Navigate diabetes concerns with Meri Sehat. Discover comprehensive insights and effective strategies to manage sugar levels. T

diabetes

Navigate diabetes concerns with Meri Sehat. Discover comprehensive insights and effective strategies to manage sugar levels.

Diabetes

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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

Overview

The International Diabetes Federation (IDF) defines diabetes as a chronic disease characterized by the pancreas&#39;s inability to produce insulin, or the body&#39;s inability to use the produced insulin<a href="#accordion">[1]</a>.

According to the organization&#39;s latest figures, approximately 537 million people worldwide are suffering from diabetes<a href="#accordion">[2]</a>. This roughly translates to 1 in 10 individuals. Moreover, the incidence of the disease has significantly increased in low- and middle-income countries.&nbsp;

Its increasing prevalence has made diabetes one of the leading causes of death across the globe. In 2021, 6.7 million deaths occurred as a result of diabetes<a href="#accordion">[2]</a>.&nbsp;

While the numbers have increased worldwide, Pakistan has seen a 70% increase in cases since 2019. Although the whole country is affected by diabetes, the province of Sindh has demonstrated the highest prevalence, and Khyber Pakhtunkhwa has the lowest<a href="#accordion">[3]</a>.&nbsp;Furthermore, with 33 million adults suffering from diabetes, the country has the highest national prevalence in the world<a href="#accordion">[2]</a>. 
&nbsp;

Although there are different types of diabetes, all are characterized by elevated levels of glucose in the bloodstream. The main types are:

&nbsp;

<ul dir="ltr">
	<li>Type 1 Diabetes Mellitus - Also called &#39;juvenile&#39; diabetes, the autoimmune disease most commonly appears in children and young adults. It accounts for 10% of all diabetes cases<a href="#accordion">[1]</a>. The body&#39;s immune cells end up attacking the pancreas beta cells that are responsible for producing insulin. Thus, resulting in a lack of the hormone.&nbsp;</li>
</ul>

&nbsp;

<ul dir="ltr">
	<li>Type 2 Diabetes Mellitus - More than 95% of all diabetes cases are type 2<a href="#accordion">[4]</a>. It usually occurs in older adults and is also called adult-onset diabetes. The increasing prevalence of type 2 diabetes is often blamed on the lack of physical activity, increasing levels of obesity, and urbanization.</li>
</ul>

&nbsp;

<ul dir="ltr">
	<li><a href="https://merisehat.pk/disease/diabetes-gestational">Gestational Diabetes</a> (GDM) - Gestational diabetes develops in women during pregnancy and often leads to maternal and fetal complications. However, it usually disappears after pregnancy.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Prediabetes - This is a condition characterized by high blood glucose levels, but not high enough to be diagnosed as type 2 diabetes. However, these people are at a higher risk of developing type 2 diabetes and cardiovascular disease. In Pakistan, the prevalence of prediabetes was found to be approximately 11%<a href="#accordion">[3]</a>.</li>
</ul>

&nbsp;

Signs And Symptoms

Elevated blood glucose levels can manifest themselves in various ways depending on the type of diabetes. Common symptoms for both type 1 and type 2 include:

<ul>
	<li>Polydipsia (increased thirst)</li>
	<li>Polyuria (increased urination)</li>
	<li>Polyphagia (increased hunger)</li>
	<li>Blurry vision</li>
	<li>Frequent infections</li>
	<li>Delayed healing of wounds like sores or cuts</li>
	<li>Dry mouth</li>
	<li>Numbness or tingling in hands or feet</li>
	<li>Fatigue</li>
	<li>Unexplained weight loss</li>
</ul>

&nbsp;

Women with diabetes often complain of dry and itchy skin, urinary tract infections, and yeast infections. Whereas men frequently experience erectile dysfunction, decreased sex drive, and decreased muscle strength.&nbsp;

In type 1 diabetes, symptoms develop all of a sudden, mostly as a child or young adult. Nausea, vomiting, and stomach pain are common in type 1 diabetics. Moreover, most people present with diabetic ketoacidosis which is an emergency condition characterized by hyperglycemia, ketoacidosis, and ketonuria.&nbsp;

Unlike type 1 diabetics, people with type 2 diabetes are mostly obese or overweight adults. However, due to rising levels of physical inactivity and poor diet, type 2 diabetes is increasingly occurring in children and young adults. They may remain asymptomatic for years before developing symptoms such as recurrent infections and slow healing.

&nbsp;

Causes

The beta cells of the pancreas are responsible for producing the hormone, insulin. Insulin helps cells take up glucose from the bloodstream and convert it into energy. However, the lack of insulin (due to the destruction of beta cells) or an inability of the cells to respond to insulin (insulin resistance) causes an accumulation of glucose in the blood. As a result, the blood glucose levels become elevated (hyperglycemia).&nbsp; 
&nbsp;

Autoimmune destruction of the beta cells in type 1 diabetes involves a combination of genetic and environmental factors. Multiple genes may be involved in bringing about the condition; however, the risk is increased for those with a parent or sibling with type 1 diabetes. Moreover, certain viruses such as mumps, rubella, and enterovirus can also trigger immune-mediated destruction of beta cells.

Individuals with type 2 diabetes are mostly obese which further contributes to insulin resistance. Due to the cells not responding to the hormone, the blood glucose levels become elevated. However, higher blood glucose levels do not result in high insulin levels. Instead, beta cell dysfunction results in reduced insulin secretion. Although genetic factors also play a role in the development of type 2 diabetes, the exact mechanism remains unclear.&nbsp;

&nbsp;

In Pakistan, more than 26.9% of adults living with diabetes are undiagnosed<a href="#accordion">[2]</a>. The delay in diagnosis can further increase one&#39;s risk of complications and reduce their quality of life. Therefore, people with symptoms or risk factors for diabetes should be routinely screened for the condition. There are several screening tests for both type 1 and type 2 diabetes.

The American Diabetes Association (ADA) recommends that people aged 45 and above undergo screening for diabetes type 2 every three years. Especially, if they are overweight or obese, have hypertension, or suffer from high cholesterol. Moreover, women who have had gestational diabetes and overweight children with risk factors of diabetes should also undergo screening for type 2 diabetes.

The following tests are used to screen for diabetes: 
&nbsp;

Fasting Plasma Glucose Test (FPG) - The test is typically conducted in the morning after a fast of 8 hours. Normal levels are between 70 and 100mg/dl. However, in diabetes, the levels can go to 126mg/dl and higher. Two separate blood tests should reveal elevated levels for a diagnosis of diabetes.

Hemoglobin A1C Test (HbA1C) - This helps determine an individual&#39;s diabetes control over 3 months. A value of 6.5% or higher is often enough to diagnose one with diabetes.

Random Blood Sugar Test - It is a primary screening test for type 1 diabetes and does not require an 8-hour fast. Instead, a blood sample is taken at a random time. Levels of 200mg/dl or higher suggest diabetes.&nbsp; 
&nbsp;

Researchers do not recommend screening for type 1 diabetes in asymptomatic low-risk individuals. However, those with multiple risk factors should undergo yearly screening for anti-islet antibodies. Moreover, if someone (adult or child) presents with ketoacidosis, they should be tested for diabetes.

&nbsp;

Diagnosis

As per the American Diabetes Association, the following are the diagnostic criteria for diabetes<a href="#accordion">[5]</a>:

<ul>
	<li>FPG levels of 126mg/dl or higher, or</li>
	<li>2-hour plasma glucose levels of 200mg/dl or higher</li>
	<li>Random plasma glucose levels of 200 mg/dL (11.1 mmol/L) or higher in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis</li>
</ul>

&nbsp;

To distinguish between type 1 and type 2 diabetes, doctors test for diabetes-specific autoantibodies such as anti-insulin, islet-cell, and anti-GAD65 autoantibodies.

&nbsp;

Treatment

Treatment aims to keep an individual&#39;s blood glucose levels within the normal range. This is accomplished by a combination of medications, insulin therapy, and lifestyle changes.

&nbsp;

Insulin Therapy: Individuals with type 1 diabetes require lifelong insulin therapy. There are four types of insulin, and most people require 2 or more daily injections. The doses are often adjusted based on the person&#39;s blood glucose levels.&nbsp; 
&nbsp;

<ul>
	<li>Rapid-Acting Insulin - As the name implies, the insulin works rapidly, within 15 minutes of administration, and its effects can last for 3-4 hours. People often administer it before meals. Examples include glulisine, aspart insulin, and lispro.&nbsp;</li>
	<li>Short-Acting Insulin - Also called regular insulin, it starts to work around 30 minutes after injection and lasts for 4-6 hours. Both rapid-acting and regular insulin are effective at controlling post-meal hyperglycemia.&nbsp;</li>
	<li>Intermediate-Acting Insulin - This includes NPH insulin that has a slower onset of action compared to others (within 1-2 hours), but a longer duration of action. Its effects can last for 12-24 hours.&nbsp;</li>
	<li>Long- And Ultra-Long-Acting Insulin - These types of insulins help keep stable glucose levels for more than 24 hours. Examples include glargine and detemir.&nbsp;</li>
</ul>

Insulin may be delivered via subcutaneous injections or an insulin pump that helps deliver specific amounts of the hormone throughout the day. Common side effects of insulin therapy include hypoglycemia, high triglycerides, and diabetic ketoacidosis.&nbsp;

&nbsp;

Diabetes Medications: In type 2 diabetes, individuals are often prescribed a combination of various medications. These drugs help lower blood glucose levels in various ways. They include: 
&nbsp;

<ul>
	<li>Biguanides - Metformin (Glucophage) is the only biguanide used for treating diabetes. It lowers basal and postprandial glucose levels by decreasing the amount of glucose the liver makes. And also makes the cells more sensitive to insulin. Common side effects include nausea, diarrhea, bloating, and abdominal pain.</li>
	<li>Sulfonylureas - These drugs stimulate the pancreas to secrete more insulin; thus, helping lower glucose levels. Examples include glipizide, glimepiride, and glyburide. Weight gain and low blood glucose are possible side effects of the drug.</li>
	<li>SGLT-2 Inhibitors - By lowering the renal glucose threshold, these drugs increase the excretion of glucose in the urine. Moreover, the drugs can also lower the risk of stroke and heart attack in people at high risk. Examples include canagliflozin and dapagliflozin. Common side effects include urinary tract infections, low blood pressure, vaginal yeast infections, and high cholesterol.&nbsp;</li>
	<li>Alpha-Glucosidase Inhibitors - They help prevent postprandial hyperglycemia by slowing down the breakdown of sugars and prolonging carbohydrate absorption. However, they can cause gastrointestinal side effects. Examples include acarbose and miglitol.</li>
	<li>DPP-4 Inhibitors - Examples include sitagliptin, saxagliptin, and linagliptin. They help lower blood glucose levels and can be administered as a monotherapy. Possible side effects include joint pain and an increased risk of pancreatitis.&nbsp;</li>
	<li>Glucagonlike-Peptide 1 (GLP-1) Agonists - These injectable medications (exenatide, dulaglutide, liraglutide) slow down digestion and stimulate insulin release. When given in combination with sulfonylureas and/or metformin, the drug causes significant weight loss. Common side effects include nausea, vomiting, diarrhea, and an increased risk of pancreatitis.&nbsp;</li>
	<li>Meglitinides - Similar to sulfonylureas, meglitinides also stimulate insulin secretion. However, they are much shorter acting. Examples include repaglinide&nbsp;and nateglinide. Side effects include low blood sugar and weight gain.</li>
	<li>Thiazolidinediones - Both rosiglitazone and pioglitazone act as insulin sensitizers. They are often used in combination with sulfonylureas, metformin, insulin, or other diabetic medications. However, it can increase one&#39;s risk of congestive heart failure, bladder<a href="https://www.merisehat.pk/disease/gallbladder-cancer" target="_blank"> </a>cancer, and fractures.&nbsp;</li>
</ul>

Other than the above medications, type 2 diabetics may also need insulin therapy. The doctor will determine the person&#39;s regimen depending on their glucose control, age, and medical history.&nbsp; 
&nbsp;

Dietary And Lifestyle Changes: A nutritionist can help both type 1 and type 2 diabetics create a well-balanced diet plan to help them reach their caloric requirements. Individuals are mostly required to limit their carbohydrate intake and increase the consumption of lean proteins, whole grains, vegetables, and fruits. Moreover, daily exercise is also recommended for the management of diabetes. Especially, in type 2 diabetics as it can help them lose weight. In type 1 diabetics, sugar levels must be checked before, and after starting, any new physical activity to prevent any hypoglycemic episodes. 
&nbsp;

Glucose Monitoring: Regular self-monitoring of blood glucose levels can help better manage diabetes. Moreover, it helps people adjust their insulin dose accordingly. Monitoring can be done using blood glucose meters or sensors.&nbsp; 
&nbsp;

Bariatric Surgery: In type 2 diabetics with a body mass index (BMI) of 35 or higher and poor blood glucose control, weight-loss surgery might be recommended. The surgery aims to aid weight loss and manage the patient&#39;s diabetes and other obesity-related conditions. 

&nbsp;

The elevated blood glucose levels associated with diabetes are detrimental to a person&#39;s vascular and organ health. Common complications include:

<ul>
	<li>Recurrent skin or urinary tract infections (mostly bacterial or fungal)</li>
	<li>High blood pressure, atherosclerosis, stroke, cardiovascular disease</li>
	<li>Nerve damage causing neuropathy in limbs characterized by numbness, burning, tingling, or pain in toes or fingers</li>
	<li>Microvascular damage in the retinal blood vessels can lead to vision loss in diabetics. Cataracts<a href="https://www.merisehat.pk/disease/cataract" target="_blank"> </a>and glaucoma can also develop from eye damage.</li>
	<li>Chronic kidney disease</li>
	<li>Slow healing of cuts and wounds that can often become serious infections. In severe cases, people can also form gangrenes that result in toe, foot, or leg amputation.&nbsp;</li>
	<li>Increased risk of inflammation of the gums</li>
	<li>Depression</li>
</ul>

&nbsp;

Diabetic Ketoacidosis: This is a life-threatening complication that most commonly results from uncontrolled type 1 diabetes. In type 1, and sometimes type 2 diabetes, the lack of insulin means glucose cannot be utilized for energy. As a result, the liver starts to break down fat for energy. This results in the production of ketones which build up in the blood and turn it acidic. Symptoms include fast and deep breathing, fruity-smelling breath, headache, flushed face, dry skin and mouth, nausea and vomiting, and tiredness. Eventually, people may develop a coma that can result in death.&nbsp;

 
Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS): This slow-developing complication results from elevated blood sugar levels over a long period. Symptoms include increased thirst, drowsiness, frequent urination, lack of energy, and vision changes. It typically occurs in elderly type 2 diabetics and is triggered by an illness or stress. Their blood glucose levels can reach levels greater than 600mg/dl.

&nbsp;

The following factors increase one&#39;s risk of type 1 diabetes:

<ul>
	<li>Age (more common in children and teenagers)</li>
	<li>Family history&nbsp;</li>
	<li>Environmental factors such as exposure to certain viruses</li>
	<li>Presence of diabetes-specific autoantibodies</li>
</ul>

&nbsp;

Risk factors for type 2 diabetes include:

<ul>
	<li>Age (more common in ages 45 and above)</li>
	<li>Family history&nbsp;</li>
	<li>Ethnicity (African Americans, Asians, and Hispanics are at higher risk)</li>
	<li>Prediabetes</li>
	<li>Overweight and sedentary lifestyle</li>
	<li>History of gestational diabetes</li>
	<li>History of<a href="https://merisehat.pk/disease/hypertension-57"> high blood pressure</a> or high <a href="https://merisehat.pk/disease/cholesterol">cholesterol</a></li>
	<li><a href="https://merisehat.pk/disease/polycystic-ovary-syndrome-pcos">Polycystic ovary syndrome</a> in women increases the risk of diabetes</li>
</ul>

&nbsp;

Since type 1 diabetes is an autoimmune condition, it cannot be prevented. However, certain steps can be taken to prevent the development of complications.&nbsp;

The following steps can help prevent type 2 diabetes and complications of type 1 diabetes: 
&nbsp;

<ul>
	<li>A healthy, balanced diet consisting of more protein, whole grains, fruits, and vegetables</li>
	<li>Small, frequent meals throughout the day</li>
	<li>Exercising (walking, cycling) for at least 30 minutes every day or five days a week</li>
	<li>Losing weight if overweight or obese</li>
	<li>Practising stress-reduction techniques</li>
	<li>Limiting alcohol and smoking</li>
	<li>Properly managing chronic conditions such as high blood pressure and high cholesterol</li>
	<li>Treatment with metformin for patients with prediabetes</li>
	<li>Regular follow-ups for monitoring of HbA1c, eye exams, and cardiovascular risk factors</li>
	<li>Regular foot exams</li>
</ul>

&nbsp;

Key Points

<ul>
	<li>Diabetes mellitus is characterized by elevated blood glucose levels either due to the absence of insulin or the body&#39;s inability to use the produced insulin.&nbsp;</li>
	<li>Type 1 diabetes is an autoimmune disease that results from the destruction of pancreatic beta cells that are responsible for producing insulin. Whereas, in type 2 diabetes the cells are unable to respond to insulin. The insulin resistance combined with reduced insulin secretion contributes to its development.&nbsp;</li>
	<li>Common signs and symptoms of diabetes include increased thirst, increased urination, increased appetite, fatigue, frequent infections, and unexplained weight loss.</li>
	<li>Diagnosis of type 1 and type 2 diabetes is based on the results of a fasting plasma glucose test, HbA1c test, or a random blood sugar test.</li>
	<li>Treatment of diabetes involves a combination of insulin therapy, diabetes medications, and lifestyle changes.</li>
</ul>

&nbsp;

[1] International Diabetes Federation, 2020. What is diabetes.

[2] International Diabetes Federation, 2021. With 1 in 4 adults living with diabetes, Pakistan has highest diabetes prevalence in the world. s.l.:s.n.

[3] Akhtar, S., Nasir, J. A., Abbas, T. & Sarwar, A., 2019. Diabetes in Pakistan: A systematic review and meta-analysis. Pakistan journal of medical sciences, 35(4), pp. 1173-1178.