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Diabetes Mellitus is a complex metabolic disorder due to partial or complete deficiency of the hormone Insulin resulting in high blood sugar and the complications due to this uncontrolled hyperglycaemia. Diabetes is a serious, chronic disease that occurs either when the pancreas does not produce enough insulin (a hormone that regulates blood sugar, or glucose), or when the body cannot effectively use the insulin it produces.  This condition is also associated
with a situation called “insulin resistance” in the patho-physiology of the disease which is more true in the Asian populations.

Diabetes Mellitus has reached almost epidemic proportions worldwide as we stepped into the new millennium.

Key facts

l     The number of people with diabetes has risen from 108 million in 1980 to 422 million in 2014 (1).

l     The global prevalence of diabetes* among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014 (1).

l     Diabetes prevalence has been rising more rapidly in middle- and low-income countries.

l     Diabetes is a major cause of blindness, kidney failure, heart attacks, stroke and lower limb amputation.

l     In 2015, an estimated 1.6 million deaths were directly caused by diabetes. Another 2.2 million deaths were attributable to high blood glucose in 2012**.

l     Almost half of all deaths attributable to high blood glucose occur before the age of 70 years. WHO projects that diabetes will be the seventh leading cause of death in 2030 (1).

l     Healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use are ways to prevent or delay the onset of type 2 diabetes.

l     Diabetes can be treated and its consequences avoided or delayed with diet, physical activity, medication and regular screening and treatment for complications.

GLOBAL BURDEN: Globally, an estimated 422 million adults were living with diabetes in 2014, compared to 108 million in 1980. The global prevalence (age-standardised) of diabetes has nearly doubled since 1980, rising from 4.7% to 8.5% in the adult population. This reflects an increase in associated risk factors such as being overweight or obese. Over the past decade, diabetes prevalence has risen faster in low- and middle-income countries than in high-income countries. Diabetes caused 1.5 million deaths in 2012. Higher-than-optimal blood glucose caused an additional 2.2 million deaths, by increasing the risks of cardiovascular and other diseases. 43% of these 3.7 million deaths occur before the age of 70 years. The percentage of deaths attributable to high blood glucose or diabetes that occurs prior to age 70 is higher in low- and middle-income countries than in high-income countries. Because sophisticated laboratory tests are usually required to distinguish between type 1 diabetes (which requires insulin injections for survival) and type 2 diabetes (where the body cannot properly use the insulin it produces), separate global estimates of diabetes prevalence for type 1 and type 2 do not exist. The majority of people with diabetes are affected by type 2 diabetes. This used to occur nearly entirely among adults, but now occurs in children too.

Indian Scenario:

Until recently, India had more diabetics than any other country in the world, according to the International Diabetes Foundation, although the country has now been surpassed in the top spot by China. Diabetes currently affects more than 62 million Indians, which is more than 7.1% of the adult population. The average age on onset is 42.5 years. Nearly 1 million Indians die due to diabetes every year.

According to the Indian Heart Association, India is projected to be home to 109 million individuals with diabetes by 2035. A study by the American Diabetes Association reports that India will see the greatest increase in people diagnosed with diabetes by 2030. The high incidence is attributed to a combination of genetic susceptibility plus adoption of a high-calorie, low-activity lifestyle by India’s growing middle class. India tops the list of countries affected with the disease burden in the sequence as India, China, USA, Indonesia, Japan, Pakistan, Russia, Brazil, Italy and Bangladesh. Moreover, unique to Indians is part of a condition called ‘Asian Indian Phenotype’ characterised by higher predisposition to insulin resistance, coronary artery disease, greater waist circumference, waist to hip ratio, central obesity, more visceral fat for a given BMI.

Classification of Diabetes :

Diabetes mellitus is classified into four broad categories: type 1, type 2, gestational diabetes, and “other specific types”. The “other specific types” are a collection of a few dozen individual causes.... The term “diabetes”, without qualification, usually refers to diabetes mellitus.

Type 1 Diabetes, formerly called, IDDM, or juvenile diabetes, is due to absolute insulin deficiency. >95 % of Type 1 DM develop before the age of 25 yrs.

Type 2 Diabetes, formerly called, NIDDM, adult onset, is characterised by insulin resistance and an hormone secretory defect of the beta cells of pancreas. This is the most common type of diabetes.

Other specific types of diabetes are due to some genetic defects of beta cell functions.

Lastly, GDM (Gestational Diabetes Mellitus) is high blood sugar first diagnosed during the pregnancy.

Are you having Diabetes?

Polydypsia (excessive thirst), Polyphagia (excessive hunger) and polyuria (excessive urination) are the three most common symptoms of diabetes. 80% cases of Type 1 diabetes happen before the age of 20. Type 2 diabetes usually occurs in the later parts of life (> 30 years of age). Other symptoms may be due to complications of untreated diabetes with various corgan involvements: heart, brain, vascular, kidneys, eyes, nerves, skin etc.

If the above symptoms are present and specially when one belong to a high risk group which include a positive family history, obesity, habitual physical inactivity, Asians, hypertension (B.P.>140/90), high cholesterol, low HDL,
he or she must consult a doctor to undergo tests for diagnosis of diabetes.

Diagnostic criteria:

Symptoms of Diabetes + a Random Plasma Glucose >/= 200 mg/dl or a Fasting Plasma Glucose >/= 126 mg/dl or a 2 Hrs post meal plasma glucose is >/= 200 mg/dl. HBA1C >/= 6.5.

What Next?

Once diagnosis is confirmed one must follow the advice from the doctor. The success of diabetes management programme not only depends on the medications prescribed but equally on the patient’s understanding of the problem and cooperation. Patient education is an integral part of the treatment plan. The principal aim of the management of diabetes is to prevent and treat complications of diabetes which is mainly dependent on a set of complex self-management skills of the patient and a structured approach to health care provision.

A proper diet control and regular physical activity, are the two most important component of any treatment plan. Next come the medications: appropriate oral anti diabetic drugs (non-insulin) and different types of Insulin to be decided by a dialectologist or physician experienced in treating diabetes.

In situations of border-line diabetes or pre diabetes (FPG >/=110 to <126 and 2 HRS PPG > 140 to <200 mg %) lifestyle modification including proper diet control, regular physical exercise can delay the onset of diabetes.

A primary diabetes health care team include a primary care physician, diabetes educators (nurse and dietitians), in some cases the diabetes specialists. The expanded team members include other health professionals depending on the needs of the patients (with complications): an eye specialist, cardiologist, nephrologist, neurologist, foot care specialist, obstetrician, surgical specialist.

Complications of uncontrolled high blood sugar:

Uncontrolled hyperglycaemia, sooner or later adversely affects all important functions of the body. Diabetic ketoacidosis is a life threatening acute complication Incidences of coronary heart diseases, brain stroke, foot ulcers, gangrene, diabetic retinopathy and other eye diseases, diabetic neuropathy and other nerve diseases, diabetic nephropathy and other kidney diseases, chronic infections of various structures of the body, sexual dysfunctions are quite high in diabetics.

Conclusion:

Before I conclude, I would let all the esteem readers know that with a proper treatment plan and compliance to the advice given by the treating doctor, diabetes can be kept under control and the individual can lead almost a normal life (lot of celebrities of international repute are diabetic). But, on the other hand, lack of understanding of the disease and poor compliance will invite complications with resultant sufferings, increase morbidity and mortality.

— The authors, Dr. Dimbeswar Das is Consultant, Internal Medicine & Diabetologist, ILS Hospital, Agartala

[The views expressed by the author in this article is his own.]