DIABETES MELLITUS

INTRODUCTION

We all eat adequate diet for normal growth and development. Adequate diet entails energy giving (carbohydrate and fats), body building  (protein), protective and regulatory foods (vitamins and mineral) and water in the right proportion. All these food classes gets absorbed from our intestine into our blood stream and blood circulates them to various organs in our body (like our brain, eye, heart etc) where they are needed for normal growth and functi
oning of the body. This is in the healthy state. 

WHAT HAPPENS IN DIABETES MELLITUS
In diabetes mellitus, when all this nutrients gets into the blood stream, fat and protein enters into the cells but glucose (which is the absorbed form of carbohydrate in the body) cannot get inside the cells that makes up the body tissues (and glucose is the major source of energy) so for the body to keep functioning, it turns to protein and stored fats for energy generation. As our cars that are powered by petrol normally produces toxic carbon monoxide through the exhaust, metabolism of fats also generates end product that are toxic to the body. The glucose on the other hand would keep on accumulating in the blood leading to elevated blood glucose, what doctors calls hyperglycemia. This is also toxic to the blood vessels. Some glucose gets excreted by the kidney (glucosuria as doctor would refer) and because glucose is osmotically active, it pulls more body water alongside it leading to voiding large volume of urine (polyuria).

WHAT CAUSES DIABETES MELLITUS
An organ well hidden behind our intestines called pancreas normally produce a hormone called 'insulin' . What the insulin does is to convey the glucose from the blood stream into the cells of the body's various organs. Thereby making glucose (the chief energy source) available for energy production and suppressing the utilization of fat and protein for energy production.
Hence, in the presence of insulin;
1. There will be no accumulation of glucose in the blood stream; meaning that there wouldn't be destruction of blood vessels by the glucose.
2. There also won't be utilization of fats and proteins for energy production; meaning there won't be production of these toxic end product and weight loss.
    This insulin is produced by a particular group of cells within the pancreas that doctors calls the beta cells.

And when there is reduction or permanent ceasation in the production of the insulin by this cells, diabetes mellitus results.

    That's why Doctors defines diabetes mellitus as "a chronic metabolic condition characterized by abnormalities in the metabolism of carbohydrate, protein and fat, with multisystemic manifestation,  resulting from decreased or lack of insulin". 

    Also in some individuals the cells are functioning but the insulin cannot convey the glucose into the cells because the cells doesn't recognize it again (insulin resistance).

WHO GETS DIABETES MELLITUS 
Both the 'young' and 'older age' people can develop diabetes. Doctors researches shows that what causes diabetes in the young is quite different from what causes it in the old.

Type 1 DM: it's the commonest cause in the young and it's as a result of destruction of the beta cells by our body's immune system, by infections affecting the pancreas, or by cancers of the pancreas. 

Type 2 DM: it's the commonest cause in adults and it is due largely to insulin resistance. 

Another type seen in pregnant women only is called Gestational diabetes mellitus and it is due to interference with the insulin receptors on cells by a placental hormone (the human placental lactogen).

WHAT SUGGESTS DIABETES MELLITUS

1. Urinating more than you used to (polyuria).
2. Drinking more water than you used to because you now frequently gets thirsty (polydipsia).
3. Eating a lot more than you used to (polyphagia).
4. Feeling of numbness or tingling sensation in the feet or hand (paresthesia).
5. Poor wound healing.
6. Poor sexual perfomance.
7. Poor vision.
8. Weight loss.

WHAT TO DO
Visit a hospital where your blood glucose level would be checked. You might be scheduled for a glucose tolerance test. A glycated hemoglobin (HBA1C) might also be carried on subsequent visits after the diagnosis had been made to monitor the control of you blood glucose over 3 months. All these would be explained (in details) to you at the hospital.

PROBLEMS OF TYPE 1 DM
Total destruction of insulin producing cells that occurs over time in this type leads to absence of insulin and by implication glucose would continue to accumulate in the blood leaving the cells of the body no option other than to turn to the body's fat stores for energy generation. The end product of fat metabolism is acetone (which has a sweet smell) which makes the body acidic and because it is continually produced in the absence of insulin, the body's acidity would eventually overwhelm the body's pH buffer system. 
Individuals with type 1 DM might be dehydrated from frequent urination (polyuria) and acetone acid can induce vomiting in them which would further worsen  the dehydration. Evidence of this is usually their dry sky. When they are ill, they can develop a severe abdominal pain. The breathing pattern in them during this period can be very rapid and shallow breath in bid to breath out acids in the form of Carbon (iv)oxide to compensate for the body's acidic state. Doctors calls this kausmal breathing. Their breath my also smells like sweets (the smell of acetone). Any young person that complains of abdominal pain, that is vomitting, looking dehydrated with dry skin, breathing rapidly with breathe of sweet smell should be coveyed to the hospital without delay irrespective of whether or not he or she is a known diabetic patient as this might be the first indicator of diabetes mellitus in them. This is because if not properly treated, they soon would go into coma and die. So it is an emergency. Doctors calls this DIABETIC KETOACIDOSIS (DKA). 

PROBLEMS OF TYPE 2 DM
Acetone is not produced here in Type 2 DM because the pancreas still releases enough insulin to suppress the utilization of fats for energy generation. When type 2 DM patient are faced with an acute illness, they tend to experience a drop in the level of their insulin production and this would make their blood glucose level to go up (hyperglycemia). As this happens, more glucose would be lost in their urine which would also pulls more body water alongside it (glucosuria and polyuria) and make them dehydration, blood hyperosmolarity and they go into fatigue . This is also a medical emergency. Doctors calls it HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS).

MANAGEMENT

1. Lifestyle modification.....It begins with you, 
a. Stop cigarette smoking.
b. Stop alcohol intake.
c. Maintain a healthy weight (Check the 'weight management' label of this blog on how to maintain a healthy weight).
d. Reduce salt intake.
e. See a dietician or an endocrinologist for counselling on foods and diet.

2. Be compliant and adhere to your doctor's prescribed diabetic medications.
3. Be regular and punctual at follow up clinics.

    These would help reduce the progression into the possible deleterious complications

COMPLICATIONS

1. HYPOGLYCEMIA
    It is also a Medical emergency. It result when the blood glucose level falls below the normal range. Notable causes are; over zealous injection of insulin and lack of proper education on how to administer insulin by injection. It is commoner among type 1 DM patients. It is very dangerous as it kills very fast if there is no intervention.
Suspect this if after insulin injection patient starts sweating, became very anxious, shaking, feeling hungry. He or she may also feels tired, weak, dizzy, may behave inappropriately and not able to concentrate. If it persist coma and death may ensue.
This is because our brain runs EXCLUSIVELY on glucose and for this reason a drop below the normal range would impair the activities and functioning of the brain and the above features are the external index of the internal malady.

WHAT TO DO: If patient is still conscious, give an energy drink. Unconscious patients should be taken to the hospital "as fast as possible".

2. DISEASES OF LARGE ARTERIES  (MACROVASCULAR COMPLICATIONS)
    In diabetes the large arteries that supply blood (nutrient and oxygen) to major organs like our heart and brain are diseased for reasons in part due to hyperglycemia and other due to high levels of free circulating fatty acid in the blood (which is toxic to the blood vessels). This deposit in the wall of the artery thus making the lumen narrow as depicted by the picture below.

thus reducing the blood (nutrient and oxygen) flow to the organ supplied by that artery. Doctors calls this artherosclerosis. As the plaque grows, it can occlude the lumen and thereby starving the organ supplied by that artery or some part of the plaque can detached from the parent plaque and carried by the blood till it get to region of smaller vessels and occlude the vessel lumen completely. Either way, the end result is death of the part supplied by that artery.

1. Brain- where it would cause stroke or a transient loss of consciousness that is not more than 24 hours.
2. Heart- where it would cause a sudden cardiac death (Heart attack).
3. Leg- pains that comes and goes (intermittent claudication), sore on the lower leg and toes. 

3. DISEASES OF SMALL ARTERIES (MACROVASCULAR COMPLICATIONS)
    Similarly the smaller arteries supplying the eyes, kidneys, gastrointestinal tracts and nerve are affected and patient start to show symptoms of impairment in the function of this organs like visual impairment.
    When the blood supply to the nerves are compromised, patient won't feel any sensation again. Even when they step on sharp object the won't feel it. Doctors calls this neuropathy. 

DIABETIC FOOT
     The interplay of both arterial disease of the leg and neuropathy of the leg results into diabetic foot. Injury to the foot would not be noticed on time because of the neuropathy and it might not heal if the large artery supplying it is severely diseased (because oxygen and nutrient would not get to the leg again, a devitalized limb as doctors would say). This would progress to the death of that leg even while the individual is still alive. Doctors calls this foot gangrene. It is an increasing cause of leg amputation. If the limb is not amputated, the high blood glucose would be very difficult to control.

MANAGEMENT OF DM COMPLICATION
    Because multiple body systems are involved, management is a multidisciplinary approach. Patients would be referred to Specialists in the area of the organs affected who would manage them effectively. 

Compliant to the prescribed medications and being regular on follow up clinic visits is central in the management and would greatly slow down the development of these complications.

PREVENTION

1. HEALTHY DIET: Crave for foods that are rich in fibres and low in fat and calories. The Theme for this year's WORLD DIABETES DAY "HEALTHY LIVING STARTS AT BREATFAST" strongly advocate starting each day right by having a healthy breakfast such as the food described in the above context for breakfast as food rich in calorie raises the blood sugar rapidly and leaves you hungry before lunch.

2. PROPER EXERCISE: At least 30 minute in one day and at least days in a week

3. MAINTAINING A HEALTHY- Find out how in the "WEIGHT MANAGEMENT" label of this blog

4. LIFE STYLE MODIFICATION:  Stop smoking and Moderation in alcohol intake and by NOT living a sedentary life.

THESE, FOR THE MOST PART, ARE APPLICABLE TO TYPE 2 AND NOT TYPE 1.

CONCLUSION
Diabetes is a disease that affects almost all the systems in our body. Have your blood glucose checked at least once in a year to be sure you have not developed diabetes. If you are diabetic be compliant with your doctor's prescribed medications and be regular at follow up clinic to limit complication.