SYMPTOMS AND DIAGNOSIS OF DIABETES

The main initial symptoms of diabetes are: 1. Polyuria (Excess urination) 2. Polydypsea (Excess drinking of water) 3. Polyphagia (Excess hunger) 4. Weight loss, fatigue 5. Skin infection especially genital itching due to fungal infection can be presenting symptoms. 6. Impotence may also be presenting symptoms.

Criteria for the diagnosis of diabetes Venous plasma glucose mg/100 ml § Fasting > 400 § 2 hours after ingestion > 200 § Random > 200

Who should undergo test for diabetes? All individuals with a definite risk for diabetes should be tested. These include: 1. All persons with symptoms suggestive of diabetes as discussed above. 2. All persons who have a close relative (blood relation) who is diabetic. 3. All pregnant women. 4. All adult patients suffering from tuberculosis or recurrent infections. 5. All obese patients. 6. All patients with high blood pressure. Lipid problems, heart disease or paralytic strokes. Many diabetics may not fit into these groups, hence, all persons above the age of 40 years should have tests for detecting diabetes at least once a year. Should medication be taken on the day of blood test? Very often it has been observed that patients do not take their medications whether tablets or insulin on the day of their test. This is wrong. The test is being done to see how well your diabetes is controlled when on these dedications, so it is important to take medicines as usual. What should be the diet on the day of blood sugar test? The diet on the day of the test should be exactly like what it is daily. Only then can be doctor judge the efficacy of the treatment. How often should the blood sugar be tested? Initially checkup is quit often, till the doctor is satisfied about diabetes control. Once the blood sugar is stabilized, then testing and checkup every three months is advisable.

DIABETES MELLITUS AND WOUND HEALING

INTRODUCTION

Wound healing is the process of repair that follows injury to the skin and other soft tissues. Wounds may result from trauma or from a surgical incision. In addition, pressure ulcers (also known as decubitus ulcers or pressure sores), which develop on areas of the body where the blood supply has been reduced because of prolonged pressure, might also be considered wounds. The capacity of a wound to heal depends in part on its depth, as well as on the overall health and nutritional status of the individual.

DIABETIC ULCERS

These ulcers may be because of diabetic neuropathy and loss of sensation or they may be because of ischemia as a result of Diabetic Vasculopathy. It is also known that there is negative chemotaxis, poor functioning of macrophages and opsonin. Infections may play a major role in causing more morbidity and mortality.

HEALING PROCESS

Following injury, an inflammatory response occurs and the cells below the dermal layer begin to increase collagen production. Later, the epithelial tissue (the outer skin layer) is regenerated. Dietary modifications and nutritional and herbal supplements may improve the quality of wound healing by influencing inflammatory or reparative processes.

DIETARY CHANGES THAT MAY BE HELPFUL:

 Pressure ulcers and diabetic ulcers frequently develop in malnourished and/or institutionalized individuals. Malnourished people applied to their skin 20 ml of a solution containing essential fatty acids (linoleic acid extracted from sunflower oil) plus vitamins A and E. Solution was applied to the skin three times per day. The solution containing essential fatty acids significantly reduced the incidence of pressure ulcers and improved the hydration and elasticity of the skin.

In a study of malnourished people with pressure ulcers, those who were given a diet containing 24% protein showed a significant reduction in the size of the ulcer, whereas those given a diet containing 14% protein had no significant improvement. This study suggests that increasing dietary protein in malnourished individuals can improve wound healing.

NUTRITIONAL SUPPLEMENTS THAT MAY BE HELPFUL

Vitamin C participates in the process of wound healing by promoting the synthesis of collagen. Supplementation with vitamin C (1–2 grams per day)increases the rate of healing of experimental gingival wounds. In patients with decubitus ulcers, supplementation with 500 mg of vitamin C twice a day accelerated ulcer healing.

The mineral zinc plays a role in cell division and cell proliferation, both of which are involved in the process of wound healing. Zinc deficiency is associated with impaired wound healing. The healing time of a surgical wound was reduced by 43% following oral supplementation with zinc sulfate in the amount of 50 mg three times per day. Zinc supplementation also improved healing in elderly patients suffering from chronic leg ulcers and pressure sores. In another study, intravenous administration of zinc significantly reduced the number of post-operative complications in surgical patients.

In a study of patients deficient in zinc, topically applied zinc oxide (as an additive to a gauze bandage) enhanced the regeneration of epithelial tissue on leg ulcers. In addition, inflammation and bacterial growth were reduced. In a study of thirty-seven elderly individuals with leg ulcers, application of zinc oxide compresses promoted ulcer healing. Although zinc oxide produced beneficial effects in these studies, topically applied zinc sulfate was ineffective.

Rats fed a vitamin A supplemented diet showed enhanced wound healing, compared with those fed a standard diet. The beneficial effect of vitamin A on wound healing may be due to an increase in collagen synthesis. Supplementation with vitamin A also reversed the impairment of wound healing seen in rats with experimentally induced diabetes.

Animal studies have shown that supplementing with vitamin E can decrease the formation of unwanted adhesions following a surgical wound. In addition, wound healing was more rapid in animals fed a vitamin E-rich diet than in those fed a standard diet. However, in another study, wound healing was inhibited by supplementation with a massive amount of vitamin E (equivalent to about 35,000 IU).  This adverse effect of vitamin E was prevented by supplementation with vitamin A. Although the relevance of these studies to human is not clear, many doctors of natural medicine recommend supplementing with both vitamins A and E in order to enhance wound healing and prevent adhesion formation.

Copper is a required cofactor for the enzyme lysyl oxidase, which plays a role in the cross-linking (and strengthening) of connective tissue. Doctors of natural medicine often recommend a copper supplement as part of a comprehensive nutritional program to promote wound healing.

Thiamine (vitamin B1), pantothenic acid (vitamin B5), and other B vitamins have each been shown to play a role in wound healing. For this reason, doctors of natural medicine often recommend a B vitamin supplement to promote wound healing.

Ingestion of bromelain, an enzyme derived from pineapple, prior to and following a surgical procedure has been shown to reduce swelling, bruising, healing time, and pain. Supplementation with bromelain has also been shown to accelerate the healing of soft-tissue injuries in men following a boxing match.

HERBS THAT MAY BE HELPFUL

Herbalists in a topical dressing to assist in wound healing useCalendula. Studies indicate a potent anti-inflammatory effect.

Traditional herbalists frequently recommend a combination of herbs for wound healing in order to achieve a desired effect. The herbs St. John’s wort, calendula, chamomile, and plantain (Plantaginis lanceolatae) have all been shown to exert anti-inflammatory effects in a rat model. It is unknown whether a synergistic effect may be achieved by using the combination of these herbs rather than single herbs. These herbs have shown beneficial actions; for example, plantain acts as an anti-inflammatory when used externally, and St. John’s wort in a topical application demonstrates an anti-inflammatory action.

In addition, comfrey is an external anti-inflammatory that may decrease bruising. Witch hazel can be used both internally and externally to decrease inflammation and stop bleeding. Horsetail can be used both internally and externally to decrease inflammation and promote wound healing. In a rat model of skin inflammation, both topical and oral aloe Veras have proven beneficial in decreasing inflammation and promoting cellular repair.

INSULIN THERAPY

Insulin was discovered in 1921 and it plays a key role in the homeostasis of glucose. Exogenous insulin administration is used in control of Diabetes Melliturs. The conventional insulin and impurities. Hence newer insulin (Human Insulins) have been manufactured. Human Insulin is obtained by one of the two ways.

I. Semi synthetic method in which porcine insulin is converted to human insulin.II. Bio synthetic method in which Human Insulin is manufactured by genetic recombinant DNA technology.

INDICATIONS OF NEWER INSULINS.

1) Insulin Allergy

2) Immunogenic Insulin Resistance (IIR)

3) Insulin Lipodystrophy4) Pregnant diabetic patients5) Diabetic patients requiring temporary insulin therapy while undergoing stress (Surgery, IIIness etc)6) Diabetic patients with angiopathies and renal damage7) Preferably all newly diagnosed insulin dependent diabetics8) Insulin antibodies and immune complexes interfere with measurement of circulating plasma insulin levels. Use of the newer insulins eliminates these complexes and thus permits a more accurate assessment of insulin level, and thus, aids in the determination of an appropriate insulin dosage. 9) Diabetic Vegetarians and diabetics who have "religious reservations" to the use of insulin of animal origin.

TYPES OF INSULIN:

The insulins are divided into three major categories based on the duration of action as Short acting] Intermediate acting] Long acting] Insulin

APPROXIMATE TIME-COURSE OF ACTION OF VATIOUS INSULIN PREPARATIONS

Kind of Insulin Preparation

Onset of actiom (hr)action (hr) Peak of activity(hr) Total duration of action

(hr)SHORT SCTING

Regular 0.5-1 2-4 4-6Semilente 1-2 3-6 8-12

UNTERMEDIATE INSULINNPH 3-4 10-16 20-24Lente 3-4 10-16 20-24

LONG ACTINGPZI 6-8 14-20 32Ultralente 6-8 14-20 32BIPHASICPREMIXED (NPH+REG) 0.5 2-10 12-18

* All these types of insulin are available as porcine, bovine, a combination of porcine and bovine, highly purified monocomponent insulins and human insulins. ** The onset of action is rapid with human insulin. *** Biphasic insulins are available in various ratio of regular and NPH (30:70;50:50:25:75etc.,)

This hormone has proved to be a lifesaver for many diabetics. The current thinking is that injections of insulin may not be necessary for some adults with mild diabetes, but that this therapy is almost always necessary for juvenile diabetics and adult diabetics whose insulin secretion is inadequate. Sometimes, insulin-dependent diabetics may appear to have a remission of their disease so that it may see m that injections of the hormone are no longer necessary. It is believed that injections of insulin reduce the stress on the few insulin-secreting cells which remain functional. Thus, the rested pancreatic cells may be able to cope for a while on their own. However, many doctors believe it is wise to continue the administration on insulin throughout temporary periods of remission so as to keep the insulin-dependent diabetic in a consistent pattern of regulation.    Like many other therapies, injections of insulin have their drawbacks. First of all, it is not always easy for the doctor to determine the dose that is needed.  Too little gives poor control, which is still better than no control, while too much may produce hypoglycemia (low blood sugar). Second, it was mentioned earlier that some doctors suspect t that excessive insulin might accelerate the buildup of fatty materials in atherosclerotic plaques, since insulin promotes the uptake of fat by cells and the synthesis of storage fat. Finally, some diabetics develop various types of physiological blocks against the actions of the hormone. It is now suspected that occurrence of these problems might be greatly curtailed if the requirements for insulin were to be lowered in mainly diabetics by strict dietary control and regular programs of moderate to vigorous physical activity.    Determination of the amounts and types of insulin to be administered is the responsibility of the attending physician. Likewise, the choice of a diet to be used by an insulin-dependent diabetic must also be determined by the doctor who usually asks a dietitian to work out the details. Although this situation differs from that of the mild diabetic treated by diet alone (where the dietary prescription may merely be to consume less energy so as to lose weight), extra precautions are necessary in order to coordinate the effects of both diet and insulin injections (and, in some cases, the added effects of strenuous exercise).

There are two life-threatening crises which may occur in diabetes:

diabetic coma hypoglycemia. 

The measures to be taken depend upon the correct identification of the critical condition, since the wrong treatment may do more harm than good. It is not always easy to distinguish between diabetic coma and hypoglycemia because 

1. Vigorous treatment of the coma may lead to hypoglycemia,  2. Prolonged hypoglycemia causes brain abnormalities which have many features like those of diabetic coma. 3. The metabolic reaction to hypoglycemia (increased secretion of diabetogenic hormones) in severe diabetes may

lead to diabetic coma. 

DIABETIC COMA. 

     The acetone breath which accompanies this condition has often led to the mistaken identification of a comatose diabetic as a drunk.  Subsequent confinement in a prison has sometimes resulted in severe complications, and in a few cases, death. Therefore, a diabetic should always wear an identification tag. (Purses or wallets are often lost or stolen during emergency situations.) A doctor should be immediately summoned, since attempts at first aid by lay persons may be ineffective, or even dangerous. The family of a diabetic shout not attempt to administer insulin unless the doctor so advises, since the injection of insulin may be fatal to a person suffering from hypoglycemia. 

HYPOGLYCEMIA (Insulin Shock).      All diabetics should have available at all times a source of readily available sugar for use in case of hypoglycemia (low blood sugar). Convenient sources of sugar are items such as soft candy (hard candy may dissolve too slowly), cubes or paper packets of table sugar, dextrose tablets (a form of pure glucose which is sold in certain health foods stores and pharmacies), and malted milk tablets. If a diabetic is at home, he or  she may drink a glass of fruit juice. However, nothing should be placed in the mouth of an unconscious person. In the latter case, a doctors should be called immediately. 

   Some doctors recommend that diabetics keep home supplies for the injection of glucagons, and that family members be instructed in its administration in the event that emergency care is not available. Each of these emergency measures should be used with great discretion, for the rapid raising of the blood sugar may worsen diabetes. Hence, each diabetic should be very familiar with the specific symptoms of hypoglycemia, and should refrain from using these measures for getting a lift from feelings of depression or tiredness.

Classification of oral agents used in the therapy of Diabetes Mellitus 

Insulinotropic agents:

First-generation agents : Tolbutamide , Chlopropamide

Second-generation sulfonylureas :

Glipizide Glibenclamide

Gliclazide

Third generation sulfonylureas

Glimepiride

Repaglinide

 Inhibitor of hepatic gluconeogenesis

 Metformin

 Inhibitors of rapid glucose absorption

 Glycosidase inhibitors e.g. Acarbose

 Insulin sensitisers

 Troglitazone

These drugs are effective in lowering the blood sugar only when the diabetic is able to secrete sufficient insulin. They are not usually effective for either juvenile or adult-onset diabetics who are dependent upon injections of insulin, nor do they help much where there has been a history of ketosis or acidosis. Hence, they are mainly used to treat adult-onset diabetics who are unable to control their disease by diet alone, but who may be able to use these drugs in lieu of infections of insulin. Some doctors believe that when patients secrete adequate insulin it is best to avoid giving injections of extra insulin provided oral drugs reduce the high blood sugar levels and stop the spilling of sugar in the urine. The reason for avoiding extra insulin is that this hormone stimulates the production of fat from carbohydrate, and most adult-onset diabetics already have too much body fat. There are two main types of oral antidiabetic drugs, descriptions of which follow.

SULFA-TYPE DRUGS (SULFONYLUREAS). 

   The main action of these compounds is stimulation of the pancreatic cells to release insulin. Some, like tolbutamide are short acting (6 to 12 hours), while others like acetohexamide and tolazamide are intermediate acting (12 to 24 hours), and chlorpropamide is long acting (24 to 72 hours). These drugs sometimes cause hypoglycemia, which may be prolonged in the case of chlorpropamide, particularly when given to elderly people who eat poorly or who have kidney disorders. In the latter case, the drug may not be excreted from the body, so the patient may require dialysis in order to correct the low blood sugar. 

NOTE: People who are receiving tolbutamide should avoid alcoholic beverages because the drug may interfere with alcohol metabolism to the extent that they become nauseous and feel poorly.28 The symptoms are very similar to those which occur when a person drinks an alcoholic beverage after taking Antabuse.28

PHENFORMIN. 

    This drug slows the rate of glucose absorption from the intestine (which results in a slowing in the rise of blood sugar after meals) and increases the utilization of carbohydrate. Its disadvantages are that its effects are short lived (4 to 6 hours), it may irritate the gastrointestinal tract, and occasionally it may be the cause of lacticacidosis. Hence, the dosage level of this drug has to be limited. However, it works well in combination with the sulfa-type drugs, since the antidiabetic effects of the two agents are additive.

DIABETES MELLITUS AND HYPERTENSION TREATMENT IN DIABETICS

INTRODUCTION Persons with diabetes who take calcium-channel blockers to control high blood pressure may be at increased risk factor for heart attack.  

INTRODUCTION AND ACE INHIBITORS  Researchers at the University of Colorado Health Sciences Center studied the effects of the calcium-channel blocker nisoldipine and the ACE inhibitor enalapril in 470 patients with both diabetes and hypertension to collect data. Five-year follow-up studies showed the risk of heart attack among users of the calcium-channel blocker was 9.5 times that of those treated with ACE inhibitor.The report notes that the level of blood pressure control and heart disease risk factors were similar between both groups at the end of the study. Authors say the finding show that ACE inhibitors should be the preferred treatment for hypertension in diabetics and suggest that persons who suffer from both conditions consult their physicians concerning the possibility of switching to ACE inhibitor treatment.

DIABETES MELLITUS AND COENZYME Q10

OTHER NAMES:

CoQ10, UBIQUINONE

MECHANISM OF ACTION:

A POWERFUL ANTIOXIDANT

Coenzyme Q10 is a powerful antioxidant that protects the body from free radicals. Coenzyme Q10 is also called ubiquinone, a name that signifies its ubiquitous (widespread) distribution in the human body. As a coenzyme, this nutrient aids metabolic reactions, such as the complex process of transforming food into ATP, the energy on which the body runs.

A WAY TO IMPROVE PHYSICAL ENDURANCE

Coenzyme Q10 supplementation has been investigated as a way to improve physical endurance because of its effect on energy production. However, most research shows that coenzyme Q10 does not improve athletic performance. Synthesis of sperm requires considerable energy. Due to its role in energy production, coenzyme Q10 has been studied in infertile men. Preliminary research reports that supplementation of coenzyme Q7, a related molecule; increased sperm counts in a group of infertile men.

HEALING

Healing of periodontal tissue (the gums of the mouth) may require increased energy production; therefore, researchers have explored the effects of coenzyme Q10 supplementation in people with periodontal disease, which has been linked to coenzyme Q10 deficiency. Double blind research shows that people with gum disease given coenzyme Q10 achieve better results than those given placebo.

ENERGY FORMATION

The role of coenzyme Q10 in energy formation also relates to how the body uses carbohydrates. Preliminary research suggests that a close relative of this nutrient lowered blood sugar levels in a group of diabetics. Virtually every cell of the human body contains coenzyme Q10. The mitochondria, the area of cells where energy is produced, contain the most coenzyme Q10. The heart and liver, because they contain the most mitochondria per cell, have the greatest amount of coenzyme Q10. Coenzyme Q10 helps people with congestive heart failure-an effect proven in double blind research. Coenzyme Q10 may take several months to show beneficial results. People with congestive heart failure taking coenzyme Q10 should not stop taking it suddenly because sudden withdrawal may exacerbate the symptoms of congestive heart failure.

IMPROVEMENTS IN PEOPLE WITH CARDIOMYOPATHIES

Similar improvements have been reported in people with cardiomyopathies-a group of diseases affecting heart muscle. Research (including double blind studies) in this area has been consistently positive.

Also, due to its effect on heart muscle, researchers have studied coenzyme Q10 in people with heart arrhythmias. Preliminary research in this area reported improvement after approximately one month in people with premature ventricular beats (a form of arrhythmia) who also suffer from diabetes.

Angina patients taking 150 mg per day of coenzyme Q10 report a greater ability to exercise without problems. This has been confirmed in independent investigations.

Coenzyme Q10 appears to increase the heart's tolerance to a lack of oxygen. Perhaps as a result, preliminary research has shown that problems resulting from heart surgery occurred less in people given coenzyme Q10 compared with the control group.

OTHER ACTIONS

Muscle mitochondria lack adequate coenzyme Q10 in people with muscular dystrophy, a problem that could affect muscle function. In a preliminary double blind three-month trial, four of eight people with muscular dystrophy had improvements in heart function and sense of well-being when supplementing coenzyme Q10. Mitochondria function also appears to be impaired in people with Alzheimer's disease. Due to coenzyme Q10's effects on mitochondria functioning, one group of researchers has given coenzyme Q10 (along with iron and vitamin B6) to several people with Alzheimer's disease and reported that the progression of the disease appeared to have been prevented for one and one-half to two years.

IMMUNITY

Coenzyme Q10 also modulates immunity. Perhaps as a result, preliminary research suggests that women with a high risk of breast cancer recurrence show evidence of protection when given very high (390 mg per day) levels of coenzyme Q10 for up to five years.

TO MODULATE BLOOD PRESSURE

Coenzyme Q10 appears to modulate blood pressure by reducing resistance to blood flow. Several trials have reported that supplementation with coenzyme Q10 for at least several months significantly reduces blood pressure in people with hypertension.

SOURCE:

Coenzyme Q10 is primarily found in fish and meat.

CLINICAL INDICATIONS:

ANGINA PECTORIS

CONGESTIVE CARDIAC

FAILURE DIABETES MELLITUS

PERIODONTAL DISEASE

SYSTEMIC HYPERTENSION

MITRAL VALVE PROLAPSE

ALZHEIMER'SAMBAR

DISEASE COPD INFERTILITY

Deficiency is poorly understood, but it may be caused by synthesis problems in the body rather than an insufficiency in the diet. Low blood levels have been reported in people with heart failure, cardiomyopathies, gingivitis (inflammation of the gums), morbid obesity, hypertension, muscular dystrophy, AIDS, and in some people on kidney dialysis. Coenzyme Q10 levels are also generally lower in older individuals. The test used to assess coenzyme Q10 status is not routinely available from medical laboratories.

DOSAGE

Adult levels of supplementation are usually 30-90 mg per day, although individuals with specific health conditions may supplement with higher levels (with the involvement of a nutritionally oriented physician). Most of the research on heart conditions has used 90-150 mg of coenzyme Q10 per day. People with cancer who consider taking much higher amounts should discuss this issue with a nutritionally oriented doctor before supplementing. Most nutritionally oriented doctors recommend that coenzyme Q10 be taken with meals to improve absorption. Some, but not all, research supports the idea that oil-based suspension of coenzyme Q10 absorbs better than forms that lack oil. Of the oil-based products, solubilized coenzyme Q10 absorbed the best according to one group of researchers.

ADVERSE REACTIONS OR INTERACTIONS

Congestive heart failure patients who are taking coenzyme Q10 should not discontinue taking coenzyme Q10 supplements without first consulting a doctor. An isolated test tube study reported that the anticancer effect of a certain cholesterol-lowering drug was blocked by addition of coenzyme Q10. So far, experts in the field have put little stock in this report because its results have not yet been confirmed in animal, human, or even other test tube studies; the drug used in the test tube is not used to treat cancer; and preliminary information regarding the use of high amounts of coenzyme Q10 in humans suggests the possibility of anticancer activity DOSAGE