Essay on Diabetes: Features and Symptoms

In this essay we will discuss about the Diabetes Mellitus:- 1. Meaning of Diabetes 2. Types of Diabetes 3. Clinical Features 4. Symptoms 5. Diagnosis 6. Management 7. Treatment 8. Choice of Therapeutics 9. Clinical Features of Ketoacidosis 10. Diseases Suffered 11. Problems in Management 12. Prognosis 13. Prevention.

Contents:

1. Essay on the Meaning of Diabetes
2. Essay on the Types of Diabetes
3. Essay on the Clinical Features of Diabetes
4. Essay on the Symptoms of Diabetes
5. Essay on the Diagnosis of Diabetes
6. Essay on the Management of Diabetes
7. Essay on the Treatment of Diabetes
8. Essay on the Choice of Therapeutics for Diabetes
9. Essay on the Clinical Features of Ketoacidosis
10. Essay on the Diseases Suffered by Diabetic Patients
11. Essay on the Problems in Management of Diabetes
12. Essay on the Prognosis of Diabetes
13. Essay on the Prevention of Diabetes

---

Essay # 1. Meaning of Diabetes:

Diabetes mellitus is a syndrome due to different diseases characterized by a raised glucose concen­tration in the blood, due to diminished effective­ness of insulin. The disorder is chronic and also affects the metabolism of fat and protein. It has an increased risk of atherosclerotic diseases and of certain obstetrical difficulties.

It is the commonest endocrine disorder. There are two major types -Type 1 insulin dependent dia­betes which was formerly known as juvenile onset diabetes occurring between 10 and 12 years of age. Type 2 non-insulin diabetes occur in middle age or later. Genetic and dietary factors, infections and possibly stress may increase the risk of developing diabetes.

---

Essay # 2. Types of Diabetes:

i. Primary Diabetes:

a. Genetic Factors:

Many separate genetic mechanisms increase the risk of diabetes and its various manifestations, and these differ in type 1 and type 2 diabetes.

b. Obesity:

Although most type 2 diabetics are obsese, only a minority of obese pa­tients develop diabetes. In simple obesity there is insulin resistance, particularly in muscle, and hyper-insulinemia. There is impaired insulin uptake by receptors in target tissues.

In general, the more carbo­hydrate tolerance is impaired in obese dia­betics, the more deficient the insulin se­cretory response to various stimuli. Obese people in general are less physically ac­tive than those whose weight is normal. It is possible that physical exercise may re­duce the risk of diabetes in susceptible individuals.

c. Dietary Restrictions:

Restrictions on the food supply of community, affect diabe­tes. Rationing is beneficial to individuals susceptible to diabetes.

d. Sugar Intake:

A high intake of sugar is definitely associated with a high preva­lence of obesity. Sucrose has a specific diabetogenic effect, though the very high intake may contribute to the high preva­lence of diabetes.

e. Dietary Fibre:

The high fibre content of the diet causes the reduced prevalence of diabetes. Most diets now recommended for diabetics are high in fibre.

f. Infections:

Diabetes is frequently diag­nosed by finding glucose in the urine with an acute staphylococcal or other infec­tions. Infections cause a non-specific out­pouring of catabolic hormones which antagonize insulin action and this may trig­ger the onset of the disorder.

More evi­dences show that type 1 diabetes espe­cially in younger patients is caused by virus infection. The virus may trigger an autoimmune reaction in the pancreatic is­lets and this impairs insulin secretion and ultimately destroys the beta cells.

g. Stress:

Stress causes a sudden increase in secretion of catabolic hormones which may precipitate the disorder. It probably does not cause diabetes in people who would never have developed it. The im­paired secretion by pancreatic islet cells may cause the disorder.

Many environ­mental factors may lead to such impair­ment. Genetic factors appear as the main determinant of susceptibility to such en­vironmental factors, those leading to over­weight and obesity being the most impor­tant in type 2 diabetes and viral infections in type 1.

ii. Secondary Diabetes:

A minor cases of diabetes occurs as a result of pan­creatitis, haemochromatosis, carcinoma of the pan­creas and pancreatectomy. Diabetes may also accompany endocrine dis­orders which increase concentrations of catabolic hormones or modify the regulation of insulin receptors.

---

Essay # 3. Clinical Features of Diabetes:

Type 1 Diabetes:

This usually appears in early age (between 10 to 12 years of age) in patients of nor­mal or less than normal weight. Symptoms are usu­ally severe and develop rapidly. Severe Ketoaci­dosis occurs and is often fatal without insulin treat­ment. Since insulin is required for their survival an alternative name for this patient is insulin depend­ent.

Type 2 Diabetes:

This usually appears in mid­dle age or later in patients who are often obese and their hyperglycemia is controlled by dietary means alone or by an oral hypoglycemic drug. The pa­tients are less prone to develop Ketosis. Therefore, type 2 is less severe disease than type 1.

---

Essay # 4. Symptoms of Diabetes:

(a) Some patients complain of some or all of the classical symptoms which are thirst, polyuria, nocturia, tiredness, loss of weight, reduced visual activity, white marks on clothing, polydipsia.

(b) Many patients are first found to have gly­cosuria in the course of some routine ex­amination e.g., for insurance, for employ­ment purposes. They may have few or no symptoms.

(c) Ketoacidosis may occur in diabetics in in­fection. Epigastric pain and vomiting may be the main complaints. These are usually type 1 diabetes.

(d) Patients may complain one of the symp­toms like failing vision; parasthesia in the limbs or pain in the legs; impotence; infection of the skin, lungs or urinary tract.

Physical Signs:

There is dehydration, loose dry skin, dry furred tongue with cracked lips. The pulse is rapid and the blood pressure is low. Breath­ing may be deep and rapid. The sweet smell of acteone may be noticeable in the breath. There may be coma. Early signs of diabetic neuropathy are depres­sion of the ankle jerks and impaired vibration sense in the legs. The presence of neuropathy may be indicated by proteinuria.

---

Essay # 5. Diagnosis of Diabetes:

Urine Testing:

(a) Glycosuria

(b) Ketonuria.

Random Blood Sugar:

The oral glucose toler­ance test.

---

Essay # 6. Management of Diabetes:

Diabetic patients no longer die in Ketoacidosis in any number as they once did. The increased death rate of treated diabetic patients is due to coronary heart disease. Many of those whose duration of life has been extended are chronic invalids. They may live for many years with cerebral, coronary, or pe­ripheral vascular disease, or with renal disease or serious visual impairment.

---

Essay # 7. Treatment of Diabetes:

i. Diet alone.

ii. Diet and oral hypoglycemic drugs.

iii. Diet and insulin.

About 40 per cent of new case of diabetes can be controlled adequately by diet alone, about 30 per cent require insulin and another 30 per cent need an oral hypoglycemic drug. Insulin is needed for juvenile diabetes; older patients do not require insulin except when control of their diabetes by an illness, infection or operation.

i. Diet:

(a) In all diabetics the amount and time of food intake, especially the carbohydrate, should be controlled to prevent the fluc­tuations of blood glucose beyond the nor­mal range.

(b) Intake of refined sugars should be low be­cause their consumptions is followed by absorption and a high peak of blood glu­cose.

(c) Patients should avoid fasting or feasting; their intake from day to day should be maintained with adjustments for exercise and appetite; they should not miss a meal or over-indulge.

(d) Type 1 patients require insulin and their food, particularly carbohydrate, should be adjusted to match the time of action of their insulin. This depends on the type of insulin being used and whether the pa­tient is having a single injection or more than one each day.

The balance between insulin and meals has to be adjusted from time to time. They usually want to take moderate and sometimes strenuous exer­cise. They, therefore, require a generous amount of dietary energy.

(e) Type 2 patients are usually obese. Being middle aged or elderly they may not take much exercise. For these reasons the daily energy intake should be restricted to about 1,000 k cal. The flying career of airline pilots depends on avoiding insulin or drugs.

(f) The nature of carbohydrate is important. Sucrose should be eliminated or greatly reduced. Starchy foods rich in dietary fi­bre are beneficial to diabetics. There are two essential points about a diabetic diet. First, energy intake should be adjusted to maintain ideal body weight. Secondly, all patients taking insulin should follow a regular pattern of meals, matched to the injected insulin.

(I) Carbohydrate:

(a) A minimum of 100 grams is needed to pre­vent ketonuria.

(b) Foods rich in sucrose and other sugars should be kept to a minimum.

(c) 60 grams of fructose should be taken a day; obese diabetics should not use fruc­tose and sorbitol as they have the same energy value as other sugars. Although fructose may not raise blood glucose as much as sucrose or glucose, it may raise plasma triglycerides more.

(II) Protein:

Amino acids stimulate insulin secretion in both normal subjects and in those with type 2 diabetes. A smaller rise in blood glucose also occurs when carbohydrate is consumed along with protein. A minimum amount of about 50 grams of protein should be specified in all diabetic diets unless the patient is obese.

(III) Fat:

As diabetic patients have an increased risk of death from coronary heart disease and as this may be re­lated to the amount of saturated fat in the diet, the total amount of fat should be restricted even in those who are not obese.

ii. Types of Diet:

There are two types of diet:

(a) Measured diet:

The amount of food to be eaten at each time of the day is specified.

(b) Unmeasured diet:

The patient is supplied with a list of foods grouped in three cat­egories – foods with a high concentrated carbohydrate content which are to be avoided altogether, foods with a relatively stable un-concentrated carbohydrate con­tent which are to be eaten in moderation only, and non-carbohydrate foods which may be eaten as desired.

iii. Alcohol:

Patients may take alcohol if they need to have energy value and carbohydrate content. Beer may contain 10 to 30 grams of carbohydrate per half litre and this provides 150 to 400 kcal depend­ing on the strength of the beer.

iv. Sweetening Agents:

Saccharin and aspartate may be used but have no energy value.

v. Drugs:

A good number of compounds reduce hyperglycemia in patients who would require in­sulin. The sulphonylurea compounds, tolbutamide, chlorpropamide, glibenclamide, glipizide, gliquidone, metformin have a place in the manage­ment of 30 per cent of diabetic patients. It is dan­gerous to attempt to control juvenile-onset diabe­tes with these compounds.

vi. Insulin:

Most diabetics now manage with two injections daily, one before breakfast and one be­fore the evening meal, each containing soluble and depot insulin.

(a) Soluble insulin:

This is a clear solution whereas depot insulin’s are cloudy. It be­gins to lower the blood glucose in 30 min­utes: the effect is maximal in 4 to 6 hours and ends after 6 to 10 hours.

Soluble insu­lin is essential in the following circum­stances:

1. For new cases with severe dehydra­tion or Ketoacidosis.

2. For emergencies associated with ketosis, such as acute infection, gastro­enteritis or some surgical operations.

3. For the treatment of nearly all young patients.

(b) Depot Insulin’s:

Depot insulin’s do not lower blood sugar before 5 to 6 hours; the effect is maximal at 8 to 14 hours and ends only after 20 to 30 hours.

---

Essay # 8. Choice of Therapeutics for Diabetes:

(a) All young patients who develop diabetes before the age of 40 years require treat­ment with insulin. The majority are best controlled by a combination of short-act­ing and intermediate-acting (depot) insu­lin injected twice daily, before breakfast and before the evening meal.

(b) Most patients developing the disease over the age of 40 years can be controlled by diet alone. Obese patients should be treated by dietary restriction and weight reduction but others may do well on di­etary therapy alone. Insulin and the sulphonylureas increase the appetite and thus may increase weight and intensify disability.

(c) Those over the age of 40 who are not con­trolled by dietary measures alone usually respond well to sulphonylureas. If ad­equate control is not achieved by one drug, a combination of sulphonylurea and biguanide may be tried. If this fails, insu­lin is needed.

(d) Elderly patients who require insulin often do well with a small dose (20 units) of a depot insulin alone. But those who require more than 40 units a day should be given soluble insulin in addition.

---

Essay # 9. Clinical Features of Ketoacidosis:

The most common cause of Ketoacidosis is neglect of treatment due to carelessness, misunderstanding or illness. There is intense thirst and polyuria. Constipa­tion, muscle cramps and altered visions are com­mon. Sometimes, there is abdominal pain with or without vomiting. Weakness and drowsiness are commonly present.

The signs include dry tongue, soft eyeballs due to dehydration, hyperventilation indicated by rapid, deep, sighing respirations and rapid, weak pulse, with low blood pressure and acetone may be smelt in the breath. Sometimes there is abdominal rigidity and tenderness.

Ultimately, coma appears. Laboratory tests show heavy glycosuria and ketonuria, blood glucose usually between (360 and 720 mg/100 ml), and low plasma bicarbonate and blood pH.

Treatment of Ketoacidosis:

This condition should be treated with the utmost urgency in hospital. Intravenous therapy is required although the patient is able to swallow. Extracellu­lar fluid is repleted first with sodium chloride infu­sions. It is better to give low dose insulin starting with 6 to 9 units per hour and halving the dose when the blood glucose has returned to normal.

In the majority of cases potassium therapy should be started from the outset. Intracellular fluid is replaced once the blood glucose has fallen below 250 mg/ 100 ml by infusing glucose solution. Intensive medical care is needed and the blood glucose, pH, electrolytes and ketones have to be monitored, hourly at first.

---

Essay # 10. Diseases Suffered by Diabetic Patients:

i. Vascular Disorders:

Atherosclerosis occurs commonly and extensively in diabetics. Diabetics are more prone to myocar­dial infarction and gangrene of the toes and feet at an earlier age than other people. The peripheral pulses in the legs are often di­minished, ischaemic changes in the feet are fre­quently apparent.

Defective circulation in the legs results in the dangerous complication of gangrene. Diabetic gangrene usually starts in one foot. Toxic absorption from necrotic tissue and secondary in­fection may kill the patient unless the limb is am­putated. Amputation of a toe, a foot or even a whole leg is sometimes necessary to save life.

ii. Cataract:

Cataract is more prevalent in old people having diabetes. Rarely a specific type of opacity of the lens occurs in diabetic children whose disease has not been adequately controlled.

iii. Infections:

Poor control of diabetes has lowered resistance to infection.

The following forms are especially im­portant:

(a) Carbuncle:

The development of a carbun­cle may unmask diabetes and may even precipitate ketosis and coma. Cleanliness is very important in the prevention of skin infection in diabetes. Once infection has occurred a suitable antibiotic is needed.

(b) Urinary Tract Infections:

The presence of glucose in the urine provides a favourable medium for the growth of bacteria. Intrac­table infections of the urinary tract fre­quently occur and for this reason catheterisation should be avoided. Once infection has been started treatment consists of con­trolling the glycosuria and the adminis­tration of suitable antibiotics.

(c) Pulmonary Tuberculosis:

In countries where this is prevalent all new diabetic patients should have a chest radiograph.

(d) Vulvitis:

Candida albicans is nearly al­ways present in diabetic women. In the majority, the treatment is abolition of gly­cosuria which brings rapid relief.

---

ADVERTISEMENTS:

Essay # 11. Problems in Management of Diabetes:

i. Children:

(a) Diabetes is not common in childhood, but when it occurs it is relatively severe and always requires treatment with insulin. The problem of matching the dose of insulin to the food intake raises practical difficul­ties.

(b) As the children should be growing, their energy requirements are large and diffi­culties arise in meeting them. It is impor­tant to make sure that the child does not become too fat because too much insulin can lead to excessive appetite and hence to obesity. It is better to encourage them to take responsibility of their own care. They should be trained to swim under su­pervised pools.

(c) Children are not expected to lead a steady life and their activities fluctuate unex­pectedly. Excessive activity may result in hypoglycemia, and lethargy in hyperglycemia. Hyperglycemia may be caused by infectious disease. A combi­nation of one of the depot insulin’s and soluble insulin before breakfast and a second dose of soluble insulin before supper.

ii. Pregnancy:

(a) Pregnancy in a diabetic woman carries certain risks. In the later stages, she may develop an excessive accumulation of amniotic fluid; in addition the fetus is sometimes unusually large leading to difficulty in labour. There is also an in­creased risk of her baby having a neural tube defect or other error in develop­ment. A planned pregnancy reduces the risk.

(b) A pregnant diabetic patient requires close supervision by a team consisting of phy­sician, obstetrician, anesthetist, nurse and dietician. After the diagnosis of pregnancy, the patient should be seen at first fort­nightly and later at weekly intervals. In the later stages of pregnancy, lactosuria occurs and may lead to confusion. There­fore, blood glucose estimation should be done by finger-prick.

(c) Nowadays, many pregnancies are allowed to go on to full term with improved glycemic control and caesarian section is less used.

iii. Diabetes and Surgery:

Any surgical operation causes a metabolic stress which the diabetic is less able to meet. The posi­tion is worse if there is tissue wasting with much breakdown of fat and protein. It is to be kept in mind that there is the need to provide an adequate supply of energy for the tissues and the need to be on the alert for acidosis. Diabetes is to be first diag­nosed before operation.

---

Essay # 12. Prognosis of Diabetes:

The prognosis of diabetes has improved steadily since the introduction of insulin. It is difficult to estimate the prognosis of an individual patient be­cause so many variable factors have to be consid­ered. The incidence of the complications of diabe­tes is mainly related to the duration of the disease but probably also to the precision with which it has been controlled.

---

Essay # 13. Prevention of Diabetes:

Diabetes is a disease of the prosperous and in wealthy countries. It is one of the major health prob­lems. Sufficient exercise and avoidance of excess diet have repeatedly been stated. Diabetes, like obesity and atherosclerosis, is likely to occur in persons who eat too much and exercise too little.