DIABETES – FACTS AND FIGURES
Current statistics
- In 2013, about 382 million people worldwide are known cases of diabetes. It is expected that this figure will rise to 592 million by 2030. Moreover, of the total number cases of diabetes, about 46% remain undiagnosed.
- According to 2004 statistics, Diabetes was the 12th largest killer in the world. It is estimated that it will move to the position of the 7th largest killer by 2030.
Gender-specific statistics
- Men are at slightly higher risk of developing diabetes than women.
- Women who develop gestational diabetes are at a much higher risk of develop type 2 Diabetes in later years. This risk is about 35 to 60 percent.
- Role of inheritance – Any child who has a parent with type 2 Diabetes has a 15% chance of developing diabetes. The risk increases to 75% if both the parents are diabetic.
WHO Facts
According to the World Health Organization (WHO):
- More than eight of every 10 diabetes-related deaths occur in low- and middle-income countries.
- WHO states that 50 percent of people with diabetes die of cardiovascular disease, primarily heart disease and stroke.
- Individuals with diabetes are twice as likely to suffer from depression as individuals without a diabetes diagnosis.
- Diabetics have twice the risk of death of any cause compared to individuals of the same age without diabetes.
Continent-specific Statistics
According to the International Diabetes Federation (IDF), the 2013 figures for known cases of diabetes in different continents are:
Western Pacific – 138 million
South East Asia – 72 million
Europe – 56 million
North America and Carribean – 37 million
Middle East & North Africa – 35 million
South & Central America – 24 million
Africa – 20 million
These figures represent only the diagnosed cases of diabetes. A vast number of people remain undiagnosed, especially in under-developed or developing countries.
Country specific statistics
According to the International Diabetes Federation (IDF), the number of people diagnosed with Diabetes are the highest in the following countries:
China – 98.4 million
India – 65.1 million
USA – 24.4 million
Brazil – 11.9 million
Russia – 10.9 million
Mexico – 8.7 million
Indonesia – 8.5 million
Germany – 7.6 million
Egypt – 7.5 million
Japan –7.2 million
PATHOPHYSIOLOGY OF DIABETES
Normal working of insulin
The beta cells (Islets of Langerhans) of the pancreas secrete the hormone insulin. Insulin is responsible for regulation of the blood sugar levels. Whenever food is consumed, the components of the food are broken down and the blood sugar levels rise. At such times, insulin is released into the bloodstream in order to facilitate the movement of this sugar into the body’s cells for energy. The amount of insulin released is in proportion to the blood sugar levels. Any excess sugar is converted into glycogen and stored into the liver, under the influence of insulin. During fasting or vigorous exercise, the blood sugar levels fall and so does the amount of insulin secreted by the pancreas.
What happens in Type 1 diabetes?
In Type 1 diabetes, the body is unable to produce insulin. Type 1 diabetes is an autoimmune condition, in which one’s own immune system attacks cells of the body. Anti insulin or anti-islet cell antibodies are produced and the beta cells of the pancreas are destroyed; thus producing absolute insulin deficiency. In such a scenario the blood sugar levels cannot be regulated unless insulin is administered from outside.
What happens in Type 2 diabetes?
Type 2 diabetes occurs due to a relative deficiency of insulin or due to peripheral insulin resistance. Due to deficiency of beta cells, the pancreas is unable to release adequate levels of insulin to regulate the blood sugar. Also the body cells may develop resistance to the action of insulin. In such a scenario even if the pancreas is able to produce adequate amounts of insulin, the insulin receptors of the body tissues may develop resistance to its action. Thus the body cells cannot use the glucose present in the blood adequately unless the levels of insulin in the blood are increased.
CLINICAL PRESENTATION
Symptoms
Diabetes is labeled as a ‘silent killer’. It is entirely possible to have diabetes for years and yet not notice anything abnormal. The following symptoms are produced when you have diabetes:
Polyuria – The person experiences a frequent need to urinate
Polydipsia – The person may need to have a lot of fluids to keep hydrated.
Polyphagia (Increased hunger) – This is because even though the person is eating, his cells are not being able to pick up the glucose from the blood.
Changes in weight – A person with type 1 diabetes may consistently lose weight whereas a person with type 2 diabetes will gain weight.
Lack of energy – Since the cells are not getting enough glucose, the patient may feel fatigued all the time.
Complications
Long-term or uncontrolled diabetes can affect various body systems giving rise to a number of complications such as:
Diabetic retinopathy – Uncontrolled blood sugar levels affect the small blood vessels of the eye giving rise to several eye conditions such as glaucoma, cataracts and even blindness.
Diabetic nephropathy – Diabetes can affect the filtering units of the kidney giving rise to albuminuria.
Diabetic ketoacidosis – The blood becomes acidic and there is accumulation of ketone bodies.
Heart and circulatory disturbances – People with diabetes are at a higher risk of developing hypertension, stroke, ischemic heart disease and other conditions of the heart or blood vessels.
Erectile dysfunction – Since diabetes affects the circulation, it can cause erectile dysfunction in men.
Diabetic foot – Diabetics are prone to suffer from unnoticed foot injuries leading to formation of ulcers or gangrene.
Infections – Diabetics have a higher susceptibility of catching infections compared to the normal population.
Poor healing – Cuts, wounds, bruises or other injuries take a longer time to heal in patients with diabetes.
Hyperosmolar Hyperglycemic Nonketotic Syndrome – This is an emergency condition characterized by very high blood sugar levels in the absence of ketones in the blood or urine.
Peripheral arterial disease – Characterized by intermittent pain and tingling in the leg
Diabetic coma
Additional complications – Diabetic patients are more prone to hearing troubles and gum disease.
INVESTIGATIONS
- Blood glucose levels – fasting, post-prandial and random levels are tested. Diabetes is suspected if:
- Fasting blood glucose levels, measured after at least 8 hours of fasting are higher than 126 mg/dL. The normal fasting blood sugar levels range from 80-110 mg/dL.
- Random or post-prandial blood glucose levels are higher than 200 mg/dL. Random samples are taken anytime whereas post-prandial samples are taken 2 hours after a main meal. The normal post-prandial blood sugar levels range from 110-140 mg/dL.
These tests can be easily performed with glucometers at home; however laboratory analysis using plasma yields more accurate results.
- Oral glucose tolerance test – The patient is instructed to fast for 8 hours following which, a measured dose of glucose water is fed to him/her. Blood sugar levels are tested before in the fasting state as well at several timed intervals after the liquid is fed. If the blood glucose levels are higher than the specified levels at the specified intervals on more than 1 occasion, the person is said to have diabetes.
- Glycosylated haemoglobin test (HbA1c) – These levels measure not just the current sugar levels but give an estimate of the average blood sugar levels during the past 1 to 3 months. Non-diabetic people have HbA1c levels of up to 6%. A reading of 6.5% or higher is suggestive of diabetes.
- Plasma fructosamine levels – Similar to HbA1c, this test also gives an estimate of blood sugar levels of the previous 1 to 3 weeks. Since the duration of measurement is shorter, this test gives a quick assessment of blood sugar levels over the past few days.
- Test for anti-Islet antibodies – This test is performed in children who are at a high risk for developing Type 1 diabetes.
- Urinary albumin levels – All pre-diabetic and diabetic patients must undergo testing for urinary albumin in order to detect changes of nephropathy.
TREATMENT
There is no permanent cure for diabetes. Treating diabetes is a life-long task. The aim of treatment is to stabilize blood sugar levels and prevent or delay complications. The treatment plan includes a combination of lifestyle changes, oral medication and injectible insulin.
- Lifestyle changes: Lifestyle changes are essential for all diabetics, whether type 1 or type 2. The following changes are recommended:
Diet – A low-calorie, low-fat diet is advised. Meal timings must be kept consistent. The patient is encouraged to eat smaller portions several times a day, rather than large portions at a time. Any food or drink that causes a sudden spike in the blood sugar levels is to be avoided. Examples of such foods include chips, sweetened drinks, desserts, deep-fried food and confectionaries. These are known as high hypoglycemic index foods. Foods that increase the blood sugar levels steadily and slowly are recommended. Examples include whole grains, fruits, vegetables, low fat dairy etc. These are known as low hypoglycemic index foods.
The American Diabetes Association, recommend that 50% to 60% of daily calories come from carbohydrates, 12% to 20% from protein, and no more than 30% from fat. One can enlist the help of a dietician to plan their meals.
Exercise – An active lifestyle is recommended for all diabetics since a sedentary life increases the peripheral insulin resistance. Patients are advised to exercise at a moderate intensity 5 times a week.
Weight management – It is very essential for a person with diabetes to maintain a healthy body weight, recommended for his/her gender, age and height. Obesity increases the peripheral insulin resistance, thus making it difficult to normalize blood sugar levels. Being obese as well as diabetic also puts you at a very high risk of developing heart disease.
- Medication: Medications form the mainstay of treatment in people with type 2 diabetes.
Various classes of medications are beneficial for patients with diabetes. The physician selects 1 or a combination of these drugs for each patient.
Sulfonylureas – These drugs stimulate the pancreas to release more insulin.
Meglitinides – These drugs also stimulate the pancreas to release more insulin, but through a different mechanism.
Biguanides – These drugs reduce the amount of glucose produced by the liver.
Sodium-glucose co-transporter 2 (SGLT2) inhibitors – These drugs stimulate the kidney to increase excretion of glucose.
Thiazolidinediones – These drugs increase the sensitivity of cells to insulin
Alpha glucosidase inhibitors – These drugs reduce the carbohydrate absorption by the intestine.
Synthetic amylin – This is an injectible drug. When given with insulin, the effect is much better than that produced by insulin alone.
DPP-IV inhibitors – These drugs inhibit the enzyme DPP IV from breaking down GLP-1.
- Insulin – Insulin is the primary line of treatment for patients with type 1 diabetes. In patients with type 2 diabetes, Insulin is used if the blood sugar levels fail to stabilize with the help of lifestyle changes and oral medication.
Insulin can be derived from animals (bovine) or human sources.
According to how quickly insulin acts, it is classified as rapid-acting, intermediate-acting and long-acting.
Insulin is administered subcutaneously, either through pre-filled insulin pens or insulin pump.
RECENT UPDATES
Pancreas transplantation is a new and advanced treatment option. People with type 1 diabetes can receive a healthy pancreas from a donor. This procedure can cure diabetes and stop the need of receiving insulin; but it’s associated with several side-effects.
Stem cell therapy is being tested in the hope of finding a cure for diabetes.
Bariatic surgery is being considered as a supportive treatment option for obese diabetics.
Newer tools and devices are being developed for the administration of insulin.
SUMMARY
- Diabetes is a metabolic disease, now more of a lifestyle disease.
- By 2030, it is estimated that more than 592 million people globally will be affected by Diabetes mellitus: a huge health burden.
- Diabetes is of 2 types:
Type 1 – Insulin dependent or juvenile diabetes
Type 2 – Non insulin dependent or late onset diabetes
Other forms are Gestational (during pregnancy) and malnutrition (new entity).
- Blood sugar levels of FBG > 120 mg/dL and post-meals >140 mg/dL persistently is labeled as Diabetes mellitus.
- Diabetes is characterized by polyuria, polydipsia, polyphagia and sometimes weight loss.
- Diabetes if untreated, can lead to complications involving almost all organs. Commonly affected organs include the eyes, heart, kidneys and the foot.
- Diabetic retinopathy, diabetic nephropathy and diabetic foot are the commonest complications.
- The management of Diabetes requires multifocal approach comprising of lifestyle modification, dietary management and medications.
- Lifestyle management requires shedding sedentary lifestyle habits, exercise, yoga, meditation and a ‘Be happy’ attitude.
- Dietary management requires a balanced diet with lots of fiber along with avoidance of high glycemic index food items. The American Diabetes Association, recommend that 50% to 60% of daily calories come from carbohydrates, 12% to 20% from protein, and no more than 30% from fat.
- Medical management includes insulin therapy in type 1 diabetes. In type 2 diabetes, single oral anti-diabetic drug or a combination of more than 2 oral drugs are used. These medications may have to be supplemented with insulin to gain proper blood sugar control.
- Every diabetic patient must have a glucometer at home in order to monitor blood sugar levels.
- Newer innovations in the treatment of diabetes include bariatic surgery in obese diabetics, pancreatic transplant, and stem cell research along with newer tools for delivery of insulin.
- Not to forget, ‘Treat diabetes: Stabilize blood sugar levels, Avoid complications’.
- Let us pledge on 14th November, on the occasion of ‘World Diabetes Day’ to ‘Treat Diabetes: Save our Future’.
