop using tobacco and alcohol, and control high blood pressure and high cholesterol.

• If your blood glucose levels are within the normal range, it is reasonable to be checked every 3 years. If you have pre-diabetes, follow your doctor’s advice to check for Type 2 diabetes. 

People with pre-diabetes don’t often have symptoms. Some people have no symptoms at all! 

Stress and diabetes 

Acute physical and mental stress affects blood glucose levels.

During stress times, the body increases the levels of other hormones which do not allowinsulin to work effectively on glucose.

Nowadays, young adults  are under tremendous stress at work because of  irregular timing, pressure of deadlines, irregular meals, working at night  and lack of  physical exercise.

People are very busy with their lives  and face a lot of stress, anxiety and have unhealthy food habits such as depending on fast foods and packaged foods.

Lack of physical activity in school children along with overeating, eating large amounts of high-calorie food and the stress of school seem to be the reason for large increase in cases of diabetes among children.

Over- feeding  by parents and the resulting obesity in childhood leads to obesity in adulthood. Overfed children, who don't play and spend too much time in front of the computer and TV are prone to diabetes.

Lifestyle, lack of exercise, high carbohydrate diet, abnormal cholesterol levels lead to early diabetes.

Prevention of Type 2 diabetes

Control  your  weight.

Eat healthy. Avoid high-calorie/high-fat and high sugar diets.  Replace white bread, pasta and white rice with brown rice, millets and whole grain flour. Eat a lot of fresh fruits and vegetables and replace red meat with fish or white meat. 

Be active. Half an hour of cardiovascular activity daily like running or swimming is good.

Be aware.  Health education should start from the school level. Schools should conduct workshops to make students aware about the disease.  

 

Nurture your children. Children should not be allowed to take junk food and should be encouraged to increase physical activity.

No smoking. Restrict alcohol

Prevent obesity, especially central obesity and increased visceral fat due to physical inactivity.

Prevention begins right from pregnancy. Studies have shown that if the mother is undernourished then the risk for diabetes in the off spring is great. And if the mother is optimally nourished you can reduce that risk to a large extent.

Regular heath check- up is a must because if diabetes remains undiagnosed it can lead to severe complications.

Quality Care for People with Diabetes

The DAWN study that was initiated in 17 countries in 2001 provided startling evidence that managing diabetes was more than just blood glucose reading and medications. Diabetes care must also focus on personal issues of the individual, the health system and how society views the condition of diabetes.The study identified that to improve the health and quality of life of people with diabetes, there should be

• Better communication between them and their healthcare providers 

• Better communication among healthcare professionals 

• Promotion of effective self - management skills for people living with diabetes.

• Improved psychological care for people with diabetes.

“Not everything that can be counted counts, and not everything that counts can be counted” –Albert Einstein

Living with diabetes is not only about treatment and management, outcome and numbers, it also involves 

• How people with diabetes are coping 
• what is important to them
• The barriers they have to face every day while managing their condition and their life 
• Treating them with dignity and respect
• Listening carefully to what they say 
• Equipping them with the knowledge ,tools and relationships  with family friends and diabetes specialists for efficient self- management, health and well - being. 

A new needs model for diabetes.

People with diabetes should be able to cope with their condition and live a full healthy and productive life

Family and friends should provide emotional and practical support

Community should provide medical care and treatment, access to quality diagnosis, treatment, care, and information.

Lifestyle–People with diabetes should have the same opportunities to enjoy life as others.

Work/school – Show support for and understanding of the condition.

Society- a healthcare system, government and public willing to listen, change and be supportive of the condition.

The DAWN 2 study was initiated 10 years later with the goals of providing a better understanding and awareness of the potential impact that diabetes can have on the quality of life of people with diabetes and their family members.

It was found that people with diabetes

• Often find it difficult to accept, make and maintain life style changes,and
• Face some societal issues such as discrimination, intolerance, lack of community support and observance of rigid religious practices among others.

Results from India

India reported high scores on person centred care and strong support from family, community and healthcare teams,but scored poorly on self - monitoring, adherence and foot care. 

Indian respondents reported low participation in educational programs and very few people found participation useful. 

According to the study, areas that need to be dealt with include primary prevention, early diagnosis and treatment of diabetes, and concerns about the risk of hypoglycemia. Also reported are the need for more diabetes educators and nurses, access to psychologists, and better communication within the healthcare team.