Diabetes Calculator

What is Diabetes

Diabetes mellitus is a metabolic disorder that occurs due to either a deficiency of insulin or insulin action or both. It raises blood glucose levels (hyperglycaemia), which may affect the eye, kidney, nerves and blood vessels.

Normal blood gluose varies in humans between 70-100mg/dl in the fasting state and 100 -140 mg/dl in the fed state. Glucose is the principal fuel for energy in the body. The main source of blood glucose is food that is digested and absorbed from the gut. The other source is stored carbohydrate i.e. glycogen in the liver and muscle. In the fed state body mainly depends on glucose derived from the ingested food. In the fasting state the body maintains blood glucose by breakdown of stored glucose especially from the liver (glycogenolysis).

This delicate balance of blood glucose throughout 24 hours is maintained accurately by the action of insulin which is secreted from the beta cell of the pancreases irrespective of the eating pattern and physical activity. Another important determinant of maintaining blood glucose is the sensitivity of the insulin action on the muscle, fat and liver tissues. When insulin sensitivity is decreased, body needs more insulin to burn glucose to produce energy. This is called insulin resistance.

Insulin resistance is commonly seen in obese people who have more fat in the body and in the muscle. When this delicate balance is affected body will not be able to use (metabolise) glucose and there will be accumulation of blood glucose. This state of increased blood glucose level is called Diabetes Mellitus.

Causes of Diabetes:

Ageing populations, economic development, urbanization, unhealthy diets, increased sugar consumption, low fruit, low vegetable intake and reduced physical activity are generally associated with diabetes. There are many modifiable factors and Non modifiable factors which cause diabetes. They include the following

  • Genetic predisposition
  • Obesity or overweight
  • Central obesity
  • Sedentary life style
  • Unhealthy diet
  • Mental and physical stress
  • Multiple pregnancies
  • Gestational Diabetes mellitus

Stages of Diabetes:

Diabetes develops and progresses because of loss of beta-cell function. UKPDS clearly shows loss of 50% of beta-cell function at the time diagnosis, which continued to decline, progress and worsen diabetes. This is shown in the graph below,

In early stages of development of diabetes, insulin resistance is compensated by increased insulin secretion. This causes higher than normal blood levels of insulin (Phase 1). Insulin resistance in due course tends to worsen so that postprandial hyperglycemia develops despite elevated insulin concentration (Phase 2). Over a period of time, as the pancreatic beta cells get exhausted, it’s secreting capacity decreases. This results in lower insulin secretion and diabetes develops (Phase 3). As blood glucose rises, this in turn causes further reduction in insulin secretion (glucotoxicity). Presence of insulin resistance, decreased insulin secretion and glucotoxicity produces a decompensated state of glucose metabolism leading to Diabetes Mellitus.

Classification of Diabetes

Type 1 Diabetes

Type 2 Diabetes

Gestational Diabetes

Other Specific Types of Diabetes

  • Genetic defect of beta cell dysfunction
  • Genetic defects in insulin action
  • Diseases of exocrine pancreas
  • Endocrinopathies
  • Drugs or Chemical induced
  • Infections
  • Uncommon forms of immune-medicated diabetes

Stage before Diabetes:

Prediabetes

Impaired Glucose Tolerance

Impaired Fasting Glucose

Combined Glucose Intolerance

Type 1 Diabetes

In persons with type 1 diabetes, the beta cells of the pancreas, which are responsible for insulin production, are attacked by the misdirected immune system. It is believed that the tendency to develop abnormal antibodies in type 1 diabetes is, in part, genetically inherited, though the details are not fully understood.

Type 1 diabetes tends to occur in young, lean individuals, usually before 30 years of age; however, older patients do present with this form of diabetes on occasion. This subgroup is referred to as latent autoimmune diabetes in adults (LADA). LADA is a slow, progressive form of type 1 diabetes.

Type 2 Diabetes

In type 2 diabetes, patients can still produce insulin, but due to prevalent insulin resistance, it is inadequate for their body’s needs. In many cases this actually means the pancreas produces larger than normal quantities of insulin. A major feature of type 2 diabetes is a lack of sensitivity to insulin by the cells of the body.

In addition to the problems with an increase in insulin resistance, the release of insulin by the pancreas may also be defective and suboptimal. In fact, there is a known steady decline in beta cell production of insulin in type 2 diabetes that contributes to worsening glucose control. Finally, the liver in these patients continues to produce glucose through a process called gluconeogenesis despite elevated glucose levels. The control of gluconeogenesis becomes compromised.

While it is said that type 2 diabetes occurs mostly in individuals over 30 years old and the incidence increases with age. Most of these cases are a direct result of poor eating habits, higher body weight, and lack of exercise.

While there is a strong genetic component to developing this form of diabetes, there are other risk factors – the most significant of which is obesity. There is a direct relationship between the degree of obesity and the risk of developing type 2 diabetes, and this holds true in children as well as adults.

Regarding age, data shows that for each decade after 35 years of age regardless of weight there is an increase in incidence of diabetes.

Gestational Diabetes

Diabetes can occur temporarily during pregnancy. Significant hormonal changes during pregnancy can lead to blood glucose elevation causing gestational diabetes. Gestational diabetes usually resolves once the baby is born. However, 35% to 60% of women with gestational diabetes will eventually develop type 2 diabetes over the next 10 to 20 years, especially in those who require insulin during pregnancy and those who remain overweight after their delivery. Women with gestational diabetes are usually asked to undergo an oral glucose tolerance test about six weeks after giving birth to determine if their diabetes has persisted beyond the pregnancy, or if any evidence (such as impaired glucose tolerance) is present that may be a clue to a risk for developing diabetes.

Risk factors

There is an increased risk of gestational diabetes if:

  • body mass index (BMI) is 30 or more
  • If the previous baby weighed 4.5kg (10lbs) or more at birth
  • Gestational diabetes in a previous pregnancy
  • Family history of diabetes
  • South Asian ethnicity (specifically India, Pakistan or Bangladesh)

Prediabetes

The evolution of T2DM follows through different stages. Impaired fasting glucose and Impaired glucose tolerance are the fore-runners of future T2DM (collectively termed as Prediabetes). These states include a proportion of people who belong to the intermediate group, whose glucose levels, although do not meet the criteria for diabetes are nevertheless too high to be considered normal. These patients may develop diabetes in future if their glycemic status is not maintained by modification of lifestyle.

Impaired Fasting Glucose is present when the fasting level is ≥ 110mg/dl and ≤ 125mg/dl and the 2 hour value is < 140mg/dl.

Impaired Glucose Tolerance is present when the 2 hour value is in the range of ≥140 mg/dl – < 200 mg/dl.

Symptoms

Typical symptoms of diabetes may not be present in 70% of people with raised blood glucose. Most often the diagnosis of diabetes is incidental during blood test performed for general health check up, medical screening for new jobs or during life insurance examinations etc.

  • Increased urine output
  • Excessive thirst
  • Excessive Hunger
  • Weight loss
  • Fatigue
  • Skin problems
  • Slow healing wounds
  • Blurred vision
  • Tingling or numbness in the feet or toes.

Diagnosis

The biochemical hallmark of diabetes is elevated blood glucose. Therefore, diagnosis of diabetes is made by estimation of glucose concentrations in the blood.

When the fasting plasma glucose is ≥ 126 mg/dl or random blood glucose ≥ 200 mg/dl on more than one occasion.

Fasting Plasma Glucose:

Elevated fasting plasma glucose is always regarded to have a high degree of specificity for the diagnosis of diabetes. It is more consistent and reproducible than postprandial plasma glucose because there are more variable in the latter, such as timing and carbohydrate load. FPG may be easier to control with medications than PPG. An overnight fasting for 8 – 12 hours is considered desirable.

The ADA and WHO have recommended FPG value of ≥ 126 mg/dl as the diagnostic value for diabetes and the value of 110 – 125 mg/dl have been termed as impaired fasting glucose which is a prediabetic stage.

Postprandial Blood Glucose:

The word postprandial means after a meal and hence it refers to plasma glucose concentration after food intake. The optimal time to measure postprandial glucose concentrations is 2 hr after the start of a meal. An elevated PPG concentration is one of the earliest abnormalities of type 2 diabetes, and represents an independent risk for cardiovascular disease. Postprandial changes precipitate atherosclerosis before FPG concentrations are affected. The recommended PPG goal of treatment is a value of <160mg/dl.

Oral Glucose Tolerance Test

It is recommended for diagnosis/exclusion for diabetes.

The Oral Glucose Tolerance Test (OGTT) is done in the morning after 8-10hrs of overnight fast (water may be taken). A fasting blood sample should be taken before giving glucose load. The person then drinks 75gm of glucose in 250-300 ml of water (the glucose load should be consumed over a period of five minutes). A further blood sample must be collected 2 hours after the load.

Diabetes is diagnosed if the fasting value is ≥ 126 mg/dl or 2 hour plasma glucose is ≥ 200mg/dl.

Impaired Glucose Tolerance is present when the 2 hour value is in the range of ≥140 mg/dl – < 200 mg/dl.

Impaired Fasting Glucose is present when the fasting level is ≥ 110mg/dl and ≤ 125mg/dl and the 2 hour value is < 140mg/dl.

Glucose tolerance is normal when the fasting and the 2 hour values are < 110mg/dl and < 140mg/dl respectively.

Hemoglobin A1c (HBA1c)

The red blood cells that circulate in the body live for about three months before they die off. When sugar sticks to these hemoglobin proteins in these cells, it is known as glycosylated hemoglobin or hemoglobin A1c (HbA1c). Measurement of HbA1c gives us an idea of how much sugar is present in the bloodstream for the preceding three months. In most labs, the normal range is 4%-5.6 %. In poorly controlled diabetes, its 8.0% or above, and in well controlled patients it’s less than 7.0% (optimal is <6.5%). The benefits of measuring A1c is that gives a more reasonable and stable view of what’s happening over the course of time (three months), and the value does not vary as much as finger stick blood sugar measurements.

While there are no guidelines to use HbA1c as a screening tool, it gives a physician a good idea that someone is diabetic if the value is elevated. Right now, it is used as a standard tool to determine blood sugar control in patients known to have diabetes.  The recommended cut-off points are

Normal range: 4.5 – 5.6%

Prediabetes range: 5.7 – 6.4%

Diabetic range: ≥ 6.5%

Gestational Diabetes Diagnosis:

“One-Step” Strategy 

75-g OGTT with Plasma Glucose measurement fasting and at 1 h and 2 h, at 24-28 wks in women not previously diagnosed with overt diabetes

Perform OGTT in the morning after overnight fast ( ≥8 h)

GDM diagnosis made if PG values meet or exceed:

Fasting : 92 mg/dL (5.1 mmol/L)

1 hour   : 180 mg/dL (10.0 mmol/L)

2 hour   : 153 mg/dL (8.5 mmol/L)

“Two-Step” Strategy

50-g GLT (nonfasting) with Plasma Gluocse measurement at 1 h (Step 1), at 24-28 wks in women not previously diagnosed with overt diabetes

If Plasma Glucose at 1 h after load is ≥140 mg/dL (7.8 mmol/L), proceed to 100-g OGTT

(Step 2), performed while patient is fasting

GDM diagnosis made when two or more Plasma Glucose levels meet or exceed:

Fasting : 95 mg/dL or 105 mg/dL (5.3/5.8 mmol/L)

1 hour  : 180 mg/dL or 190 mg/dL (10.0/10.6 mmol/L)

2 hour  : 155 mg/dL or 165 mg/dL (8.6/9.2 mmol/L)

3 hour  : 140 mg/dL or 145 mg/dL (7.8/8.0 mmol/L)

Diabetes Myths

People with diabetes cannot lead a normal life – No. This is a metabolic disorder either due to defective action or deficiency of insulin. When the blood sugar is kept under control by healthy life style and drugs, a diabetic can have a healthy, normal life.

Diabetes is more common in Men – No. In most population it is not very different. Women seem to have higher prevalence in certain populations due to increased obesity. Today in India, diabetes is found almost equally in men and women.

Testing urine sugar alone is sufficient for diagnosing diabetes – No, urine testing alone will not help. In some diabetic patients there may be an increase in blood sugar without any traces of it in the urine. In few persons, urine sugar with normal blood sugar is seen. This condition is called renal glycosuria and is not related to diabetes.

People with diabetes should not donate blood – No. A diabetic person can donate blood provided he/she does not have any contagious illnesses, which are usually contraindications for blood donations. Diabetes is not contagious. A well controlled diabetic can donate blood.

Diabetes can be cured – No. Diabetes cannot be cured. It can only be controlled. In certain cases of type 2 diabetics who are obese, weight reduction can achieve a normal state without use of drugs.

All types of diabetes are same – No. The two most common types of Diabetes are; Type 1 diabetes: In this type, there is no insulin secretion and the patient has to take insulin injection throughout life. Type 2 diabetes: This type of diabetes may be managed without insulin. It can be managed with diet, exercise, tablets and may require insulin occasionally. This is the most common form of diabetes.

Diabetes does not develop after 60 years – No. Diabetes can develop at any age and it is not true that it always develops before the age of 60. The peak incidence occurs between 35 and 50 years, but it can occur at any age.

People with Type 1 diabetes have short span of life – No. A well controlled diabetic can have a normal life span. However, one has to follow a very systemic life, controlling his/her diet, taking insulin injections without fail, making necessary adjustments in the dose of insulin with his physician’s help and seeking medical advice when infection or other emergency situations occur.

People with diabetes should not travel – No. A diabetic can have a normal life just as anybody else. However, even while travelling he should try, not to break the diet rules as far as possible. He/She should also take his drugs regularly and eat at regular intervals. If these simple rules are followed, the diabetic can travel anywhere and whenever he/she likes.

Drugs for diabetes should never be withdrawn – No, is some diabetics, it is possible to withdraw the oral drugs completely and normal blood sugar is maintained only with diet regulations and exercise. These people may have had severe hypoglycaemia at diagnosis, but with the help of diet and oral drugs, they show rapid response. The drugs can be gradually reduced and then withdrawn if the blood sugar response is continuously under control. Such people show hypoglycaemia symptoms with small doses of drugs. However, they must always be under proper dietary regulations and periodic blood sugar estimations must be done.

Insulin injections can be taken at the same site repeatedly – No. The best sites for injecting insulin are the abdomen around the navel and outer aspects of the thighs. It is advisable to change the sites. The site can be changed every day, by half to one inch space from the previous site of injection.

Blood sugar test strips can be stored more than one year – No. The blood sugar test strips can be stored in a cool, dark place, till the date of expiry mentioned on the bottle. The test strips contain enzyme and other chemicals which deteriorate slowly and therefore it is not possible to keep them for a very long period. If the batch of strips is fresh, its expiry date may be even longer than a year.

Blood glucose measurement by Blood glucose meter will not be accurate – No. The blood glucose meters are precise, convenient and very useful for home glucose monitoring. The strips only contain the reagent and it is essential to follow the instructions correctly for their use and storage. The strips can get spoiled if kept in improperly capped containers. The blood glucose values can be erroneous with such strips. If the strips are in good conditions they can very reliable results. The results are very similar to that obtained in the laboratories.

We can relax the diet regimen when diabetes is under good control – No. It is not advisable to relax the diet for long periods even when diabetes is in good control as the extra calories from forbidden foods can overstrain the pancreas in the long run. Other problems will set in later on, which means restrictions in the diet will be much more than what it was in the beginning. Increased food intake also leads to obesity and prevents control of diabetes.

Fruits are to be avoided – No. Fruits can be included in the diet, when the blood sugar levels are under control. Fruits that contain less carbohydrate are sweet lime, apple, papaya, guava. Whole fruits are better than fruit juices.

Diabetes Monitoring

Self monitoring of blood glucose is considered as an effective tool for the management of diabetes, especially for those who require insulin treatment.

Self blood glucose monitoring allows you to know your blood glucose level at any time and helps prevent the consequences of very high or very low blood sugar. Monitoring also enables tighter blood sugar control, which decreases the long term risks of diabetic complications.

The following steps include general guidelines for testing blood sugar levels; you should get specific details for your glucose monitors from the package insert or from your doctor or a specialised nurse. Never share blood glucose monitoring equipment or finger stick lancing devices. Sharing of this equipment could result in transmission of infection, such as Heaptitis B.

  • Wash hands with soap and warm water. Dry the hands.
  • Prepare the lancing device by inserting a fresh lancet. Lancets that are used more than once are not sharp as a new lancet, and can cause more pain and injury to the skin.
  • Prepare the blood glucose meter and test strips.
  • Use the lancing device to obtain a small drop of blood from your fingertip. If you have difficulty getting a good drop of blood from the fingertip, try rinsing your fingers with warm water, shaking the hand below the waist or squeezing the fingertip.
  • Apply the blood drop to the test strip in the blood glucose meter. The results will be displayed on the meter after several seconds.
  • Dispose of the used lancet in a puncture resistant sharps container.

Following are the routine monitoring tests for a diabetic patient during clinic visits;

Blood Glucose  – Controlled (HbA1c < 7%) – every 3 months

– Uncontrolled – every 2 weeks until target sugars achieved

   HbA1c – Controlled (HbA1c < 7%) – 6 months to 1 year

– Uncontrolled – every 3 months

Test for neuropathy

Monofilament – Annual

Biothesiometer – Annual

Foot examination – Once in 3 months

Testing  for Eyes

Fundus examination – Annually. If evidence of retinopathy detected at first visit,

follow-up every 3-6months

Test for Nephropathy

Urinay albumin – Annual

Serum Creatinine  – Annual

Miscellaneous Tests

ECG – Annual

Treadmill Test – By 5 years after onset of Diabetes, then once in 2 years

Lipid Profile (cholesterol)- Annual, If abnormal every 6 months

Prevention of Diabetes

Healthy Diet

Calorie Requirements based on weight and usual activity for adults:

  • Obese inactive, sedentary men/women – 20 kcal/kg of present weight
  • Normal BMI, sedentary men/women – 22 – 25 kcal/kg
  • Normal BMI, active men/women  – 30 kcal/kg
  • Thin/Very active – 40 kcal/kg

The calorie requirements, in addition to the above mentioned criteria should be based on the patient’s usual food intake. One third of the total calories can be distributed for early morning and breakfast. Another one third for mid morning snack and lunch and the remaining one third for evening snack and dinner.

Carbohydrates:

  • Carbohydrates should approximate 55 – 60% of total calories /day
  • Minimum of 130gm/day
  • 25 -50gms of carbohydrates from fiber per day may be given

Proteins:

  • Daily requirement is 15 – 20% of the total calories/day
  • 1gm/kg of present body weight/day
  • 1gm/kg of ideal body weight if obese
  • 0.6-0.8 mg/kg body weight in nephropathy
  • 50% of daily protein has to be from Class 1 sources

Fats:

  • Daily requirement is 15 – 20% of the total calories/day
  • Saturated fat < 7%
  • Polyunsaturated fat – up to 10%
  • Monounsaturated fat – up to 20%
  • Intake of trans fat should be minimized (Bakery products)
  • Limit dietary cholesterol to less than 200 mg/day
  • Daily visible fat intake is 3 – 5 tsp/day
  • Oil – 500 gm/month/person

Physical Activity

Routine exercises belong to three categories namely: 1) Aerobic exercise, 2) Flexibility Exercise and 3) Strength exercise.

Aerobic Exercise:

This is a rhythmic, repeated and continuous movement of the large muscle groups. A total of about 30 – 45 minutes a day, at least 5 days a week is recommended.  Walking, bicycling, jogging, continuous swimming, water aerobics and sports activities should be performed at sufficient intensity and frequency.

Flexibility Exercise:

Stretching the body’s muscles provides freedom of movement to do the things you need to do and the things you like to do. Stretching can improve your flexibility, although it will not improve your endurance or strength.

Stretching exercise should be done after your regularly scheduled aerobic activities. You should do stretching every day. Do each stretching exercise at least 4 times each session. Slowly stretch into the desired position, as far as possible without pain, and hold the stretch for 15–60 seconds. Relax, then repeat, trying to stretch a little farther. Always remember to breathe while stretching. Counting out loud can help ensure that you are breathing.

Benefits of Exercise

Exercise is beneficial for all, especially people with diabetes. In diabetic subjects regular exercise improves insulin sensitivity which helps in reducing blood glucose. Exercise also reduces blood pressure, cholesterol and reduces the risk for heart disease and stroke. Regular exercise relives stress, strengthens one’s heart, muscles and bones. In addition, it improves blood circulation and keeps joint flexible.

Patients with diabetes should take the doctor’s advice before beginning an exercise program. It is recommended that older patients with diabetes who have complications should avoid strenuous exercise, to avoid sudden deterioration of their complications.

Routine exercises belong to three categories namely: 1) Aerobic exercise, 2) Flexibility Exercise and 3) Strength exercise.

For most people, it is best to aim for a total of about 30 minutes, at least 5 days a week.

Strength training exercises done several times a week helps to build strong bones and muscles. Flexibility exercises also called stretching helps to keep the joints flexible and reduce the chance of injury during other activities.

In addition to formal exercise, one should try to increase the activities throughout the day. Walk wherever possible, avoid lift and take the stairs. Walking in public places such as railway station or bus stand, airport, etc must be taken as opportunities rather than burden. This will reduce stress and gives one the benefit of exercise.

The main benefits of exercise are

  • Improvement in blood glucose control.
  • Improvement in insulin sensitivity and lowered insulin requirements often leading to a reduced dosage of insulin and/or oral hypoglycemic agents especially in people with type 2 diabetes.
  • Reduction in blood pressure.
  • Reduction in Cholesterol levels.
  • Reduction in risk of osteoporosis
  • Reduction in heart related problems.
  • Favourable changes in body composition (decreased body fat and weight, increase in muscle mass)
  • Maintenance and improvement in body weight.
  • Improvement in psychological well being.

Side Effects of Exercise

  • Excessive increments in blood pressure
  • Exercise induced orthostatic hypotension
  • Increased protein excreted in urine
  • Hypoglycaemia
  • Foot ulcers
  • Accelerated degeneration of joints
  • Higher intensity resistance exercise increase in blood pressure that might cause stoke, myocardial infarction or retinal bleeds in middle-aged or older people at risk for cardiovascular disease.

Preferred Exercise

  • The type and intensity of the exercise chosen should not be too difficult for the person to master.
  • The activity or activities chosen should be enjoyable for the person to perform.
  • 5 – 10 minutes of warm up exercise such as walking or bicycling at low intensity to prepare the muscles, heart and lungs.
  • 30 minutes of aerobic exercise include walking, bicycling, jogging, continuous swimming, water aerobics and sports activities performed and sufficient intensity and frequency.
  • 5 – 10 minutes of cool down exercise consists of the same activities as the warm up.
  • Plan to increase intensity or duration of activity over time.

Treatment & Complications

Oral Hypoglycemic Drugs

Metformin is the first line of treatment for T2DM with high efficacy, low risk of Hypoglycemia, It reduces weight but is associated with  gastrointestinal side effects.

Sulfonylurea, which has moderate risk of hypoglycemia, increase in weight but the cost is low and high efficacy.

Thiazolidinedione, which has low risk of hypoglycemia and have high efficacy, but increase weight and causes edema, heart failure and bladder cancer.

DPP-4 inhibitors have low risk of hypoglycemia, decrease weight and less side effects, but the cost of the drug is very high.

SGLT2 inhibitors have low risk of hypoglycemia and decreases weight, but cause urinary tract infection, dehydration and the cost is very high.

GLP-1 analogues have low risk of hypoglycemia and decreases weight, but causes gastrointestinal disturbance and the cost is very high.

Since the drugs listed above act in different ways to lower blood glucose levels they may be used in combinations for better control and management. For example, a Metformin and a sulfonylurea may be used together. Many combinations can be used. Though taking more than one drug can be more costly and can increase the risk of side effects, combining oral medications can improve blood glucose control when taking only a single drug does not have the desired effects.

Insulin

Different preparations of insulin provide a range of options in terms of how quickly they take effect, their peak time of action and their overall duration of effect:

  • Rapid-acting insulin analogs have an onset of action at between 5-15 minutes, a peak action at 30-90 minutes and an overall duration of effect of 3-5 hours
  • Short-acting, regular insulin has an onset of action at between 30-60 minutes, a peak action at 2-3 hours and an overall duration of effect of 5-8 hours. The optimum time for injecting is 30 minutes before eating
  • Intermediate-acting insulin has an onset of action at between 2-4 hours, a peak action at 4-12 hours and an overall duration of effect of 10-18 hours
  • Long-acting insulin has an onset of action at between 2-10 hours, a peak action at 6-16 hours (except insulin glargine, which has no peak) and an overall duration of effect of 16-24 hours. These insulins maintain glucose levels fairly uniformly over a 24-hour period.

Side effects of insulin that are more common include:

  • Hypoglycemia – low blood sugar levels that can result from the timing of the insulin injection. Hypoglycemia might be avoided by shifting a pre-dinner dose of intermediate-acting insulin to bedtime, or reducing a bedtime dose
  • Weight gain – this may happen initially when insulin therapy is started, due to correction of protein and energy metabolism. Later weight gain may be caused by fluid retention or excessive eating due to hypoglycemia
  • Lipohypertrophy – raised lumps in the skin caused by repeated injections at the same site; this is can be prevented by the rotation of injection sites

Other local effects – these are less common than lipohypertrophy and include infection, injection site abscess (both of which can be prevented with good injection practices), allergy and lipoatrophy (loss of fat tissue).

Acute Complication

Hypoglycemia

Hypoglycemia is a state of low blood glucose in the blood. i.e. below 60mg/dl.

Symptoms of Hypoglycemia:

  • Excess hunger
  • Sweating
  • Giddiness
  • Shivering (tremors)
  • Weakness
  • Palpitation (rapid heartbeat)
  • Blurred vision
  • Behavioural change
  • Fainting attacks or blackouts
  • Convulsions (fits)

Causes of Hypoglycemia:

  • Over dose of diabetes medications
  • Delaying or missing meals, wrong timing of insulin and meals
  • Excessive exercise, especially on empty stomach
  • Consumption of alcohol on an empty stomach,

Treatment of Hypoglycemia:

If the person is conscious and alert, any food or drink can be taken immediately.

If reaction is severe and the person is unconscious, place some sugar or glucose in the mouth between the gums and check.

If the person has still not recovered, consult the doctor immediately. Intravenous glucose infusion will be necessary.

Prevention of Hypoglycemia:

  • Consume small frequent meals with snacks at appropriate time intervals.
  • Check your blood sugar regularly.
  • Reduce dose of medication, when you experience low blood glucose symptoms.

Tips:

  • Always eat on time.
  • Have a piece of sugar candy with you always.
  • Be alert about the symptoms of hypoglycemia.
  • Do not be afraid of the previous unpleasant episodes of hypoglycemia. Over come your fears with more self care.

Diabetic Ketoacidosis

Insulin is vital to patients with type 1 diabetes – they cannot live without a source of exogenous insulin. Without insulin, patients with type 1 diabetes develop severely elevated blood sugar levels. This leads to increased urine glucose, which in turn leads to excessive loss of fluid and electrolytes in the urine. Lack of insulin also causes the inability to store fat and protein along with breakdown of existing fat and protein stores. This dysregulation, results in the process of ketosis and the release of ketones into the blood. Ketones turn the blood acidic, a condition called diabetic ketoacidosis (DKA).

Symptoms:

  • Nausea
  • Vomiting
  • Abdominal pain

Without prompt medical treatment, patients with diabetic ketoacidosis can rapidly go into shock, coma, and even death may result.

Causes:

  • Infection
  • Stress
  • Trauma
  • Missing dose of insulin

Treatment:

  • Intravenous administration of fluid, electrolytes and insulin.
  • Antibiotics are given for infections

Chronic Complication

Long-standing diabetes mellitus is associated with an increased prevalence of microvascular and macrovascular diseases. With the rising prevalence of diabetes, the number suffering from the vascular complications of diabetes will also increase.

Microvascular Complications:

In 1999 a study conducted by Dr.A.Ramachandan1 showed a prevalence of 23.7% of Retinopathy, 5.5% of Nephropathy and 27.5 % of Peri-neuropathy. The recent prevalence of microvascular complication was 16.6% of Retinopathy, 21.1% of Nephropathy and 5.1% of patients have foot ulcer.2

Eye Complications

The specific eye complication seen in diabetes is called Diabetic Retinopathy, which affects the retina. Approximately 50% of patients with diabetes will develop some degree of diabetic retinopathy after 10 years of diabetes, and 80% of diabetics have retinopathy after 15 years of the disease. Retina is the nervous sheet at the back of the eyes which is sensitive to the light and carries the images of the objective to the brain. Diabetic Retinopathy is characterized by micro dilatation of arteries, white deposits, bleeding, formation of new blood vessels and finally vitreous hemorrhage and retinal detachment. The early stage is called “non-proliferative diabetic retinopathy, which can easily be arrested by proper control of diabetes and other risk factors. This is asymptomatic and the patient is usually not aware of the condition. This can be detected by a proper examination after full dilatation. Therefore, regular checkup of the eyes at periodic intervals is absolutely mandatory for people with diabetes.

When hard exudates occur in the center of the retina, there will be a marked reduction in the vision and this is called diabetic maculopathy and if not treated properly can produce severe loss of vision. Once new blood vessels are formed the condition is called proliferative diabetic retinopathy and can produce severe bleeding resulting in severe visual loss. In these cases retinal photocoagulation with laser treatment is necessary to arrest the progress of the disease.

It is important to remember that once sever damage to retina has already occurred, there is no treatment for restoration of vision. But visual loss can be prevented by early diagnosis and treatment. This reiterates the importance of regular eye examination in people with diabetes.

The good news is that proper control of blood sugar and blood pressure can go a long way in preventing retinopathy as well as in arresting the progress of early changes.

Kidney damage

Diabetes affects kidneys and diabetic nephropathy is one of the important specific complications of diabetes. It is estimated that 30-50% of individuals with kidney failure are diabetics.

Uncontrolled blood glucose for a long period of time produces functional and later structural changes in the kidney. The unfortunate truth is that changes occurring in kidneys are not clinically obvious to the treating doctor. Neither the patient feels any symptoms until the kidney is severely affected and the disease have reached an irreversible stage.

Diabetic Nephropathy(DN) is one of the dreaded complications of diabetes mellitus and can cause severe morbidity to the patient and heavy financial burden to the family, if it is not prevented or detected and properly treated in the early stage of the disease.

Routine laboratory tests to assess renal functions are urine analysis, blood urea and serum creatinine estimations. The results are generally abnormal only till nearly 60 percent or more of normal kidney functions are affected by DN. To detect and prevent DN, test for microalbuminuria is necessary. In normal individuals albumin excretion is less than 30mg in 24 hours and this is called normoalbuminuria. Albumin excretion of more than 30mg/24 hour and less than 300 mg/24 hours is called microalbuminuria. Microalbuminuria cannot be detected by the usual dipstick method and has to be classified by a special test. Based on albuminuria, DN classified as incipient or silent DN, early overt DN, advanced DN and end stage renal disease.

Risk factors for DN include duration of diabetes, poor blood glucose control, hypertension, genetic predisposition and smoking.

Screening for DN is necessary in all diabetic patients. In type 1 diabetes mellitus, DN occurs nearly after 5 years of onset of diabetes. In type 2 diabetes, DN may be present at diagnosis as type 2 diabetes mellitus may remain without symptoms for a number of years. So screening for DN is essential in the long term management of diabetes.

Nerve damage

Almost 50% of people with diabetes would be affected with some form of neuropathy. The most common neuropathy is the dysfunction of the nerves of the legs resulting in lack of sensation, numbness, pricking pain, tingling sensation and sometimes lacerating unbearable pain.

People with lack of sensation must be careful to avoid injuries and also take prompt treatment of wound infections. Walking over hot sand or pavement in summer without proper footwear or barefoot (especially in temples) could be detrimental producing thermal injury due to lack of temperature sensation.

Diabetes can also affect muscle power and produce weakness of muscle, either in the limbs or in the girdles. Fortunately muscle weakness due to diabetic neuropathy is largely reversible. Painful diabetic neuropathy is largely reversible. Painful diabetic neuropathy is less common but could be very disturbing and in some patients can cause severe pain in the feet especially in the night.

The pain in diabetic neuropathy some times may be devastating and patients get severely depressed. This will even lead to suicidal tendencies among some and treatment with antidepressants become necessary in such cases.

Another form of diabetic neuropathy is the involvement of the cranial nerves. The commonest is paralysis of the nerves responsible for eye movements and the clinical presentation is usually double vision. This type of neuropathy can affect the face resulting in facial palsy or Bell’s palsy. These types of diabetic cranial neuropathies recover completely.

All the above discussed nerve dysfunction are related to the systemic nerves but diabetes can also affect the autonomic nervous system supplying the muscles of the heart, gut, bladder and genitalia. The most disturbing symptom especially in men is called erectile dysfunction producing sexual incompetence in them. There are very effective treatments for these conditions.

The symptoms of neuropathy can be treated and will subside by good control of blood glucose and by using other therapeutic agents. The good news of course is that proper control of diabetes will help to delay or prevent the onset of neurological complications of diabetes.

Screening of Diabetes

Risk Factor

The prevalence of Type 2 diabetes in adults varies in different populations depending upon the affluence and ethnicity. It has been reported that the major risk factors for diabetes in any population are obesity, sedentary life style and high intake of food, rich in sugars and fats. Indians have a high genetic susceptibility to develop diabetes because of the increased genetic susceptibility and the tendency to have central adiposity.

Increased availability of fast food, rich in refined carbohydrates and fats is one of the primary reasons. The sedentary life habit has worsened due to prolonged television watching. People tend to spend more time watching television and travelling rather than spending time in walking.

The younger generations who are in the information technology industry seem to be at a higher risk because of spending more time working with computers and consuming junk foods. These factors increase the risk of obesity, diabetes and hypertension. Invariably this will increase the risk of cardiovascular diseases and other related complications.

Type 2 diabetes testing should be done in all adults > 45 yrs, who are overweight or obese (BMI ≥25 or ≥23 in Asian Americans) who have ≥1 diabetes risk factor 1

  • Physical inactivity
  • First-degree relative with diabetes
  • A1C ≥ 5.7%, IGT, or IFG on previous testing
  • Conditions associated with insulin resistance: severe obesity, acanthosis nigricans, PCOS
  • Women who delivered a baby >9 lb or were diagnosed with GDM
  • Cardio Vascular Disease history
  • HDL-C <35 mg/dL ± TG >250 mg/dL
  • Hypertension (≥140/90 mm Hg or on therapy)

Risk Score

Population studies done by India Diabetes Research Foundation in India have helped to establish  the diabetes risk score for Asian Indians . This score is simple, determined using easily measurable variables and can identify people having the risk of undetected diabetes. This can be applied by clinicians without any laboratory tests. It is also very cost effective to use on a large scale.

Risk score is used to identify people having undetected diabetes.

The likelihood of detecting diabetes in people with a score of 21 or more is high and they need to be tested with an oral glucose tolerance test.

Variables Risk Score
Age (30 – 44) yrs 10
Age (45 – 59) yrs 18
Age (> 59) yrs 19
Family history of diabetes 7
Body mass index ≥ 25 kg/m2 7
Waist: Male ≥ 85, Female ≥ 80 cm 5
Sedentary Physical Activity 4
Maximum Score 42
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