Diabetes - What We Should Know?

Dr.Vipin V. P
Senior Specialist Endocrinology
Aster Medcity, Kochi

World Diabetes Day

World Diabetes day is celebrated every year on 14 November. It was Introduced by WHO (World Health organisation) and IDF (international Diabetes Federation) to raise awareness about diabetes among people. The logo of World Diabetes Day is a blue circle. Each year, World Diabetes Day carries a particular theme and will work on that for the entire year. In 2014 to 2016 theme was healthy living and diabetes, particularly concentrating on healthy eating. Last year, there was a focus on starting each day right by having a healthy breakfast.

The theme for 2017 is women and diabetes – it’s our right to have a healthy future. This was keeping in the mind the fact that around 200 million women has diabetes in the world and in many developing countries and underdeveloped countries women with diabetes are being neglected and don’t get the equal standard of care as men. This year’s focus is to improve the awareness among women regarding diabetes and giving them the standard of care to have a healthy life.

Trends of diabetes prevalence and incidence over the years

The incidence and prevalence of diabetes all over the world is increasing. As per IDF study now the prevalence of diabetes is 1 per 11 person and it is likely to increase to 1 per 10 person by 2040. The increase in incidence as well as prevalence is mainly in developing countries like India, South Asian Countries and Africa. In India also, the

prevalence of diabetes is increasing. India stands only behind China to earn the title, Diabetes Capital of the World. Different states of India has different prevalence of diabetes due to differences in life-style, culture, diet, genetic and environmental factors. Previous studies have shown the prevalence is more in southern states of India, especially Kerala and Tamil Nadu. Kerala is known as diabetes capital of India as prevalence of diabetes is high i.e. 17-20% which is double the national average of 6-9%. The average age at which diabetes develops also has decreased from 40-50 years to 30-40 years. There is also an increase in the diabetes among adolescents and young adults. These changes in trends of diabetes could be due to

• Change in the dietary habit with easy access and more frequent use high calorie diet like burgers, pizzas, colas, and fried food items and other junk foods rather than homemade foods, especially among youngsters.

• Gradual decline in physical activity among youngsters and adults, with majority of time being spend with watching television, laptops, using mobiles etc. This will increase the prevalence of obesity in the young population with later development of diabetes.

• Increase in the stress levels at various stages of life – increased pressure being put on children for academics, increased job pressure for adults.

• Exposure to environmental pollutants like hydrocarbons, insecticides, pesticides and others which may function as endocrine disruptors and affect pancreatic function.

• Genetic predisposition – Indians have more abdominal and visceral fat deposition even at a normal BMI, which in turn results in increased insulin resistance and there by predisposes to diabetes

Types of Diabetes

1. Type 2 diabetes - It is the most common type (>90%), commonly occurring adults (> 40 years). It occurs due to resistance to the action of insulin. Mainly characterized by obesity, acanthosis nigricans and commonly occurs in persons with a sedentary lifestyle

2. Type 1 diabetes - usually occurs in children and young adults due to destruction of the beta cells of pancreas. Patients are lean, has very high blood sugars, weight loss and sometimes presents with breathlessness and altered sensorium. They require insulin from the time of diagnosis to control blood sugars.

3. Gestational diabetes mellitus (diabetes diagnosed in the second or third trimester of pregnancy) - due to hormones and enzymes secreted by placenta which opposes the insulin action.

4. Diabetes due to other pancreatic diseases (such as chronic pancreatitis, cystic fibrosis and malignancy) – presents with diabetes, abdominal pain and difficulty in digesting fatty foods and weight loss

5. Genetic forms of Diabetes - usually rare, due to mutations in different genes involved in insulin secretion or action. E.g. MODY (Maturity onset diabetes of young)

6. Drug- or chemical-induced diabetes (such as treatment with steroids after organ transplant or in the treatment of HIV/AIDS)

At risk individuals for diabetes who should undergo screening

1. Any person > 45 years (especially overweight or obese)

2. Adults who are overweight (BMI ≥ 23 kg/m2) and have additional risk factors like

• Physical inactivity

• First-degree relative with diabetes

• Women who delivered a baby weighing > 4 kg or were diagnosed with gestational diabetes

• Systemic hypertension (BP≥140/90 mmHg),

• Cholesterol abnormality

• Women with polycystic ovary syndrome,

• Past history of pre-diabetes or history of cardiovascular disease (heart attacks or stroke).

Screening and Classification according to blood sugar level

Screening should be done in those patient who are at risk of developing diabetes or who has symptoms of diabetes (excessive thirst, increased urination, weight loss and tiredness) or in patients who are undergoing surgery or other procedures. The main tests to diagnose diabetes are

• HbA1C (average of 3 months blood glucose)

• Fasting blood glucose

• 2-hour post glucose (75gram) blood sugars

If results are normal at first testing, testing should be repeated at a minimum of 3-year intervals. Those with pre-diabetes should be tested yearly.

Prediabetes is a phase which can progress to diabetes if we do not take any action (at a rate of 10% per year) and it can be reverted to normal if we take appropriate actions (30% of the cases).

Checklist in the evaluation and follow up of Diabetes patients

Once diabetes is diagnosed one has to seek proper medical advice for further management. It will help to control the blood sugars, prevent the complications and helps in diagnosing and treating diabetes related complications. The important things to be monitored during diabetes management are

• Fasting blood sugar / 2 hour post prandial blood sugars – For day today control of diabetes (at least monthly and more frequently if uncontrolled

• HbA1C – average sugar of past 3 months (3 monthly)

• Creatinine – to know kidney function (yearly or 3-6 monthly if it is abnormal)

• Urine albumin/creatinine ratio – to look for proteinuria (yearly)

• Lipid profile – to look for cholesterol abnormalities (yearly)

• ECG/ECHO – if cardiac symptoms are present

• Fundus (eye) examination – to look for retinopathy(yearly)

• Diabetic foot examination – each clinic visit

• BP check-up and weight check-up– each clinic visit

Treatment goals of Diabetes

The main treatment goal of diabetes is to educate patients to self-manage their diabetes and to help them to clear off the myths related to diabetes. One should aim to control blood sugars, treat associated co-morbidities there by try to prevent complications of diabetes. The targets are

• HbA1C <7.0%

• Pre-meal blood sugar / Fasting blood sugar - 80–130 mg/dl

• Post meal blood sugar <180 mg/dl

• BP < 140 /< 90 mmHg

• LDL Cholesterol <100 mg/dl and Triglyceride < 150 mg/dl

• Avoid hypoglycemia

• Avoid complications

What we should do to prevent Diabetes?

The most important step in prevention of diabetes is improving awareness regarding diabetes prevention in the community especially targeting the school going children and the youth (Can be done through schools, community organizations, camps and seminars etc.).

Cut down the calories: Overweight or obese adults at risk for diabetes should reduce energy intake to promote weight loss. They should try to reduce the portion/quantity during each meals, avoid eating in between meal times and should avoid high calorie food items (like colas, fried items, burgers and excess quantity of direct sugars). We should promote carbohydrate intake from vegetables, fruits, whole grains, legumes, and dairy products over intake from other carbohydrate sources, especially those that contain added fats, sugars, or sodium.

Each step counts: Each step we walk in a day will help in preventing diabetes. So everyone should be encouraged to increase the number of steps walked per day. Children with obesity or overweight should exercise at least 60 min /day. Adults with diabetes risk should do 150 min/ week of moderate-intensity aerobic exercise (like speed walking, jogging, cycling, swimming or skipping). All individuals should be encouraged to reduce sedentary time, particularly by breaking up extended amounts of time (if sits for >90 min, then should walk for 5-10 min) spent sitting. A weight loss of minimum 5% of body weight - prevents diabetes.

All individuals should be motivated to quit smoking/ not to use tobacco products and to avoid alcohol.

So on the occasion of this November 14th- word diabetes day, we should acquire the motivation to take steps to prevent diabetes. Act today to stay healthy.