diabetes

investigations

Criteria for diagnosis of diabetes mellitus

FPG 126 mg/dl (7.0 mmol/l). OR Symptoms of hyperglycemia and a casual plasma glucose 200 mg/dl (11.1 mmol/l). OR 2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT.

Laboratory methods

Glucose determination in blood and urine

The simplest measurement of carbohydrate homeostasis is glucose determination.

Chemical methods:
orthotoluidine,neocuproine,ferricyanide Enzymatic methods: hexokinase-G6PDH,glucose dehydrogenase, glucose oxidase-peroxidase (ABTS)glucose oxidase (GOD) with other indicator reactions.Qualitative/Semiquantitive paper test strips: Clinistix, Glucostix ,Glucometer(Glucometer Elite XL, Accu-Chek) and newer noninvasive devices(infrared imager, ultrasound imager etc) for self monitoring

glucometer

Oral glucose tolerance test (OGTT) The OGTT is a provocation test to examine the efficiency of the body to metabolise glucose.More sensitive for the diagnosis of diabetes than fasting plasma glucose.

Glycated proteins : All proteins with reactive sites can be glycated and the concentration of the glycated proteins that can be measured in blood is a marker for the fluctuation of blood glucose concentrations during a certain period. Opinion about diagnostic efficacy is divided.HbA1c is of most interest serving as a retrospective indicator of the average glucose concentration over the previous 8 to 10 weeks.Procedures employed are column chromatography(micro and macro), HPLC, FPLC, isoelectricfocussing, monoclonal antibodies etc.Reference level:HbA1c 4.4 6.4%

Urine albumin excretion : The early signs of diabetic nephropathy cannot be detected by the routine screening tests for proteinuria, so that more sensitive methods for detecting abnormal albumin excretion must be used. The early stage of albuminuria is clinically defined as an albumin excretion rate of 30300 mg/24 hours.The following procedure is suggested for the routine analysis of albuminuria in diabetes. Begin: Type 1 diabetes after 5 years of the disease Type 2 diabetes with diagnosis of the disease Commonly employed screening tests are spot urinary albumin:creatinine ratio or spot urine albumin concentration.RIA or immunoturbidometric assays or nephelometric assays are also used.

URINE KETONE AND BLOOD KETONE: TOOL FOR DIAGNOSIS OF DIABETIC KETOACIDOSIS .Urine total ketones should be measured by chemical( nitroprusside, etc) or enzymatic( reagent tabs) or electrochemical methods.Expired air acetone testing can also be done.hydroxybutyrate assays are more sensitive

C-PEPTIDE: A NEW TEST IN DIABETIC MEDICINE: C -peptide is a simple, cost-effective and non-invasive method in the assessment of beta-cell capacity.It is mentioned useful in followup of the diabetic complication.It is noted for the good diagnostic property for diabetic neuropathy, one of the most common complications of DM.

INSULIN TEST: A DIRECT MEASUREMENT OF HORMONE The measurement of insulin by RIA can be done but it is not practically used in routine diabetic clinic. Glucose clamp technique (the hyperinsulinemic-euglycemic clamp in assessing in vivo insulin sensitivity and the hyperglycemic clamp in assessing insulin secretion) is also performed to measure insulin secretion and sensitivity.

Other tests. Routine blood count and coagulation screen .Arterial blood gases-in any emergency like diabetic ketoacidosis. Serum electrolytes and urea-creatinine. Lipid profile,Liver function tests,Chest Xray ECG,Infection screen(depending on clinical correlates)

FOUR PILLARS OF MANAGEMENT ARE..

1.DIET 2.DRUGS 3.PATIENT EDUCATION and

4.EXERCISE

In type 1 DM patients the total energy input has to be relatively higher in order to regain ideal weight and growth.

In type 2 DM patients calories need to be restricted in order to avoid obesity

Goals of medical nutrition therapy

To maintain near normal glycemia. To maintain optimal lipid profile. To maintain normal blood pressure. To restore and maintain ideal body weight.

The following points have to be considered while prescribing a diet for diabetic :

The type of diabetes type1 or type2

The weight of the individual in comparison with his ideal body weight (BMI) His occupation and activities and to assess his caloric requirements. The presence of any complications.

TOTAL CALORIC INTAKE

This is the most important step while prescribing a diet. The body mass index (BMI) will help to determine total caloric requirement.
BMI = Weight (in kg)/ height in m`2 It is desirable to keep BMI between 22 & 25.

Ideal body weight can be calculated by the formula :

IDEAL BODY WEIGHT= Height(cm)-100

Endocrine / physiological responses during exercise :

Suppression of insulin release- directly as well as through epinephrine. Sympathetic system activation- which inhibits insulin release and stimulates lipolysis. Non-insulin dependant glucose uptake in the periphery.

Benefits of exercise

It improves insulin sensitivity Decreases triglyceride, increases HDL cholesterol and decreases LDL cholesterol It lowers blood glucose concentration It lowers BP in mild to moderate hypertension It helps in cardiovascular conditioning

Risks of unsupervised exercise in uncontrolled diabetic :

Hypoglycemia Hyperglycemia after very strenous exercise Precipitation of cardiovascular disease Worsening of long term diabetic complications

For the average middle aged indian diabetic the following exercise regimen is adequate
walk 3km on level ground over a period of 45 mts Swim for 30 mts at average speed without cardiovascular distress Cycle on level ground at 8km/hr for 30mts Regular sports and game activities Yoga exercises

MANAGEMENT OF HYPOGLYCEMIA

Management consist of emergency measures to correct the blood glucose level. If the patient can swallow, 50g of glucose dissolved in 200ml water should be given orally.symptoms start improving within 5-7 mts and the patient becomes normal within 20-40 mts. If glucose is not at hand sweet articles and cereal foods can be given.

If the patient is unconscious, parenteral glucose should be administered. About 15-20g of glucose is usually needed. This is best administered by IV infusion of 200-250ml of 100% dextrose, which is safe and effective.

THERAPEUTICS

The homeopathy drug treatment used in diabetes can be classified in to six groups namely acids, metals, other minerals, vegetables, drugs from animals, and organotherapic remedies.

The acids used for treatment of diabetes are acetic acid, lactic acid, phosphoric acid, nitric acid, picric acid, carbolic acid, and flouric acid. Acids are often used in patients with debility or persistent weakness. Acid can prevent acidosis one of the greatest danger of diabetic mellitus

Metals Aurum met, Argentum met, Argentum nitricum, Uranium nitricum, Vanadium, Plumbum met, Cup ars are used as a homeopathic treatment for diabetes.

 Other minerals (such as Ars alb, Sulphur, Silicea,

Iodum, Natrum sulph), vegetables (such as Cephalandra indica, Chimaphilla, Chionanthus, China, Curara, Nux vom, Helleborus niger), and products from Animal kingdom (such as Moschus, Crotalus horridus, Lachesis, Tarentula, Lac defloratum) are prescribed based on the individual characteristics and symptoms of the patients.

 Insulin an organo therapic remedy is prescribed

in critical cases of diabetes, in lean and thin consumptive patients and also in coma. Pancreatin, adrenalin, urea, lecithin are the other organo therapic remedies. Biochemic remedies for diabetes mellitus are Nat mur, Nat sulph, Kali phos, Kali mur and Kali sulph.

 The metals are used for treatment of patients

with hypertension, diabetic nephropathy, arteriosclerosis, mentally and physically exhausted and various other symptoms. The minerals, vegetables and animal products are used to manage symptoms such as weakness and prostration, gangrene, diabetes complicated with digestive troubles, impotence, ocular troubles and other complications of diabetes. The homeopathic remedy prescribed to a patient depends on his/her symptoms and characteristics. Hence two patients may have diabetes but their prescriptions may be completely different.

 Homeopathic treatment with drugs can improve

the general well being of the person with diabetes. In patients with poor general health it can be very difficult to achieve good control of diabetes. Improvement of general health improves the general sense of well-being, decreases the dose and number of drugs needed to control blood glucose and improves blood glucose control. Remedies such as Syzygium, Uranium nitricum, Phloridzin (obtained from the root of the apple and other fruit trees) are given to improve the general health of the patient.

PHOSPHORUS

Adapted to tall slender persons of sanguine temperament. Nervous, weak, desire to be magnetised. Over sensitiveness of all senses.
A weak, empty, all gone sensation in head, chest and entire abdomen. Constipation: feces slender, long, dry, tough and hard. Voided with great difficulty. It is useful in diabetes and pancreatic ds especially in those of a tuberculous or gouty diathesis.

URANIUM NITRATE

It has polyuria, polydypsia, dryness of mouth and skin. It causes sugar in the urine. It lessens sugar and quantity of urine. Enormous appetite and thirst.

BRYONIA

Adapted to persons of rheumatic or gouty diathesis. Excessive dryness of mucous membrane of entire body, lips and tongue dry, parched, cracked. Great thirst.
Constipation: inactive, no inclination, stool large, hard, dark, dry, as if burnt. Persistent bitter taste. The patient is languid, morose and dispirited.

PHOSPHORIC ACID

The urine is increased, perhaps milky in colour and containing much sugar. There will be loss of appetite. Unquenchable thirst Patient passes large qty of pale colorless urine. phosphatic deposit in urine

INSULIN

It maintains the blood sugar at normal level and the urine remains free of sugar.

LACTIC ACID

Urinates copiously and freely. Urine light yellow and saccharine. Thirst, nausea, debility, voracious appetite and costive bowels Dry skin, dry tongue,gastralgia.

SYZYGIUM JAMBOLANUM

Capable of diminishing the amount of sugar in urine. Used as palliative.

CAUSTICUM SCILLA STROPHANTHUS may be of use in diabetes insipidus.

NATRUM SULPH corresponds to the hydrogenoid constituition, with dry mouth and throat. LYCOPODIUM patients are emaciated,weary, increased appetite and great thirst. Pale profuse urine. ACETIC ACID it has passing of large quantities of pale urine, intense thirst,hot,dry and marked debility.

PODOPHYLLUM has a bitter taste, but the tongue is flabby. It may be of use in the ds. CHIONANTHUS thirst and copious urine. Constipation with light colored stools devoid of bile. NAT SULPH polyuria, intense itching of skin of thighs. ARGENTUM MET urine is profuse, turbid and sweet odor. Micturition frequent and copious.