Management

Chronic Complications in Diabetes Mellitus

India has about 58 million diabetics and China lags behind at 43 million!

Exercise regularly to prevent diabates

We are in the midst of an epidemic of diabetes mellitus and India is considered as the capital of the world of diabetics. This is because one fifth of the world's diabetic population (285 million) are Indians. At the recently concluded IDF conference, it was mentioned that India has about 58 million diabetics and China lags behind at 43 million! These numbers are expected to increase another 50 per cent in next 20 years or so. For every diabetic patient that is diagnosed in a population, there is one undiagnosed patient.

Symptoms & Studies

Presenting symptoms of diabetes mellitus are varied. However, an important fact is often overlooked that that nearly 50 per cent patients are asymptomatic. Awareness about this disease (and the complications that can develop) will prompt patients and the public at high risk to go for a regular follow up. Diabetic complications generally develop after 12-15 years of diabetes. Around 15-25 per cent patients are unfortunate enough to have varying degree of complications at the time of diagnosis. This is explained by the fact that when the diagnosis of diabetes is made, the patient has already had some degree of glucose intolerance (undiagnosed) for an average of six to eight years. These complications lead to organ dysfunction and damage. The damage could be in sight/limb/any organ or even be life threatening!!

The good news is that that we now know how to prevent diabetic complication or at-least slow them down. Two landmark trials (i) DCCT (Diabetes Complication Control Trial; in type 1 diabetics) and (ii) UKPDS (United Kingdom Prevention of Diabetic complications Study; in type 2 diabetics) have confirmed that good glucose control can prevent or delay the appearance of complications. Intensively treated patient group showed a 30-50 per cent reduction in the risk of diabetic complications. Patients of both these studies have been followed up for an additional 10 years after the formal termination of the studies.

"Susceptibility to infection, decreased blood flow, diminished vision and reduced sensations all contribute in varying degree to the high frequency and poor outcome of foot problems" - Dr Manoj Chadha The writer is Consultant Endocrinologist PD Hinduja Hospital Mumbai

All the patients received conventional treatment from their primary care physicians. Within six months of initiating the follow up study, the HbA1c was the same in the originally intensively and conventionally treated patients. Surprisingly, both extension studies have shown that the beneficial effect of reduction of microvascular and macrovascular complications in the 'originally' intensively treated patients persists! This persistence of the protective effect of initial good control has been called Metabolic Memory (EDIC study) or Legacy effect (UKPDS extension). The most important point to be stressed here is that that utmost care has to be taken to have tight glycemic control right from the day of diagnosis of diabetes mellitus. There is nothing like a 'touch of diabetes'. This would be the best method to reduce the burden of diabetic complications.

Complications

What are these complications we need to know about? The chronic complications are divided into two categories

a) Those which are typical to diabetics (microvascular complications) and include retinopathy, nephropathy, neuropathy and vasculopathy.

b) Those which could occur in the general population too (macrovascular complication) and includes atherosclerosis, acute myocardial infarction or stroke. These complications do occur more frequently in the diabetics as compared to non-diabetics.

Retinopathy

Most patients are asymptomatic at the onset of this complication, just because the patient does not complain does not mean that everything is fine. There is a need for examination by an ophthalmologist for early diagnosis of eye involvement in diabetes. Visual complaints would indicate that already eye complications have reached an advanced stage!

Nephropathy

Patients have no physical complaints or biochemical changes till 50 per cent damage to the kidneys has occurred. Hence there is a need for regular check up and investigations. A simple urine test (microalbuminuria) could point to the onset of nephropathy.

As nephropathy progresses the patient could develop:

• Edema feet.
• Puffiness of face specially on getting up in the morning.
• Change in frequency of urination.
• Loss of appetite.
• Nausea, vomiting.

Neuropathy

This is possibly the commonest of chronic complications. It presents with

• Tingling, numbness, burning sensation (specially feet at night).
• Constipation, diarrhea, alternating constipation and diarrhea.
• Bloating sensation.
• Postural giddiness.
• Sexual disturbances.
• Unexplained episodic sweating.

Vasculopathy

It is the involvement of small arteries especially of the feet. It is probably the most easily preventable and at the same time the most overlooked complication.

Foot problems could include:

• Delayed wound healing.
• Extensive infection.
• Gangrene.

Susceptibility to infection, decreased blood flow, diminished vision and reduced sensations all contribute in varying degree to the high frequency and poor outcome of foot problems.

Neglect of the feet could lead to problems which may culminate in amputation of toe/ foot/ leg. If one were to see a person with a non-traumatic amputation of toe/ foot, then it would be safe to guess that he is either a diabetic or/and a smoker.

Prevention

• Take your medications and check your blood glucose levels regularly.
• Keep your blood glucose and glycosylated hemoglobin levels as close to the ideal value as possible.
• Follow a healthy eating plan that is low in cholesterol and saturated fat with lots of whole grains, vegetable and fruit. Refined sugars are prohibited.
• Tight blood pressure control.
• Aim for ideal body weight.
• Exercise regularly.
• Quit smoking.
• Limit alcohol.
• Stress reduction.
• Brush and floss your teeth everyday.
• Check your feet everyday for cuts, sores, redness, swelling, blisters.

Screening for Complication

Annual screening for complication including:

• Fundoscopy (examination of retina).
• Urinary microalbumin (earliest manifestation of kidney damage).
• Lipid profile,
• Glycosylated hemoglobin (ideally every three to four months).
• BP check up and examination of feet on every visit to the doctor.

Conclusion

To prevent complications:

• Live a life of moderation exercising balance in whatever you do.
• Discipline yourself.
• De-stress yourself.
• Treat diabetes as your friend.
• Remember that 'absence of complaints does not mean absence of complications!'

You can lead a normal life and do practically everything that a non diabetic does.

mchadha59@gmail.com