DIABETES- AN OVERVIEW WITH HOMOEOPATHIC TREATMENT

DIABETES- AN OVERVIEW WITH HOMOEOPATHIC TREATMENT

Diabetes once diagnosed is for life. The perseverance and self discipline needed over a lifetime can often tax even the most robust of people to the limit. Those caring for them also require perseverance and an understanding of humanity combined with a cautious optimism, to guide those with diabetes through the peaks and troughs of their lives.

Definition

Diabetes occurs either because of a lack of insulin or because of the presence of factors that oppose the action of insulin. The result of insufficient action of insulin is an increase in blood glucose concentration (hyperglycaemia). Many other metabolic abnormalities occur, notably an increase in ketone bodies in the blood when there is a severe lack of insulin.

Diagnosis

The diagnosis of diabetes must always be established by a blood glucose measurement made in an accredited laboratory.

Glucose tolerance test

The glucose tolerance test is not normally needed in routine clinical practice, and then only if uncertainty exists in younger patients, or to establish an exact diagnosis in pregnancy. For reliable results, glucose tolerance tests should be performed in the morning after an overnight fast, with the patient sitting quietly and not smoking; it is also important that the patient should have normal meals for the previous three days and should not have been dieting. False results may also occur if the patient has been ill recently or has had prolonged bed rest. Blood glucose concentrations are measured fasting and then one and two hours after a drink of 75 g of glucose in 250-350 ml water (in children 1·75 g/kg to a maximum of 75 g), preferably flavoured, for example, with pure lemon juice. Urine tests should be performed before the glucose drink and at  one and two hours.

Interpretation of blood glucose values according to WHO criteria is shown below.

Gestational diabetes

This term embraces the criteria for both diabetes and impaired glucose tolerance when discovered during pregnancy

Glucose tolerance tests may also show:

Renal glycosuria—this occurs when there is glycosuria but normal blood glucose concentrations; this is a benign condition, only rarely indicating unusual forms of renal disease.

It is worth issuing these patients with a certificate to prevent them from being subjected to repeated glucose tolerance tests at every medical examination.

Steeple or lag curve—this is described when fasting and two hour concentrations are normal, but those between are high, causing glycosuria; this is also a benign condition, which most commonly occurs after gastrectomy but may occur in healthy people.

Impaired glucose tolerance

This is defined in the table. Patients are managed at the discretion of the physician. In general, no treatment is given to

 WHO Criteria For The Diagnosis Of Diabetes

1 Symptoms of diabetes plus casual venous plasma glucose _11·1 mmol/l. Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss

2 Fasting plasma glucose _7·0 mmol/l or whole blood _6·1 mmol/l. Fasting is defined as no calorie intake for at least 8 hours

3 2 hour plasma glucose _11·1 mmol/l during oral glucose tolerance test using 75 g glucose load

In the absence of symptoms, these criteria should be confirmed by repeat testing on a different day. If the fasting or random values are not diagnostic, the 2 hour value post-glucose load should be used

Comparison of Type 1 and Type 2 diabetes

Type 1 diabetes Type 2 diabetes

Inflammatory reaction in islets No insulitis Islet B-cells destroyed B-cells function Islet cell antibodies No islet cell antibodies HLA related Not HLA related Not directly inherited Strong genetic basis (some cases)

Other specific types of diabetes

• Genetic defects of _ cell function—chromosome 12 hepatic nuclear factor-1_ (HNF-1_) (formerly maturity onset diabetes of the young (MODY) 3), chromosome 7 glucokinase defect (formerly MODY 2), chromosome 20 HNF-4_ (formerly MODY 1), mitochondrial DNA mutation

• Genetic defects in insulin action—Type A insulin resistance (genetic defects in insulin receptor), lipoatrophic diabetes, genetic defects in the PPAR_ receptor

• Gestational diabetes

• Diseases of the exocrine pancreas—pancreatitis, pancreatectomy, carcinoma of pancreas, cystic fibrosis, fibro-calculous pancreatopathy, haemochromatosis

• Endocrinopathies—acromegaly, Cushing’s disease, Conn’s syndrome, glucagonoma, phaeochromocytoma,

somatostatinoma

• Drug induced (these agents in particular exacerbate hyperglycaemia in patients with established diabetes)—corticosteroids, diazoxide, _ adrenergic agonists (for example, intravenous salbutamol), thiazides, _ interferon

• Uncommon forms of immune mediated diabetes—stiff man syndrome, anti-insulin receptor antibodies

(Type B insulin resistance)

• Infections—congenital rubella, cytomegalovirus

• Other genetic syndromes sometimes associated with diabetes—Wolfram syndrome, Down’s syndrome, Turner’s syndrome, Klinefelter’s syndrome, Prader-Willi syndrome elderly people, but diet, exercise and weight reduction are advisable in younger subjects

Types of diabetes

Type 1 diabetes (previously insulin dependent diabetes) is due to B-cell destruction, usually leading to absolute insulin deficiency). It can be immune mediated or idiopathic.

Type 2 diabetes (previously non-insulin dependent diabetes) ranges from those with predominant insulin resistance associated with relative insulin deficiency, to those with a predominantly insulin secretory defect with insulin resistance.

Type 1 and Type 2 diabetes are the commonest forms of primary diabetes mellitus. The division is important both clinically in assessing the need for treatment, and also in understanding the causes of diabetes which are entirely different in the two groups.

Type 1 diabetes

Type 1 diabetes is due to destruction of B-cells in the pancreatic islets of Langerhans with resulting loss of insulin production. A combination of environmental and genetic factors that trigger an autoimmune attack on the B-cells is responsible, occurring in genetically susceptible individuals. Thus, among monozygotic identical twins only about one-third of the pairs are concordant for diabetes in contrast to the situation in Type 2 diabetes where almost all pairs are concordant. The process of islet destruction probably begins very early in life and is known to start several years before the clinical onset of diabetes.

Associated autoimmune disorders

The incidence of coeliac disease, Addison’s disease, hypothyroidism, and pernicious anaemia are increased in Type 1 diabetic patients, and appear to occur especially in those with persisting islet cell antibodies.

Risks of inheriting diabetes

A child of a mother with Type 1 diabetes has an increased risk of developing the same type of diabetes, amounting to 1-2% by 25 years; the risk is about three times greater if the father has this disease. If both parents have the disease the risk is further increased and genetic counselling should be sought by these rare couples.

Type 2 diabetes

There are numerous causes of Type 2 diabetes, which is now known to include a wide range of disorders with differing progression and outlook. The underlying mechanism is due either to diminished insulin secretion—that is, an islet defect, associated with increased peripheral resistance to the action of insulin resulting in decreased peripheral glucose uptake, or increased hepatic glucose output. Probably as many as 98% of Type 2 diabetic patients are “idiopathic”—that is, no specific causative defect has been identified. Whether decreasing insulin secretion or increasing insulin resistance occurs first is still uncertain, but the sequence of events may vary in different individuals. Obesity is the commonest cause of insulin resistance.

Other rare insulin resistant states are shown below:

Obesity

Relative insulin resistance occurs in obese subjects, perhaps because of down regulation of insulin receptors due to hyperinsulinaemia. Obese subjects have a considerably increased risk of developing Type 2 diabetes. Fat distribution is relevant to the development of diabetes, so that those who are “apple shaped” (android obesity, waist-hip ratio_0·9) are more prone to Type 2 diabetes than those who are “pear shaped”

(gynoid obesity, waist-hip ratio_0·7).

The importance of leptin in the evolution of lifestyle related obesity is unclear. Leptin is a single chain peptide produced by adipose tissue and its receptors are expressed widely throughout the brain and peripheral tissues; when injected into leptin deficient rodents it causes profound hypophagia and weight loss. Plasma leptin levels rise in parallel with body fat content. Although very rare cases of morbid obesity due to leptin deficiency have been reported, and are shown to respond to leptin injections, there is in general an absence of measurable biological responses to leptin, which at present has no role in the management of obesity.

Increased risk for Type 2 diabetes

• People over 40 years of age

• People of Asian or African-Caribbean ethnic origin

• Overweight people

• Family history of diabetes

• History of gestational diabetes

• History of large baby (birth weight exceeding 4 kg)

Rare syndromes

Polycystic ovary syndrome

Syndrome x* hypertension

* Syndrome x includes hyperlipidaemia, hyperinsulinaemia, and glucose intolerance

Natural history of Type 2 diabetes

Birthweight and Type 2 diabetes

Recent observations suggest a relationship between low b irthweight and the development in middle age of insulin resistance, Type 2 diabetes, and coronary artery disease. Those who are smallest at birth and largest at one year of age are most at risk.

Dominantly inherited Type 2 diabetes (MODY)

Seven genetic syndromes, three of which are shown in the box at the top of page 2, cause MODY—defined as an early onset of dominantly inherited Type 2 diabetes. Two (or at the very least one) members of such families should have been diagnosed before 25 years of age, three generations (usually first-degree) should have diabetes, and they should not normally require insulin until they have had diabetes for more than five years.

Mitochondrial diabetes

Mitochondrial diabetes and deafness is a rare form of diabetes maternally transmitted, and is related to the A3243G mitochondrial DNA mutation. Diabetes is diagnosed in the fourth to fifth decades, usually in thin patients with symptoms. Patients respond better to sulphonylureas than to diet alone. Diabetic microvascular complications do occur.

Insulin resistant diabetes

Some rare insulin resistant states exist in which hundreds or even thousands of units of insulin may be ineffective. They are often associated with lipodystrophy, hyperlipidaemia, and acanthosis nigricans. Type A insulin resistance is due to genetic defects in the insulin receptor or in the post-receptor pathway.

Type B insulin resistance occurs as a result of IgG autoantibodies directed against the insulin receptor; it is often associated with other autoimmune disorders such as systemic lupus erythematosis, and it is much commoner in women of African descent.

Ethnic variations

The prevalence of Type 2 diabetes is particularly high in Asian and African-Caribbean people and presents a considerable health burden in some inner urban areas.

Prevention Of Type 2 Diabetes

Lifestyle changes in those prone to Type 2 diabetes can effectively delay the onset of this disease. Several studies in different countries have demonstrated the feasibility of achieving this by a programme of weight reduction, improved diet (less fat, less saturated fat, and more dietary fibre) and increased physical activity. Recent investigations show that the development of diabetes can be approximately halved if these lifestyle changes are maintained over four years.

Diabetic Complications

Patients with long-standing diabetes, both Type 1 and Type 2, may develop complications affecting the eyes, kidneys or nerves (microvascular complications) or major arteries. The major arteries are affected in people with diabetes, causing a substantial increase both in coronary artery disease and strokes as well as peripheral vascular disease. The greatest risk of large vessel disease occurs in those diabetic patients who develop proteinuria or microalbuminuria, which is  associated with widespread vascular damage. The distribution of arterial narrowing tends to be more distal than in non-diabetic people, whether in coronary arteries or in the peripheral arteries affecting feet and legs.

Medial arterial calcification (Monckeberg’s sclerosis) is also substantially increased in patients with neuropathy and in those with renal impairment. The functional effects of vascular calcification are uncertain.

Symptoms

Thirst, tiredness, pruritus vulvae or balanitis, polyuria, and weight loss are the familiar symptoms of diabetes.  Dry mouth rather than thirst, and patients have been investigated for dysphagia when dehydration was the cause. Polyuria is often treated blindly with antibiotics; it may cause enuresis in young people and incontinence in elderly people and the true diagnosis is often overlooked. Complex urological investigations and even circumcision are sometimes performed before diabetes is considered.

Confusion in diagnosis

Some diabetic patients present chiefly with weight loss. Perhaps weakness, tiredness, and lethargy, which may be the dominant symptoms, are the most commonly misinterpreted; “tonics” and iron are sometimes given as the symptoms worsen.

Deteriorating vision is not uncommon as a presentation, due either to change of refraction causing myopia (mainly in Type 1 diabetes) or to the early development of retinopathy (mainly in Type 2 diabetes). Foot ulceration or sepsis in older patients brings them to accident and emergency departments and is nearly always due to diabetes. Occasionally painful neuropathy is the presenting symptom, causing extreme pain in the feet, thighs, or trunk. Glycosuria itself is responsible for the monilial overgrowth which causes pruritus vulvae or balanitis; some older men are first aware of diabetes when they notice white spots on their trousers.

Patterns Of Presentation

Symptoms are similar in the two types of diabetes (Type 1 and Type 2), but they vary in their intensity. The presentation is most typical and the symptoms develop most rapidly in patients with Type 1 diabetes; they usually develop over some weeks, but the duration may be a few days to a few months. There is usually considerable weight loss and exhaustion. If the diagnosis is missed, diabetic ketoacidosis occurs. Type 1 diabetes occurs under 40 years of age in approximately 70% of cases but can occur at any age, and even in

Symptoms in patients with Type 2 diabetes are similar but tend to be insidious in their onset; sometimes these patients deny any symptoms, although they often admit to feeling more energetic after treatment has been started. These patients are usually middle aged or elderly, but increasingly children, especially those of ethnic minorities, or those who are inert and overweight, are developing Type 2 diabetes. Microvascular and macrovascular complications are frequently already present when Type 2 diabetes is diagnosed. Type 2 diabetes is commonly detected at routine medical examinations or on admission to hospital with another illness.

Simple dietary guidelines

• Never take any form of sugar

• Do not take too much fat

• There is no need to restrict most meat, fish, or vegetables

• Control your weight

A diabetic diet: elimination of sugar/glucose/sucrose

Do not eat or drink:

• Sugar or glucose in any form and do not use sugar in your cooking

• Jam, marmalade, honey, syrup, or lemon curd

• Sweets or chocolates

• Cakes and sweet biscuits

• Tinned fruit

• Lucozade, Ribena, Coca-Cola, Pepsi-Cola, lemonade, or other fizzy drinks

You may use artificial sweeteners, such as saccharin, Sweetex, Hermesetas, Saxin, but NOT Sucron, and any sugar-free drinks including squashes and Slimline range

Fibre content of diet

The following will increase the fibre content of the diet:

Bread Wholemeal or stoneground— wholemeal for preference

If these are not available use HiBran or wheatmeal or granary loaves

Biscuits and crispbreads Ryvita, Macvita, and similar varieties. Digestive, oatcakes,

coconut, and bran biscuits, etc.

Breakfast cereals Porridge, Weetabix, Weetaflakes, All Bran, Bran Buds, Shredded Wheat, Oat Krunchies, muesli, Alpen, and similar cereals

Wholemeal flour or Should be used with white flour

100% rye flour for making bread, scones, cakes, biscuits, puddings, etc

Fresh fruit and vegetables Should be included at least twice daily. The skin and peel of fruit

and vegetables such as apples, pears, plums, tomatoes, and potatoes should be eaten

Dried fruit and nuts Eat frequently

Brown rice, wholemeal pasta

Pulse vegetables Such as peas and all varieties of beans

Foods suitable during intercurrent illness

For patients who are feeling ill but need to maintain their carbohydrate intake, the following are useful (each item contains 10 g of carbohydrate):

• 1/3 pint (0.15 l) tinned soup

• 1 glass fruit juice

• 1 scoop of ice cream

• 1 glass of milk

The following each contain 20 g of carbohydrate:

• 2 teaspoons Horlicks and milk

• 2 digestive biscuits

• 1 Weetabix and a glass of milk

• 1 ordinary fruit yoghurt

• “Build-up” made with 1/2 a pint (0.25 l) of milk and 1/2 a sachet

Optimal control may not be needed and it is best to interfere as little as possible with the patient’s usual way of life.

Diets for Type 1 diabetic patients

Greater finesse is required in managing the diets of Type 1 diabetic patients; if they eat too much, diabetic control deteriorates; if they eat too little they become hypoglycaemic. The important principles are that carbohydrate intake should be steady from day to day and that it should be taken at fairly regular times each day. Severe carbohydrate restriction is not necessarily required; indeed, if the diet is fairly generous patients are less likely to resort to a high fat intake, which may be harmful in the long term. The actual requirement for carbohydrate varies considerably; it is unsatisfactory to recommend less than 100 g daily, and control may become more difficult if more than 250 g daily is allowed. The smaller amounts are more suitable

for elderly, sedentary patients while the larger amounts are more appropriate for younger, very active people particularly athletes who may need considerably more. Although it has been observed that not all carbohydrate-containing foodstuffs are equally absorbed and that they do not have the same influence on blood glucose values, it is impracticable to make allowances for such variations other than recommending that sugar (sucrose) should be avoided except for the treatment of hypoglycaemia.

For social convenience it is customary to advise that most of carbohydrate should be taken at the main meals—breakfast, lunch, and dinner—even though these are not necessarily the times when, according to blood glucose profiles, most carbohydrate is needed; for example, less carbohydrate at breakfast and more at mid-morning and lunch often improves the profile. Snacks should be taken between meals—that is, at elevenses, during the afternoon, and at bedtime—to prevent hypoglycaemia. At least the morning and night snacks are essential and should never be missed.

For the convenience of some, and for those adopting the DAFNE method of controlling Type I diabetes and therefore needing to calculate the carbohydrate content of their meals, 10 g of carbohydrate is described as “one portion” so that a 170 g carbohydrate diet is described to patients as one of “17 portions”. Patients sometimes find it valuable to know the carbohydrate values of different foodstuffs.

Weight control: the role of exercise

Weight control towards optimal levels yields considerable health benefits to all, notably in this context to those who have the combined disadvantages of being overweight and having Type 2 diabetes. Exercise has a central role in weight reduction and health improvement. The proven benefits include reduced insulin resistance (hence enhanced insulin sensitivity) leading to better glycaemic control which may even be independent of actual weight reduction. Risk factors for cardiovascular disease,

A sample meal plan for a Type 1 diabetic

Carbohydrate Recommended food portions and drink

Breakfast

1 Fruit

1 Wholemeal cereal

1 Milk

1 Wholemeal bread

Egg/grilled bacon

Tea/coffee

Mid-morning

1 Fruit/plain biscuit

Tea/coffee/diet drink

Lunch Lean meat/fish/

egg/cheese

2 Potatoes/bread/rice/pasta

Vegetable salad

2 Fruit/sugar-free pudding

Mid-afternoon

1 Fruit/plain biscuit

Tea/coffee/diet drink

Dinner Lean meat/fish/eggs/cheese

2 Potatoes/bread/rice/pasta/Vegetable salad

2 Fruit/sugar-free pudding

Bed-time

1 Bread/fruit/plain biscuit

Tea/coffee/diet drink

Total 15

Alcohol

• Alcohols containing simple sugar should not be drunk by people with diabetes, especially sweet wines and liqueurs

• Dry wines and spirits are mainly sugar-free and do not present special problems

• Beers and lagers have a relatively high sugar and calorie content and their amount needs to be both limited and counted as part of the controlled carbohydrate intake

• Sugar-free beers are high in calorie and alcohol content and therefore have some limitations to their usefulness, whereas “low alcohol” beers are high in carbohydrate • Profound hypoglycaemia may be provoked in those who take large amounts of alcohol, and omit their normal diet, especially in those taking sulphonylureas; this can be dangerous

• Normal social drinking is usually free from this hazard but care is still needed

• Reduction in alcohol intake is sometimes an important part of helping weight loss

A Healthy Lifestyle

This include high blood pressure, also diminish. Indeed, the prevention of Type 2 diabetes itself in those at high risk has been amply demonstrated . People with osteoarthritis, chronic heart failure, and chronic lung disease all benefit from appropriate exercise programmes and weight reduction, and there are advantages to those recovering from myocardial infarction. A healthier life is also gained by the very old and by the overweight child. For those with Type 2 diabetes it is recommended that exercise of moderate intensity should be undertaken for about 30 minutes each day. This can include walking, as well as both aerobic and resistance exercise. The effects of exercise in Type 1 diabetes present the hazard of hypoglycaemia and it is not a specific contributor to improvement of diabetes control. Advice is required on the use of insulin and the need for additional food (in particular carbohydrate) before, during, and after periods of exercise

especially (since hypoglycaemia may develop after cessation of exercise) for those engaged in major sports and athletics. The challenge for sportsmen can be extreme but nevertheless people with Type 1 diabetes are known for huge achievements.

Smoking

The addiction of smoking is now well established. Its harmful effects are numerous, and include a substantial increase in cardiovascular and peripheral vascular disease as well as the best known consequences of lung cancer and chronic obstructive pulmonary disease. In diabetes, higher rates of both nephropathy and retinopathy have been well documented.