Prevention of Diabetes Mellitus for Type 1 and Type 2
Diabetes mellitus is a multifactorial disease and its inheritance is polygenic. So, the scope for primary prevention is guarded by many factors. Still, Counselling should aim at the following:
- Primary prevention: (i) Obesity is a well- documented environmental diabetogenic factor. Everyone including members of the diabetic family should avoid gaining weight by avoiding overeating. (ii) Regular exercise improves metabolism and enhances insulin action on a target tissue. (iii) Vaccination against viral diseases, such as measles, mumps, etc., in early years of life, might prevent provocation of autoimmune beta cell destruction and thereby prevent IDDM.
- Secondary prevention: Secondary prevention is practically limited to early detection and good control of blood glucose. Better compliance to treatment regimens for hyperglycemia (e.g., diet, drug, discipline and exercise, etc.) based on better understanding of aim and objective of the treatment (Diabetic Education) has shown significant improvement in preventing or delaying complication of diabetes. The regimens of treatment are (a) diet alone, (b) diet and oral hypoglycemic drugs, and (c) diet and insulin.
The dietary goal in a diabetic should be as follows: diabetic should be as follows:
- Requirement of calories should be tailored to the needs of the patient: elderly overweight patient should start on a reducing diet (1000-16000 Kcal daily), elderly lean person on 1400-1800 Kcal daily, an active young person on 1800-2500 Kcal daily; an underweight person needs energy
- Daily energy requirement from carbohydrate, protein, and fat should be in the proportion of 5055, 15 and 30-35 respectably.
- Carbohydrates should be taken in the form of starches and other complex sugars. Rapidly absorbed simple sugars, such as glucose and sucrose and food with high sugar content should generally be avoided.
- Nutrient load should be spread over the entire day as three main meals and three snacks in between the meals to slow down the rate of
- To provide variety in the diet, a system of carbohydrate exchanges should be used.
- Restriction of salt is important in the management of hypertensive diabetic patients.
Self-care. Adherence to diet and drug- regimens, examination of his/her own urine and blood glucose monitoring (capillary blood glucose measurements by one of the many glucometers available in the market or the direct reading haemo gluck-test strips) ; self-administration of insulin, maintenance of optimum weight. undergoing periodic check-ups, recognition of symptoms associated with hyper/hypoglycemia.
Oral hypoglycemic agents (OHA). A number of oral hypoglycemic agents have used in the treatment of Type 2 DM. These should be used when the patient does not respond adequately to diet control. Sulfonylureas (long acting ones: Chlorpropamide and Glibenclamide; short acting ones: Gliclazide and Tolbutamide) and Biguanides (Metformin, Glucometer) are commonly used antidiabetic drugs. The other antidiabetic drugs are Repaglinide. Acarbose and Rosiglitazone (Avandia).
Insulin. Insulin plays the key role in the metabolism of carbohydrate, fat and proteins_ Formerly the source of commercially available insulin was from the pancreas of cattle and pig. But nowadays recombinant DNA technology (using E. coli) is the main source of synthetic human insulin. Insulin is required by all patients of Type I DM, those with ketoacidosis, rapid onset of symptoms or weight loss. Insulin in Type 2 DM is also used as a combination therapy with OHA. Since it is destroyed by gastrointestinal enzymes it is given by subcutaneous injection. There are 3 types of insulin: (i) Short-acting insulin (i.e. soluble insulin) having rapid onset of action; duration of action lasting for 6-8 hours; (ii) Intermediate-acting insulin (insulin zinc suspension) having a duration of action lasting for about 24 hours; (iii) Long-acting insulin (i.e. crystalline insulin zinc suspension) with slower onset of action, but duration of action lasts for about 28 hours. Biphasic insulin (premixed) contain a combination of shOrt-acting and intermediate-acting insulin in a standard proportion. An appropriate regimen of insulin therapy needs to be individualized. Usual regimens are one injection a day, two infections a day, multiple injections a day or insulin pump.
Tertiary prevention: Tertiary prevention consists of measures like (i) Photocoagulation (LASER therapy) to preserve vision in diabetic retinopathy, (ii) Renal transplant for end-stage renal failure. etc.
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Classification of diabetes mellitus and allied categories of glucose intolerance
Diabetes mellitus (DM)
*Insulin-dependent diabetes mellitus (IDDM)
*Non-insulin-dependent diabetes Mellitus (NIDDM)
(a) Non-obese. (b) Obese
*Malnutrition-related diabetes mellitus (MRDM)
*Other types of diabetes associated with certain conditions and syndromes:
(1) pancreatic disease;
(2) disease of hormonal etiology;
(3) drug-induced or chemical-induced conditions;
(4) abnormalities of insulin or its receptors;
(5) certain genetic syndromes;
Survival is not dependent on exogenous insulin. Good -metabolic control can even be achieved at least during, early years by diet and exercise only. Oral hypoglycemic agents or exogenous insulin may be required for better control and prevention of complications in later years of life. Complications are usually of macrovascular type, e.g., Cerebrovascular Disease (CVD), Coronary Heart Disease (CHD), Peripheral Vascular Disease (PVD). etc.
‘High intake of cyanide-producing foods combined with protein malnutrition may cause damage to insulin-secreting beta cell mass of pancreas and lead to malnutrition-related diabetes mellitus (MRDM).
The term impaired glucose tolerance (IGT) is used to describe a state intermediate between normality and DM. It can only be defined by OGTT. Those people with IGT who have high glucose levels and low insulin responses early in the test (and who are not pregnant) appear to be more likely to progress from IGT to DM.
The term gestational diabetes (GDM) refers to hyperglycemia occurring for the first time during pregnancy. This may or may not disappear following delivery. Repeated pregnant, may increase the likelihood of developing permanent diabetes, particularly in obese women.