WHO chose November 14th as World Diabetes Day, birthday of Nobel laureate Banting, who discovered and injected animal insulin into human, to highlight the fact that this is the most important non-communicable pandemic of our time. Ironically, India has the dubious distinction of being its world leader with 77 million diabetics. Small Pacific island Nauru has the highest relative rate of type 2 diabetes and Finland of Type 1 diabetes.
1. Broadly there are two types of Diabetes, Type 1 and Type 2. Type 1 is as a result of auto-immune (self) destruction of insulin secreting Beta cells of Pancreas, and Type 2 diabetes due to growing resistance to use insulin by the body cells despite adequate production of insulin — generally seen in overweight adults. At some point pancreas exhausts its Beta cell reserve and may require insulin. C peptide level is good marker of pancreatic insulin reserve and its low level suggests early institution of insulin therapy.
2. More than 90% of diabetics are Type 2 and initially may have no symptoms which are generally associated with diabetes, such as excessive urine production, urge to drink extra water or increased hunger pangs. Therefore, they must undergo periodically routine tests such as HbA1C and blood sugar.
3. Nearly 30% diabetics are diagnosed very late and therefore suffer from irreparable damage of critical organs such as kidney, heart, nervous system and eyes at the very outset. Therefore, regular screening for diabetes is most important. High blood pressure is a common accompaniment and it should also be measured regularly in all adults.
4. Healthy diet consisting of good quality protein, low fat and high fibre loaded limited amount of healthy carbohydrates (with low glycemic index) should be prescribed so that desired calorie restriction is achieved. Physical exercise both aerobic and anaerobic must be done at least for 45 minutes daily and weight measured to keep it within healthy range. Pre-diabetics or those who are borderline can try to control the sugar level just by diet and exercise for three to six months. If it does not bring the desired effect, drugs should be started forthwith.
5. If blood sugar is very high right at the beginning of detection one must start with injection insulin as this has immense advantage in preventing long term damage. Once blood sugar is under control, oral drug can take over in Type 2 diabetes.
6. There have been remarkable progress in insulin with near zero impurity, the recombinant insulin, taking frontline position with excellent delivery tools such as painless pen and insulin pumps which can sense the blood sugar level round the clock and deliver insulin to match the requirement instantly, much like how our own body does. Pricks are still required, and Oral or nasal route insulin are yet to be perfected but are in the pipeline.
7. Resistance to insulin action is the major cause of Type 2 diabetes and so various ways to counter the resistance process is being addressed and have already led to the finding of several drugs such as metformin, pioglitazones etc which reverse the resistance to insulin action.
8. Oral drugs of diabetes are many in number now and better ones are coming regularly. Metformin, once feared and dumped for deadly side effects of lactic acidosis has taken a must have position. There have been breakthroughs in drugs acting through incretin contained in the gut and also by modifying the intestinal biomata. There is altogether new approach to act through pancreatic hormone glucagon (which generally opposes insulin action) known as Glucagone like peptides is being used widely now which helps obese diabetics immensly
9. Newly found drug group known as SGLT2 inhibitors which act through releasing the sugar in the urine, has been found to be a game changer as it improves not just blood sugar but also kidney and heart functions remarkably.
10. Curing diabetes has recently found focus and therefore Donor Beta cell and stem cell transplant in Type 1 diabetes is reaching a decisive stage. Better understanding of genetic control and immune mechanism are helping to win the war against diabetes.
Diabetes is not just a sugar or carbohydrate disease but a disease which upsets the whole metabolism and therefore a wholesome and yet updated approach is desirable.
The Author is Currently Professor of medicine at Manipal Tata Medical College and Formerly Professor and Head, Department of Medicine at Rajendra Institute of Medical Sciences, Ranchi, Jharkhand.