At times, diabetes develops during pregnancy. This is commonly prevalent among women having a family history of diabetes. It may occur temporarily and cease to exist after confinement. Such patients are always susceptible to develop the disease during stressful conditions later in life. Mild or borderline cases of diabetes during pregnancy needs to be controlled. Any abnormality of blood sugar level affects the foetus and increases the chances of congenital malformations.
Help Yourself… Prevent the Complications of Diabetes
Diabetes Can Affect All These Body Parts
Eye
Watch for change in vision.
Recommendations:
• See your doctor
• Control your blood sugar
• Control your blood pressure
Heart
Watch for chest pain and/ or shortness of breath.
Recommendations:
• See your doctor
• Control your blood sugar
• Limit cholesterol
• Control your blood pressure
• Avoid smoking
• Exercise as directed by the physician
Kidney
Watch for protein in urine and / or increase in blood pressure.
Recommendations:
• See your doctor
• Control your blood sugar
• Control your blood pressure
• Limit protein intake
Foot
Watch for pain, numbness, and/or wounds that won’t heal.
Recommendations:
• See your doctor
• Control your blood sugar
• Limit cholesterol
• Control your blood pressure
• Avoid smoking
• Exercise as directed by the physician
• Seek proper foot care
Controlling diabetes means keeping your blood sugar level in balance. By taking control, you can feel better now and limit serious problems later on. It is the best thing you can do for yourself and the people who care about you.
When your blood sugar is in balance, you’ll probably find that that you feel better and have more energy.
A systematic multi-disciplinary approach and a system of intensive control of diabetes mellitus will likely decrease the rate of complications, improve patients’ quality of life, and decrease the total cost of care associated with both IDDM and NIDDM.
The diabetes self-management system is divided into two phases.
Phase I: Initial Assessment
Patient’s History
The patient’s responses to the following areas of questioning should help the physician to confirm the diagnosis and duration of diabetes mellitus, establish the success or failure of previous treatment regimes, evaluate the presence of existing diabetic complications, and determine the patient’s risk for the future development of complications.
1. What is the patient’s chief complaint? How long has the patient had diabetes?
2. Did onset of diabetes include:
• Polydipsia? (Excessive Thirst)
• Polyuria? (Excessive Urination)
• Polyphagia? (Excessive Hunger)
• Unexplained weight loss or gain?
3. Is there a family history of diabetes or other endocrine disorders?
4. Did the patient have a gestational history of diabetes?
• Hyperglycemia?
• Delivery of an infant weight > 9 lb?
• Toxemia?
• Stillbirth?
• Other complications of pregnancy?
5. Has the patient lost or gained weight? What is the patient’s current nutritional regimen?
6. What is the patient’s exercise history and ability to exercise?
7. What are the patient’s current, non-diabetes-related medications?
8. What is the patient’s alcohol intake?
9. Is there a history of recreational drug use?
10. Has the patient already been diagnosed as suffering from diabetes mellitus:
i. When and how was diabetes diagnosed?
ii. Which medications have been used to treat diabetes, and in which order? Establish the current treatment regimen, including diet and exercise.
iii. How has the patient had his or her glucose levels monitored in the past? Has the patient monitored blood glucose at home? How frequently was the patient’s glycosylated haemoglobin monitered?
Were the results of these tests used to maximise the patient’s degree of diabetic control?
11. Does the patient have symptoms of existing diabetic complications of any of the following types?
• Ophthalmologic (including retinopathy)
• Neuropathy
• Renal
• Vascular (including cardiovascular, cerebrovascular, peripheral vascular system)
• Sexual dysfunction (men and women)
• Ketoacidosis
• Hypoglycemia
• Infections (eg, skin, foot, gynaecological)
12. Does the patient have any of the following identifiable risk factors for diabetic complications:
• Family history of diabetes or coronary artery disease
• Hypertension (systolic, diastolic)
• Smoking history
• Lipid abnormalities
• Central obesity
Physical Examination
Phase I should include a complete physical examination for each patient. Special attention should be paid to those aspects of the examination that focus on specific areas of risk for the diabetes patient, including:
• Height and weight measurements
• Blood pressure determination, including orthostatic evaluation
• Ophthalmoscopic examination
• Thyroid palpitation
• Cardiac examination
• Evaluation of pulses, including respiratory variation
• Foot examination
• Skin examination
• Neurologic examination, with particular attention to reflexes, vibratory sensation, touch, and proprioception
Laboratory Evaluation
Laboratory tests should be ordered to establish the diagnosis of diabetes and to determine the current level of glycemic control. In addition, Phase I laboratory testing should provide an evaluation of the patient’s general medical condition and identify associated risk factors. Laboratory tests that should be used during Phase I include:
• Fasting or random plasma glucose?
• Glycosylated haemoglobin / fructosamine (HbAlc)
• Fasting lipid profile (cholesterol, triglycerides, HDL/LDL calculation)
• Serum electrolytes?
• Serum creatinine?
• Urinalysis
• Sensitive or ultrasensitive thyroid stimulating hormone (TSH)
• Microalbuminuria and creatinine clearance
• Electrocardiogram (ECG) and/or stress test
Phase II: Assessment of Complications
The goal of Phase II is to continually assess the presence and/or severity of the complications associated with diabetes mellitus. Each of these modules should be performed in conjunction with a Phase I follow-up assessment module.
People with diabetes can develop certain problems (complications). These problems are more likely to occur if your blood sugar is not in balance.
Caring for Your Eyes
You can have problems with your eyes even if you don’t have trouble in seeing. Have your eyes checked once a year or as often as your doctor recommends? If you see dark spots, see poorly in dim light, have eye pain or pressure or notice any other problems, tell your doctor right away.
Eyes
The common causes of loss of vision are cataracts and diseases of the retina. Retinopathy appears in almost all diabetics, given sufficiently long duration of diabetes. Early recognition of retinopathy is important and examination of the retina must be a part of regular diabetes review.
Eye care, in the diabetic patient, reflects a partnership between the primary physician and the eye doctor. The primary physician plays a fundamental role in the medical management, coordination of care and education of diabetic.
Treatment
Treatment of diabetic retinopathy is a very difficult task and should be carried out jointly by a diabetologist and an ophthalmologist. There are two modes of treatment available.
Medical Management
This consists of maintenance of good glycemic control as early as possible, after the diagnosis of diabetes, for reasons mentioned earlier. Various drugs have been tried in the treatment of diabetic retinopathy and its further progression.
Surgical Management
Surgical management for diabetic retinopathy consists of photocoagulation vitrectomy. The surgical management has greatly improved the outlook of patients with diabetic retinopathy. Laser photocoagulation is beneficial in preventing further visual loss but not in reversing already diminished acquity.
Vitrectomy attempts to remove vitreous haemorrhage and fibrous tissues in the eye, and to reattach the retina. It is occasionally successful in restoring some vision in advanced diabetic eye disease. Retinopathy may be asymptomatic. A screening programme, to detect diabetic retinopathy, is thus essential.
Additional diagnostic evaluations should include:
• Test of visual acuity (Snellen chart)
• Funduscopic examination
• Intraocular pressure (IOP) test
In addition to educating the patient about the retinal complications that may be associated with diabetes, the clinical endocrinologist/physician should determine the frequency of follow-up and / or need for reference to an ophthalmologist / retinal specialist based on the patient’s history and findings of the current examination.
Symptoms
Due to changes in the retina of the eye, patients may experience the following symptoms:
• Frequent change of glasses
• Gradual reduction and blurring of vision
• Frequent pain, redness, conjunctivitis and styes
• Sudden loss of vision
• Premature cataract
If any of the above symptoms appear, it should immediately be brought to the notice of the specialist.
Kidneys
In diabetes, the work load on kidney is increased due to passing of nutrients in the urine.
Any sign of kidney involvement can be detected only by urine test for albumin. When the kidney is affected by diabetes, albumin excretion in the urine increases. This increase of urinary albumin forms the basic possibility of diabetic nephropathy.
The excretion of albumin, in urine, may be present in patients suffering from high blood pressure, heart problem, infection of urinary tract or due to intake of drugs. To avoid any discrepancies, the doctor advises to repeat the test and if it is found positive, he further investigates to know the exact cause.
Additional diagnostic evaluations should include: Test for microalbuminuria
• Creatinine clearance
Once diabetic nephropathy is established, the patient is advised to take a low protein diet. Their diet should include green vegetables, cabbage, carrots, cauliflower and fresh fruits in plenty. By restricting protein intake, the burden on the kidney is reduced, thus lessening the severity of kidney complication. Effective measures should be initiated to eradicate urinary infection and control blood pressure.
A diabetic who has evidence of kidney trouble should avoid indiscriminate use of drugs. A tendency for self-medication may precipitate kidney trouble. Such patients are advised to consult the doctor who is acquainted with their history. In severe uncontrolled cases, dialysis or transplantation of kidney becomes the only option.
Problems Involving the Nerves
Diabetic neuropathy, that is, involvement of nerves, is a frequent complication of diabetes, which, in majority of cases, may be unnoticed in the initial stage. The nerve involvement may be of a mild nature, for instance, minor pains, numbness, tingling of fingertips and limbs. In its severe form, it can be fatal; involvement of motor, sensory or autonomic nerves may precipitate the following symptoms:
• Pain in the limbs, burning sensations in the hands and feet (specially at night)
• Normal gait is affected
• Numbness and tingling of fingertips, toes and feet
• Ulcer formation
• Sexual impotency
The patient tends to neglect these symptoms or at times complains of pain in the limbs, which gets worse at night. He is completely unaware of the fact that these signs are related to diabetes. It is often noticed that neuropathy progresses rapidly in uncontrolled diabetics. A mild cut or injury, if left untreated, may develop into a serious complication like gangrene. Diabetic gangrene usually starts following a minor injury and leads to infection which may prove fatal unless the limb is amputated. Good management can minimise its severity so that it only remains a minor irritant.
Additional diagnostic evaluations should include:
• A review of symptoms relevant to peripheral nerve and autonomic dysfunction
• Module-specific testing (vibratory sensation, soft touch pinprick, evaluation of autonomic dysfunction
Erectile impotence in men are more common in diabetic patients than in men of the same age group in general. The treatment options available for diabetic impotence include improvement of glycemic control. Discontinuation of alcohol will also help. Adequate sexual performance in an adult IDDM is not only desirable but also important for good mental and physical health. These problems must be specifically inquired into by the physician.
Cardiovascular Problems
Coronary heart disease occurs more frequently and is of a very severe consequence, more in a diabetic than in a non-diabetic. The increased susceptibility to coronary heart disease is attributed to changes in lifestyle, inactivity, tension, stress and strain. The three major factors, i.e., hypertension, hyperlipidaemia and smoking, appear to be additive in their adverse impact on cardiovascular events in a diabetic individual. Diabetics are more prone to:
• Premature arteriosclerosis
• High blood pressure
• Heart failure
• Gangrene
A diabetic can reduce the risk of cardiovascular disease through diet. Though to some extent, arteriosclerosis is an ageing process, it is aggravated in people who consume calorie-rich food, refined cereals, animal food, excessive saturated fat, salt, alcohol and smoke. Such patients are advised to have a balanced vegetarian diet.
General Preventive Measures Include:
• Early detection and effective correction of hypertension
• Weight control through proper diet and exercise
• Avoid smoking
• Restricting intake of alcohol
Additional Diagnostic Evaluations Should Include:
• Thorough clinical examination
• ECG done once a year or as a routine even if there are no symptoms
• Exercise TMT
• Other tests like echocardiography or nuclear imaging, as advised by the physician
• X-ray of chest once in every two to three years
Infection should, be treated aggressively and diabetic control should be closely supervised.
To prevent gum disease or mouth problem – floss your teeth at least once a day.
Gum disease (also called periodontal disease) and other mouth problems are common in people with diabetes. To help prevent these problems, brush your teeth after every meal and floss them at least once a day. Also, see your dentist every three to six months.
Problems During Pregnancy
Some of the common problems that a diabetic faces during pregnancy and childbirth, are:
• Frequent miscarriage
• Overweight babies
• Stillbirths.
With the advancement in medical science, along with education and rehabilitation, one has been able to manage the severest of these complications. Early detection, timely treatment and effective management are the best diabetic containment.