This is a medical condition characterized by persistent and continuous increase in blood sugar on more than one occasion due to relative or absolute insulin deficiency. Diabetes Mellitus is defined as a metabolic disorder characterized by hyperglycemia resulting from either the deficiency in insulin secretion or the action of insulin. The World Health Organization (WHO) defined it as Fasting blood sugar of 140mg% and above.
Islets of Langerhan located in the pancreas, secrete two hormones namely insulin and glucagon. Insulin is secreted where there is surplus in the blood. It helps in the conversion of excess glucose to glycogen for storage in the liver. When the blood glucose falls below normal, glucagon is secreted which helps to convert glycogen to glucose. These two hormones (insulin and glucagon) help to keep the blood sugar constant. An individual whose insulin is short cannot convert excess blood sugar to glycogen. As such, glucose found in the blood increases and some of the glucose is excreted in the urine leading to a disease called Diabetes Mellitus.
Effects of malfunctioning of pancreas
- It may not be able to produce glucagon and insulin.
- Insufficient production of insulin.
- It may not be able to produce other pancreatic juice.
What causes diabetes mellitus
The primary cause of diabetes mellitus is unknown. Most people believe that the following are the causes:
- Genetics and Diabetes: Apart from the fact it tends to run in families, genes also give the body instructions for responding to changes in its environment. Type 2 diabetes has a stronger link to be caused by family history and lineage than type 1. According to a research, studies of twins have shown that genetics play a very strong role in the development of type 2 diabetes. Lifestyle and race can also influence the development of type 2 diabetes, and it is possible to prevent type 2 diabetes by exercising and losing weight.
- Diet and Diabetes: What and how we eat influences diabetes risk in us. Studies have shown that people with higher intake of vitamin B2 and B6 from foods or supplements have a lower risk for type 2 diabetes, while people with higher intake of vitamin B12 from foods have a higher risk of type 2 diabetes. Also, high intake of carbohydrates and fats have a strong association of type 2 Diabetes Mellitus.
- Physical inactivity: This is a risk factor for type 2 diabetes. Prevention of physical inactivity may increase the fat mass of the body causing obesity. Because the excessive free fatty acid released by adipose tissue decreases insulin sensitivity of muscle, fat and liver, and this makes the glucose levels to be high.
- Obesity and Diabetes: Obesity is another risk factor for diabetes mellitus. A study has shown that obesity is a stronger independent risk factor than physical inactivity for diabetes mellitus. Anyone who is overweight and/ or obese has some kind of insulin resistance, but diabetes only develops in those individuals who lack sufficient insulin secretion to match the degree of insulin resistance. Insulin thereby becomes high in those individuals.
Secondary diabetes mellitus occurs mostly secondary to another disease such as:
•Pancreatic disease:-
- Pancreatitis
- Cancer of the pancrease
- Pancreatectomy
•Hormones:-
- Cushing’s syndrome
- Phaeochromocytoma
- Acromegaly
- Thyrotoxicosis
•Drugs:-
- Steroids
- Thiazides
Clinical Features Diabetes Mellitus
- Increased thirst
- Polyuria
- Polyphagia
- Nocturia and enuresis are common
- Frequent urination
- Extreme fatigue
- Irritability
Surgical problems associated with Diabetes Mellitus:-
- Delayed wound healing
- Erectile dysfunction
- Frequent urinary tract infections
- Decreased sex drive
Gynecological problems associated with a Diabetes Mellitus include:-
- Weight loss
- Recurrent abortion
- Unexplained stillbirth
- Unexplained infertility
- Pruritus valvae due to candidiasis
Management of Diabetes Mellitus
There are three approaches to managing the disease and they include:
Diet:- Dietary approach has been reported to be the most successful in some diabetic patients. The patients affected depend mostly on protein and lipid diets. It is important to give each patient a diabetes diet chart. If this dietary regimen is prepared by experts and is followed sincerely, a remarkable improvement will be recorded.
Oral hypoglycemic drugs:- These drugs are taken orally to reduce blood sugar levels. The study has shown that any patient above thirty-five years of age requiring less than 40 units of insulin in a day should be tried on oral hypoglycemic drugs. This assertion is based on the daily output of insulin in the body being 40 units. There are two groups of these drugs but the drugs will only be listed here together. Some oral hypoglycemic drugs in common use are:
- Chlorpropamide or Diabenese
- Acetazolamide
- Glibenclamide or Daonil
- Gliclazide or Diamicron
- Metformin or Glucophage
- Phenformin
A combination of Diabenese and Glucophage is recommended and the patient is to be reviewed after three weeks. The insulin preparation commonly used is Soluble insulin and Depot insulin or lente. The process whereby a patient’s insulin requirement is determined is called stabilization. This is Lawrence’s regime where the amount of insulin given depends on glycosuria determined colorimetrically using a line test or by using glucostix. Some clinicians use the TDS regimen where they start with 20 units of soluble insulin three times daily (TDS). The colors are Red, Orange, Yellow, Green, and Blue.
Complications of Diabetes Mellitus
- Diabetic neuropathy:- This is present with Numbness and Paraesthesia, and Impotence if autonomic neuropathy sets in.
- Vascular disorder:- Angina pectoris and myocardial, Intermittent claudication, and Gangrene of the foot with a painless ulcer.
- Renal failure
- Diabetic retinopathy
- Diabetic ketoacidosis
- Hypoglycemic
Diabetes Ketoacidosis
This is a biochemical complication of diabetes mellitus. It occurs due to the patient taking little or no insulin and also in the presence of infection. The patient must have been I’ll for some days. The mechanism of diabetes ketoacidosis is not described here.
Clinical Features
- Abdominal pain
- Vomiting
- Weak volume pulse
- Reduced blood pressure
- Kussmaul breathing
On examination may be febrile to touch, with signs of dehydration, such as dry skin, dry tongue, sunken eyeball, loss of skin turgor, and breath smell of acetone.
Investigation:
- Urinalysis
- Blood for FBC; Sugar; E/U/C
Treatment of Diabetes Mellitus
Your doctor is in the right position to prescribe drugs for you. Otherwise, the following prescription can be given by a medical practitioner:
- IVF Normal Saline 1 liter each pint to run for half an hour, one hour, two hours, and four hours respectively.
- Soluble insulin 20 units (a) 10 units I.V (b) 10 units I.M. Then 5 units I.M every hour. If blood sugar falls to 250mg% or below then change to IVF D/Saline 500ml 6-hourly. Give insulin by Lawrence regime, that is, depending on the color change of the urine.
- An indwelling catheter as the patient is unconscious
- Broad-spectrum antibodies for the infection. Zinacef or Rocephin is very potent.
Hypoglycemic Coma
This is a biochemical complication of diabetes mellitus due to the patient taking more insulin than required or taking insulin when starving. The clinical features are headache, dizziness, sweating, and fainting attack. The treatment is to revive the patient back to life, followed by the others. But if the patient is in a coma, then the patient should be rushed to the hospital.
Diabetes in Pregnancy
If a patient has features suggestive of diabetes, an oral glucose tolerance test is done early in the first trimester. The patient may be an established diabetic or gestational diabetic where she is diabetic only during pregnancy. She may be a potential diabetic. Features of the potential diabetic include the following:
- Gross obesity
- First-degree family history of diabetes
- History of big baby
- Unexplained intrauterine death.
Pregnancy is diabetogenic and therefore insulin requirement increases during pregnancy. Patients who were controlled on diet and oral hypoglycemic drugs may now require insulin. This is so because pregnancy produces insulin- antagonists such as progesterone, estrogen, cortisol, human placental lactogen, growth hormone, and glucagon.
The following are the effects of diabetes on pregnancy:-
- Increased incidence of pre-eclamptic toxemia.
- Increased incidence of fetal abnormality.
- Intrauterine death
- Big baby
- Hydramnios
- High incidence of operative delivery.
Management
Ensure good control of diabetes. The individual should be regular at the antenatal clinic or in visiting the doctor. She should be seen fortnightly until the 28th week of pregnancy and thereafter weekly till delivery.
- Strict diabetic diets
- At each visit, measure the blood pressure and weight. Urinalysis is done to check for sugar and protein.
- Fasting blood sugar is done at regular intervals.
- A weekly blood glucose profile is advised. The blood sugar levels should never be more than 160mg% in a 5-point glucose profile.
- Adequate fetal monitoring.
- X-ray pelvimetry at 36th week or an ultrasound scan to rule out fetal pelvic disproportion. Diabetes with any other complication may require a cesarean section.
~ Dr. Anthony A. Ufere and Anthony Obinna.
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