About Diabetes Mellitus
Diabetes mellitus is a disease in which starch foods and sugar cannot be used normally in the body, so that sugar is passed in the urine; the disorder is due to lack of insulin which is produced by the pancreas, but the cause of this deficiency is not known. Much of the energy of the body is produced from sugar, but this can only be burned up when there is sufficient insulin. When this is deficient the sugar accumulates in the blood and is filtered off in the urine by the kidneys. It is only when sugar is being used normally that fat can also be oxidised or ‘burned’ to provide heat and energy; when fat cannot be utilised, the condition called acidosis develops, and when this is present to a serious extent it affects the nervous system and causes diabetic coma. Persons of all ages may be affected by diabetes but it is more commonly seen in those aged from thirty to sixty years.
The disease often runs in families, and more often occurs in men or elderly women who are overweight, with a high blood pressure, and often follows mental strain and anxiety.
The onset is generally gradual, the patient suffering from thirst, greatly increased appetite, constipation and weakness; there is also often great loss of weight. The thirst is generally relieved by drinking fluids copiously, so that a large quantity of urine is passed; there is often irritation or pruritus around the urethra, and women may develop gross irritation and inflammation around the vagina. Constipation is common and in severe cases the tongue is dry and red. Sexual feeling may be lost and the circulation is often poor. Rarely diabetes mellitus develops suddenly, and the patient may become comatose and die before the true condition is diagnosed.
The Urine. The urine is often increased to five or seven pints a day; it is pale in colour but the specific gravity is high owing to the sugar present, which may be detected by blood testing apparatus by the patient himself. In acidosis the urine contains acetone and smells of new-mown hay. Albumen is sometimes present.
Boils and Carbuncles are common in diabetic persons, and are apt to be recurrent.
Pruritis of the skin around the vulva and rectum is often complained of.
In old people Gangrene of the toes some-times occurs, which may become very severe, so that amputation of the limb is necessary.
Renal Involvment may occur after the diabetes has been established for many years. High Blood Pressure, hardening of the arteries, and thrombosis (or clotting) of the blood in the vessels of the brain or heart are liable to develop.
Eye Changes, such as cataract and inflam-mation of the retina, are also common, causing impaired vision or loss of sight.
Neuritis, with tingling, pain and some-times numbness is often complained of.
Coma is the most serious complication, but since treatment with insulin has been introduced it is now less often seen than formerly. It is sometimes heralded by pain in the abdomen, loss of appetite and constipation, and then drowsiness increases until deep coma may be reached, unless treatment is given. The pulse is fast and feeble, and there may be deep sighing, or 'air-hunger'.
Diabetics fall into three dif-ferent categories as regards treatment. Insulin Dependent diabetics are usually children or young adults with a failure of the pancreas to produce insulin. Even small amounts of insulin can maintain these patients in good health.
Maturity Onset diabetics show the first signs of the disorder in middle or late age and are often overweight. Diet is essential, and sometimes it is necessary to add oral hypoglyc, Tmic agents. Insulin is rarely required.
Diabetes Associated with other Disease such as acromegaly (Cushing's syndrome), thyrotoxicosis (and phxochromocy-toma), or even corticosteroid therapy. Removal of the precipitating factor usually results in the diabetes remitting. Sometimes tablets of oral hypoglycaemic agents may be needed or, rarely, insulin.
The general health of the patient must be given every care. Any form of infection, such as boils, pyorrhoea, etc., must be promptly dealt with, as sepsis affects the sugar tolerance, and the resistance to infection is poor.
Insulin is the preparation used by diabetic patients, to enable them to take a varied and adequate diet. The dose of insulin required has to be estimated for each individual case. All insulins are classified according to their speed and length of action.
Insulin is usually administered by the patient himself by means of a hypodermic syringe and sterile needle, following in-structions given by a doctor. The dosage often requires to be increased when the patient is suffering from any form of infection such as influenza, boils, etc. It must be clearly under-stood that insulin does not cure diabetes, and that continued treatment under medical supervision is likely to be necessary during the patient's lifetime, although it may be possible to reduce the dosage of insulin, or occasionally to suspend its administration.
It is most important that at all times the patient check the strength of the insulin he is using because it may be supplied as either 40 units per ml (cc) or 80 units per ml (cc).
In cases of mild diabetes, the patient's urine may usually be rendered free of sugar by restriction of diet only, on a low diet providing about 1,500 Calories a day. The diet (including extra carbohydrate food) is then increased gradually to meet the patient's normal requirements, and by following a routine diet he may be able to do without insulin. In other cases insulin will be needed to allow a diet sufficient to maintain his weight. In severe and emaciated eases insulin is prescribed at once to avoid the danger of coma developing. Diabetic children nearly always require insulin, while adult diabetics require extra dosage when they are suffering from any infection, from diabetic gangrene, or before surgical operations.
Successful pregnancy is now more common in diabetic women since insulin has become available, but diabetics tend to be less fertile than normal. During pregnancy the diabetic must take special care as her insulin requirement can fluctuate rapidly. She must be delivered in a hospital, preferably one used to dealing with diabetic problems.
Babies of diabetic mothers are usually plumper than normal but in the first few days they quickly use up the additional fat and lose weight.
The expense of insulin, and the inconvenience of continual administration by hypodermic injection, make it desirable to dispense with it when it is not essential.
When pain follows a hypodermic injection the needle has probably not been inserted sufficiently deeply beneath the skin. The usual sites of injection are on the outer side of the thighs or in the abdominal wall, but the sites should be continually varied. Ordinary soluble insulin is usually given about half an hour before a meal.
Between injections, syringes are kept in surgical spirit in small cases. The syringe must be cleared of spirit before use.
About a third of the diabetics in Great Britain are treated with tablets of antidiabetic drugs such as chlorpromazine (Largactil), tolbutamide (Artosin), phenformin (Dibotin), and others. These hypoglycaemic agents are useful adjuncts to diet treatment, especially in the case of the maturity onset diabetic with mild symptoms.
All patients must be under strict medical supervision in case the condition changes and an alternative drug may be more suitable.
Sugar in the Blood
The sugar in the blood requires to be kept within certain limits, or symptoms arising from a lack of sugar quickly develop. These are at first
clammy sweating, tremor, anxiety, hunger, coldness and pallor, and sometimes double vision, followed by disorderly behaviour, or by fainting or collapse with loss of consciousness, which may be prolonged into coma. In children lassitude and sleepiness are usually seen when the blood sugar is low. These symptoms are likely to' occur about one or two hours after insulin has been given, unless the sugar or carbohydrate intake is sufficient. The patient should, therefore, always have sugar or barley sugar ready to take with a drink of water if the above warning symptoms develop; if he remains conscious he will be able to take them by mouth, but if he collapses glucose solution may be given by a doctor by means of a nasal tube, or by injection into a vein.
To decide whether a patient is suffering from diabetic coma due to want of insulin, or to lack of sugar in the blood, the urine should be tested; if the urine is free from sugar, glucose is required; if it contains sugar the bladder should be emptied by means of a catheter, and a second sample collected and retested. If this later specimen also contains sugar, soluble insulin and glucose are given.
The following table shows the difference, between diabetic coma and shortage of sugar in the blood:
Diet in Diabetes Mellitus
Diet is important to all diabetics. Each patient has a diet which is tailored to his or her requirements as regards height and occupation. The carbohydrate distribution will be related to the insulin r6gime of the patient wherever this is applicable.
A diet usually allows generous intake of protein and average consumption of fat.
The carbohydrate part of the diet is re-ferred to as `Portions' where
1 portion = 10 grammes of carbohydrate. A certain number of portions will be specified for each meal of the day and a list of portions to choose from will be provided for the patient.
This scheme is given in the ‘Basic Exchange List for Diabetics' produced jointly by the British Diabetic Association and the British Dietetic Association.
Arranging The Portions. If the patient is a young woman working at a desk, her recommended diet would be 1,200 kcals per day, which is equivalent to 120 grammes of carbohydrate, that is 12 portions.
If this young woman is also being treated with insulin twice daily, then she would have to choose 4 portions for breakfast and midmorning, 4 portions for dinner and tea, and 4 portions for supper and bedtime. The carbohydrate is spread equally throughout the day. Protein and fat intake would not be so restricted.
At the other end of the scale a tall well-built man with a job requiring physical exertion could well be allocated 20 to 25 portions a day.
If the patient is overweight, the doctor will prescribe a diet with a more restricted carbohydrate content, e.g. 10 portions or even less.
Many diabetic products are now available but it should not be necessary to buy many of these as the diet offered to diabetics these days is so easily followed and manipulated by them that they can eat out anywhere, anytime, knowing that careful choice will allow them to keep to their daily requirements easily.
Diet in Illness
In the event of illness and any inability to take solid food then it is important to cover the effect of the insulin by carbohydrate intake of a liquid nature. Each of the following is equivalent to one ‘portion', i.e. 10 grammes of carbohydrate.
If recovery is slow or if vomiting is present then the doctor should be consulted without delay.
Stabilising The Patient
Once the diagnosis of diabetes mellitus has been made, it is necessary to stabilise the patient on his or her treatment which can involve one or more of the methods discussed, i.e. diet, tablets, or insulin.
This stabilisation may be done in hospital or as an out-patient.
The results of the treatment are checked by regular testing of the urine for sugar, using Clinitest. Routine follow-up visits to the doctor should be undertaken for ever.
It is in the patient's own interest to obtain, and carry always, a card or bracelet which will detail his diagnosis and treatment.
Alarm and despondency are out of place these days as diabetics are able to lead normal, healthy, full and active lives.
This is a rare chronic disease, in which the patient passes large quantities of pale dilute urine which is free from sugar and albumen.
In some cases there is no discoverable cause, and the condition may apparently be a hereditary disorder which usually affects men, through several generations. It is due to an inability in the kidneys to secrete concentrated urine.
In a second type of case diabetes insipidus is due to some disease of the pituitary gland in the brain, such as a tumour or other organic brain disease. Injury is also an occasional factor.
The symptoms are characteristic, with abnormal thirst, a copious flow of urine, and constipation. The patient is generally thin, and the skin tends to be dry, but the general health may be quite good.
In cases in which there is no discoverable disease the patient may live for many years. In the second group when there is some brain disease the duration of life depends on the extent and severity of the changes in the brain.
Treatment. Drugs can only alleviate the condition, not cure it. Injection of a pituitary extract, vasopressin, is an established remedy and may be given at bedtime on alternate days but some patients need an injection more frequently. In the latter case, a nasal spray of synthetic vasopressin may be used additionally.
Chlorothiazide, or other of the thiazide drugs given my mouth twice daily, effectively reduces the volume of urine and the thirst.
The fluids taken by mouth should be gradually reduced in amount but not after the quantity of urine ceases to become less. A low-salt diet should be established.
Source : Family Physician
See also: Classification of Diabetes Mellitus
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