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About Diabetes

Obesity

Pre-Diabetes, Type 2 Diabetes and Gestational Diabetes are among various forms of a disease which is already one of the major health crises of the 21st Century. The number of cases of Diabetes in its different variations is almost triple what it was 50 years ago, with 150 million people now affected throughout the world.India has over 30 million and by the year 2025 we will be having over 70 million Diabetics.

 

Currently, five million deaths are caused by Diabetes each year worldwide. The figure set to rise dramatically as obesity – a root cause of Diabetes – reaches epidemic proportions. The number of Diabetes cases is likely to double to 300 million by 2025. Research suggests that 80% of Diabetes sufferers will eventually die of a heart attack or stroke called as Cardiovascular Complicationsof Diabetes.

 

Shocking increase in Diabetes cases and other chronic diseases stemming from the spread of obesity could reverse a long upward trend and lead to a fall in overall life expectancy. Diabetes is basically a disorder in which the body either fails to produce enough insulin or does not use insulin properly to convert sugar, or glucose, in the blood stream into energy. Pre-Diabetes is a condition that occurs when a person's blood glucose levels are higher than normal but are not in the range of Type 2 Diabetes. Gestational Diabetes is a glucose and insulin disorder than often strikes pregnant women.

 

Genetics can play a part in the development of various forms of Diabetes and people with a family history of the condition are at greater risk of developing the disorder. So, too, are individuals who suffer from Insulin Resistance,caused by an imbalance of sugar and insulin in the blood stream, which may lead to weight gain and obesity and result in the onset of Pre-Diabetes. Both Insulin Resistance and Pre-Diabetes are reversible but, if left unchecked, can lead to Type 2 Diabetes – a serious condition that can only be managed, not reversed, and may finally require daily insulin.

 

Type 2 Diabetes used to mainly affect older people. But as obesity levels grow, the disease has begun to claim ever younger victims, including obese children. Type 2 Diabetes can be prevented from taking hold, however, by reversing the symptoms of obesity-related Insulin Resistance and Pre-Diabetes through weight loss via a balanced, nutritious diet and regular exercise.

 

Insulin Resistance causes an imbalance in glucose and insulin levels in the blood stream, which can stem from anunhealthy lifestyle comprising little or no exercise and a poor diet without proper nutrition. Insulin receptor sites act as a "key in a lock," allowing food that has been refined to glucose in the blood stream to pass through the cell wall and be converted to energy. The number of these receptor sites is vastly reduced by Insulin Resistance, with the result that glucose "bounces off" the cell wall and then freely floats in the blood stream.

 

Excess of the glucose is converted into fat and stored via the blood stream throughout the body. This process often leads to obesity, a key factor in the onset of Pre-Diabetes, as well as a leading cause of female infertility calledPolycystic Ovarian Syndrome (PCOS) and the cluster of cardiovascular risk factors known as Metabolic Syndrome (Syndrome X). All Insulin Resistance-related conditions are increased risk factors for heart attacks and stroke.

What is Type I Diabetes?

Type 1 Diabetes occurs when the body's own immune system attacks insulin-producing beta cells in the islets of pancreas and destroys them. This results in the pancreas producing little or no insulin, forcing an individual to take insulin through injections or an insulin pump. Symptoms include:


  • ♦  increased thirst
  • ♦ increased urination
  • ♦ weight loss despite increased appetite and growth failure
  • ♦ nausea
  • ♦ vomiting
  • ♦ abdominal pain
  • ♦ fatigue
  • ♦ absence of menstruation

Approximately 5% of Diabetics have Type 1 Diabetes. It usually occurs in children or young adults, though it can also develop or manifest later in older adults.When Immune destruction is slow and happens over the years.


A condition called as LADA - Latent Autoimmune Diabetes in Adults. This disorder increases the risk of Cardiovascular Disease, blindness (retinopathy), nerve damage (neuropathy) and kidney damage (nephropathy).


Type 2 diabetes: the basics


What is type 2 diabetes?


Your body gets energy by making glucose from foods like bread, potatoes, rice, pasta, milk and fruit. To use this glucose, your body needs insulin. Insulin is a hormone that helps your body control the level of glucose (sugar) in your blood. Type 2 diabetes is a disease in which your pancreas does not produce enough insulin, or your body does not properly use the insulin it makes. If you have type 2 diabetes, glucose builds up in your blood instead of being used for energy.


But The good news is….. You can live a long and healthy life by keeping your blood glucose levels (the amount of sugar in your blood) in the target range set by your doctor. You can do this by: Eating healthy meals and snacks Enjoying regular physical activity Taking diabetes medications (including insulin), if prescribed by your doctor Type 2 diabetes is a progressive, life-long condition; over time, it may be more difficult to keep your blood glucose levels in your target range. Your healthcare team can help by working with you to adjust your food plan, activity and medications.


Complications of diabetes Over time, high blood glucose levels can cause complications such as blindness, heart disease, kidney problems, nerve damage and erectile dysfunction. Fortunately, good diabetes care and management can prevent or delay the onset of these complications.(for understanding these see our page on complications overview)


Managing your diabetes - General Rules:-

Here are some steps you can take to manage your diabetes and help maintain your overall health and wellness – today and in the future:


  ♦ Don’t smoke
  ♦  Check your blood glucose levels regularly and keep them in your target range
  ♦  Keep your cholesterol and other blood fats in your target range
  ♦ Maintain a healthy weight
  ♦  Keep your blood pressure close to target level
  ♦  Take your medication as prescribed
  ♦  Manage your stress effectively
  ♦  Follow a balanced meal plan
  ♦  Be physically active
  ♦ Take care of your feet
  ♦  Regularly visit your dentist, eye care specialist (every one to two years) and doctor

Your diabetes healthcare team can help

Your diabetes healthcare team can answer all your questions about how to manage your diabetes well. Depending on your needs and the resources available in your community, your team might include a doctor (your family doctor or a diabetes specialist), a registered nurse and a registered dietitian.


Treatment of Diabetes


Points to take note are:

Remember Diabetes is an Interplay of ‘Insulin Resistance‘, raising the needs of Insulin and on the other hand “Inability of B cells” to cope up with the demands; together called as Insulin Resistance and Secretory defect ;unless these two happen , Diabetes can not take hold in an individual, therefore, any treatment has to address these two basic problems.


1.)Secretory defects in response to raised demands are best declared by Fasting Blood Glucose levels whereas Insulin resistance causing severely increased demands is best seen as peaking blood glucose levels, in response to a normal or glucose challenge meals. In Pre-diabetes state both may present separately or together but in a full blown Diabetic both of these are present together ,as a rule


2.)No two patients are same and no single treatment can be exactly workable for two different patients even if they are twins! In other words- No medicine is going to give exactly same effects or side effects in two different individuals


3.)Every patient passes from different stages of disease and may fluctuate from higher levels to lower and vice versa


 

4.)Over the years, Insulin producing B cells in every Pancreas go down in numbers and productivity in fact Diabetes declares on the scene when almost 50% of B cells are either non functional or dead ! Remaining B cells keep losing their Insulin making powers with the passage of time In fact over 4 to 11 % people or may be more, every year, keep losing B cells completely. At this point you need to have Insulin support from Exogenous sources!


5.)The rate of loss of B cells, though genetically determined, can be slowed for the sure, by Good weight and Diet management at Pre-Diabetes state and when Diabetes sets in, with a good control of Diabetes in addition to these two factors helps in maintaining good health of your B cells.


6.)Also note that in a Diabetic Individual, the mechanisms of slowly Increasing Insulin needs due to Insulin Resistance, after meals or Post- prandial rise in Glucose, followed by B cells “giving up” with Insulin secretion and then secretory capacities going down and down, all happen over the years and all these are stage wise progressions with many modifiable variable like Body weight, Meal size and composition, total calories per day, physical activity and stress, intercurrent diseases and medicines’ intake, are few important ones.


7.)A progressive disease like this ,needs to be matched with progressive and scientific improvisations in the treatment plans; therefore in a single individual at different times and situations we must have different strategies and plans with different Diet, Exercise and Medicinal formulations/combinations and this clearly means a treatment once prescribed ,to successfully control your blood glucose, may not remain efficient for long and sooner or later all this must be redesigned and restructured once again. Here lies the importance of Regular periodic monitoring and consultations.


8.)Metabolic Memory: Another Important fact-more aggressive you are in maintaining your Glucose levels to near normal, more benefits you will get from the treatment , an early and appropriate control is remembered by the Metabolic system in your body and rewards are sure similarly an undisciplined approach with bad controls in earlier phase ,are also similarly remembered by your system and damage control is less rewarding.

***For all Indian Individuals above 35 yrs of Age it should be mandatory to Test for Fasting Blood Glucose and for Post-Prandial Glucose at TWO hrs after 75 Gs of Glucose load and if found normal then it should be repeated at every 2 yrs!


AND Also all overweight(85th percentile weight and above) adolescents of above 10 yrs of age, should be subjected to active screening , because with “soon arriving” puberty and hormonal changes/surges ,this age group will not give you enough time for interventions while progressing from Pre-Diabetes to Diabetes, in fact within few months the damage and progress to Diabetes may be complete and the Intervention phase for Pre-diabetes gets totally missed /lost in the process !


Adolescent Overweight /Obese Children are SPECIAL HIGH RISK CATEGORY:


Moreover an adolescentif develops Diabetes will pose a bigger problem for the society. Let me explain you how. Let us assume that complications take 10 years to take roots into the system and another 10 yrs. to cripple and killyou.If Diabetes comes at 15 yrs of age then by the age of 25 when you are getting married and settling down in a job you start facing the music from Diabetes related complications, you are afraid of facing your wife because of Erection difficulty or getting transient ischemic attack while on Honeymoon! and by the age of 35 yrs when your career graph is in full swing, your children are gearing up for greater postures, you are settling down with issues like property ,assets and are consolidating your final positioning in life , and then suddenly you are getting your first heart attack! which lands you in ICU !You may or may not survive,all energies,plans,dreams and ambitions going down the drain ! Just think what kind of life we are giving to our children.Dear all I am really very serious about these issues.

 

INDIANS ARE MORE PRONE TO DIABETES-BUT Why Are We Still Not Pro-Active In Our Approach Towards Screening For Pre-Diabetes?

We the people of India have survived through centuries, with the help of a set of genes ,which ensured our survival against all odds, including long years of famine and scarcity of food! Meaning that the present population is stuffed with all the necessary genes needed for conservation of food.


At the same time Pancreas we have is equipped with a limited power in terms of production of Insulin by Beta cells. These are special cells which can produce Insulin NO OTHER CELL CAN PRODUCE INSULIN.


When a child is unborn in mothers uterus and Pancreas is developing in the fetus ,factors which can negatively influence the develpoment of Pancreas are Maternal Mal nutrition and Maternal Diabetes .A child born to such a mother will be more prone to have a "weak"Pancreas !


Our Genetic pool has some Genes which permit conditions favorable for Diabetes development.


- Our Genes are designed to avidly store fats.


- Storage of fats is predominantly different from our western counterparts , we tend to store fats, whenever available in plenty, within our abdominal cavity, within the muscles & also in Liver and thus create wrong depots!


The Fact that You have Wrong Depots is Easily recognized by Central Obesity-Waist line more than 90 cms in males and 80 cms in females.


- All these fat depots create a situation which make us not only readily “Centrally Obese” but also make us Insulin Resistant! which means more than normal Insulin is required for even normal rates of Glucose transport.


( Readers may note that Insulin is the only Hormone in the body which helps in utilization of Glucose and Glucose is the final product of our food which body uses for survival,repairs and growth.)


- It is a proven fact that an Indian, Obese or even Non-Obese, needs more Insulin Units to deal with any amount of Glucose load when compared to Caucasians/Whites counterparts.


- The situation becomes even more complex because of the fact that Indians have more fat in their body for each Gram of Muscle mass, again, as compared to whites!


More Fat-Less Muscle


- In fact even Infants in India have more fat and less muscle when compared to an Infant with the same body weight but from a "White" mother!


- Indian Infant has to produce more Insulin for each gram of Glucose when compared to Whites. That means Indians are somewhat Insulin Resistant and Hyperinsulinemic right after Birth!


--Aging is another factor which sees every hormone producing system in our body going down hill with each passing year.This happens to Pancreas and Beta cells as well.With every passing decade Beta cell function goes down and down.


- If this Insulin Resistant and genetically predisposed system is subjected to repeated and frequent surges of High Blood Glucose , created by intake of Calorie dense, greasy, starchy food ,with cokes, snacks, burgers and that too- again and again ,throughout the day and day after day ,it will not be hard to imagine what will finally happen to the poor Pancreas and it’s “limited powered” Beta Cells .....they will fail to cope up with the pressure..


In fact Beta cells of Indians can be compared with a Pentium I Processor of Older computers ,with limited RAM backing it, and if commands are too many and too frequent ,without enough processing time in between, then it is bound to crash!


Yet another aspect of modernization and changing lifestyles detrimental to Beta cells are the problems of –Physical Inactivity,emotional /work Stress & Depression (with variable grades!


We have solid scientific evidence which tells us that Risk For Cardiovascular complications in terms of Heart attacks, Brain attacks or Strokes, Peripheral Vascular Disease (along with Impotence) and Non alcoholic Steatosis and Steato-hepatitis(linked to fatty liver) which can end up as permanent Liver damage, all start YEARS before the Diabetes actually arrives on the scene ! Infact trouble starts 8 - 12 years before at " prediabetes stage "


As many as 35% to 40% of Pre-diabetes cases can actually progress to Diabetes.Even those who do not progress to Diabetes , still have High cardiac risk.


I can therefore put forward the following reasoning for “ why Pre-diabetes should be aggressively looked for in an average Indian not ony by fasting Glucose test BUT also by a a Glucose test 2 Hr after 75 G of Glucose load what we call as 2hr.PPBG.Both should be mandatory in any screening program .(at least in Indians)


Reasons are as follows:


  ♦This category as such, is clearly linked with High complications risk for all the above deadly conditions !
  ♦This category can progress to Diabetes.
  ♦Diagnosis of Pre-diabetes needs NO EXTRA effort. You are actually doing the same tests for the Diagnosis of            Diabetes.


AND while screening for Pre-Diabetes you may ,by chance, find out many cases of UNDIAGNOSED Diabetes as well !A very real possibility because around 40-50 % cases of undiagnosed in our populations.


   ♦ We can do a lot for these people through appropriate interventions including Drugs for this particular category.
   ♦AND above all - We have solid evidence, again, that these interventions ACTUALLY MAKE DIFFERENCE ! and a        world of difference! We can reduce overall risk for all the complications mentioned above and also can revert         OR at least slow down/delay. the progress to Frank Diabetes !

We should have new recommendations for Health care people and masses in general at least in south Asia:


Keeping in view the latest International Diabetes Federation’s recommendations and also the rising trends of Diabetes, Heart attacks., Strokes, Impotence and NASH-(Non Alcoholic Steato-hepatitis – linked to Fatty liver )& Peripheral Arterial Disease,we need to actively and aggressively look for Pre-Diabetes in our populations.

We should also not forget that Indians ,as a race are already genetically prone to all these conditions ,which tend to occur earlier by TEN years to us and then progress rapidly thereafter! For all the right thinking and really concerned Health Care Individuals this should be their DUTY to Pro-actively look for Pre-Diabetics-“A stitch in time saves NINE”


Therefore my recommendations are:


For all Indian Individuals above 35 yrs of Age it should be mandatory to Test for Fasting Blood Glucose and for Post-Prandial Glucose at TWO hrs after 75 Gs of Glucose load and if found normal then it should be repeated at every 2 yrs!


AND Also all overweight(85th percentile weight and above) adolescents of above 10 yrs of age, should be subjected to active screening ,because with “soon arriving” puberty and hormonal changes/surges ,this age group will not give you enough time for interventions while progressing from Pre-Diabetes to Diabetes, in fact within few months the damage and progress to Diabetes may be complete and the Intervention phase for Pre-diabetes gets totally missed /lost in the process !


Pleasantly even Americans are waking up to the idea of proactive search and drug treatment of PredIabetes as indicated by many recent publications.

Pre Diabetes- FAQs


Q1:What is meant by Pre-Diabetes?

Ans: This is a Biochemical abnormality which may be a precursor for Diabetes that’s why the name is given as that.


Q2.How do we clinically define it? How it can be detected?

Ans: The tests for detection of Diabetes and Pre-Diabetes are exactly the same, it is the extent of abnormality which differentiates them into two different classes. This is as under:
Fasting Blood Glucose      Normal Below 100 mg %(70-100)
                                            Diabetes Above 126 mg% 
Then there is a gap! 
What will you say for the Glucose Levels from 101 to 125 mg% ?


This is called as Impaired Fasting Glucose OR IFG- in short


Now, there is another way of Diagnosing Diabetes and that is, when you get Post-meals Glucose levels of 200mg% or above OR we put a challenge load of 75 Gms. of Glucose on to the system and at Two Hrs, if Glucose levels cross 200 mg %.This 200 mg % is set as the limit above which we label the patient as Diabetic..

But coming back to the levels for- after meals or at 2Hrs after 75 Gms of Glucose load, we know the Normal upper limits are 140 mg%!

So again, there is gap here, from 140 of the normal limits to 200 mg% ,a point where Diabetes starts, there is this category, from 141 to 200 mg%


what we call as Impaired Glucose Tolerance OR IGT- in short !


To summarize now-
Normal levels           Fasting                70-100 mg%
                                 Post meals         <140 mg% 
Diabetes means Fasting Bld Glucose ----126 mg% & above
OR at 2 Hrs After meals ------ 200 mg% & above
OR at 2Hrs After 75 G Glucose load —Above 200 mg%

IFG OR Impaired Fasting Glucose                 101 to 125 mg%    *
IGT OR Impaired Glucose Tolerance           141 to 199 mg%    *
**Both these later categories of IFG & IGT put together are called and categorized as Pre-Diabetes by most of the clinicians.


Q3. What are the Risk Factors for Pre-Diabetes:


Ans : RISK FACTORS FOR PRE-DIABETES ARE

There are a number of risk factors which significantly increase the likelihood of the disease's onset. These are:

  ♦ a family history of Type 2 Diabetes or heart disease
  ♦ being overweight or obese
  ♦ being aged 45 or older
  ♦ suffering from hypertension (high blood pressure)
 ♦ belonging to a high-risk ethnic group, namely African-Americans, Asian-Americans,       Latinos or Pacific Islanders
 ♦ being "apple-shaped" rather than "pear-shaped," meaning that excess weight gathers     around your waist, rather than your hips
 ♦ if female, suffering from Gestational Diabetes while pregnant or giving birth to a baby    weighing more than 9 lbs
  ♦ eating an excess amount of carbohydrates
  ♦ leading a sedentary lifestyle with little or no exercise
  ♦ being recently diagnosed as suffering from Insulin Resistance
Researchers have found a link between Pre-Diabetes and other conditions such as the cluster of cardiovascular diseases called Metabolic Syndrome (Syndrome X), as well as the hormonal imbalance called Polycystic Ovarian Syndrome (PCOS), which is a major cause of female infertility. Research has indicated that up to 40% of women with PCOS suffer from Pre-Diabetes or Type 2 Diabetes by the age of 40.



Q4.Why all this effort of creating yet another category of ab-normals out of Normals ? If you are Not Diabetic then you are Normal !Why at all Prediabetes should be created from within the Non Diabetics ? What is the logic behind this?


Ans: We have solid scientific evidence which tells us that Risk For Cardiovascular complications in terms of Heart attacks, Brain attacks or Strokes, Peripheral Vascular Disease ,Impotence and Non alcoholic Steatosis and Steato-hepatitis(linked to fatty liver) which can end up as permanent Liver damage, all start YEARS before Diabetes actually arrives on the scene !


And you know 35% to 40% of Pre-diabetes can actually progress to Diabetes. I can therefore put forward the following reasoning For Pre-diabetes being created as a separate condition:


  ♦ This category is clearly linked with High complications risk for all the above deadly conditions!
  ♦ This category can progress to Diabetes.
  ♦ Diagnosis of Prediabetes needs NO EXTRA effort. You are actually doing the same tests for the Diagnosis of Diabetes and only in the process, you encounter thesePre-diabetics !AND while screening for Pre-Diabetes you may by chance, find out few cases of UNDIAGNOSED Diabetes as well !A very real possibility.
  ♦ We can do a lot for these people through appropriate interventions including Drugs, for this particular category.
   ♦  AND above all - We have solid evidence, again, that these interventions

DO MAKE DIFFERENCE ! and a world of difference! We can reduce overall risk for all the complications mentioned above and also can revert OR at least slow down & delay the progress to Frank Diabetes !


DO MAKE DIFFERENCE ! and a world of difference! We can reduce overall risk for all the complications mentioned above and also can revert OR at least slow down & delay the progress to Frank Diabetes !


Q4: So this seems to be logical then; but what are the recommendations for Health care people and masses in general?


Ans: Keeping in view the latest International Diabetes Federation’s recommendations and also the rising trends of Diabetes, Heart attacks., Strokes, Impotence and NASH-(Non Alcoholic Steato-hepatitis –a Liver damaging situation linked to Fatty liver ),we need to actively and aggressively look for it’s presence in our populations. We should also not forget that Indians ,as a race are already genetically prone to all these conditions ,which tend to occur earlier by TEN years to us and then progress rapidly thereafter! For all the right thinking and really concerned Health Care Individuals this should be their DUTY to Pro-actively look for Pre-Diabetics-“A stitch in time saves NINE”


Therefore my recommendations will be :
For all Indian Individuals above 35 yrs of Age it should be mandatory to Test for Fasting Blood Glucose and for Post Prandial Glucose at TWO hrs after 75 Gs of Glucose load and if found normal then it should be repeated at every 2 yrs!


Adolescent Overweight and Obese-Diabetes in Children ! Overweight(85th percentile weight and above) adolescents of above 10 yrs should also be subjected to active screening ,because with “soon arriving” puberty and associated hormonal changes ,this age group will not give you enough time for interventions while progressing from Pre-Diabetes to Diabetes, in fact within few months the damage and progress to Diabetes may be complete and the Intervention phase of Pre-diabetes gets totally missed and lost in the process !


What is Gestational Diabetes?

Insulin Resistance and obesity-linked Gestational Diabetes is a condition that develops in the third trimester of pregnancy and affects 4-12 % of all pregnant women. With Gestational Diabetes, the pancreas produces insulin but not enough to lower the mother’s blood sugar levels.

 

All Indian Pregnant women must get a Fasting and /or Random Bld Glucose check test with each pre-natal visit. If HbA1c is also done that will be a great value addition.

 

To determine if a woman has this condition, she should be tested immediately as soon as pregnancy is confirmed and between 22 and 26 weeks if she is at average risk i.e. has no history of prior Gestational Diabetes and is of regular weight. Women at higher risk should be tested earlier. A patient is considered high risk if she is obese, has glycosuria (glucose in the urine) or has a personal or family history of Gestational Diabetes or is pregnant second time onwards.Practically BEING INDIAN MAKES A FEMALE A HIGH RISK CASE for Gestational Diabetes!

 

Pregnancy and Obesity

Women who are overweight before they become pregnant are most at risk for this disorder. The best way to avoid it is to lose weight before becoming pregnant via a low Glycemic Index (GI) diet and regular exercise. Gestational Diabetes usually disappears after pregnancy, but it can lead to the development of Pre- and Type 2 Diabetes years later.

 

How GDM Develops ?

As a baby grows, it is supported by the placenta. Hormones from the placenta help the baby develop but these hormones can also block the action of insulin in the mother’s body. Normally this is Nature’s way to create a situation wherein fetus gets Priority for nutrition but when exaggerated this may convert to the state of Gestational Diabetes.

 

This problem is called Insulin Resistance, which makes it hard for the mother’s body to use insulin in the normal way and requires her to need up to three times as much insulin as when she was not pregnant.

 

The process starts when the body is not able to make and use all the insulin it needs for pregnancy. Without enough insulin, glucose cannot leave the blood through the cell wall and be converted to energy. Glucose builds up in the blood to high levels, which is called hyperglycemia as explained earlier.

 

Gestational Diabetes affects the mother in late pregnancy, after the baby’s body has been formed and it is busy growing. Because of its late development, the GDM does not cause the kinds of birth defects which otherwise may develop in babies whose mothers had other forms of Diabetes before pregnancy.

 

Gestational Diabetes’ Effect on Babies

 

 

 

 

However, untreated or poorly-controlled Gestational Diabetes can hurt the baby. Although insulin does not cross the placenta, glucose and other nutrients do. So extra blood glucose gives the baby high blood glucose levels. This causes the baby’s pancreas to make extra insulin to get rid of the blood glucose. Since the baby is getting more energy than it needs to grow and develop, the extra energy is stored as fat.

 

This can lead to macrosomia, or a “fat” baby. Babies with macrosomia face health problems of their own, including damage to their shoulders during birth. Because of the extra insulin made by the baby’s pancreas, newborns may have very low blood glucose levels at birth and are also at higher risk for breathing problems.

 

Remember : A fat new born may not be a healthy baby !

Babies with excess insulin become children who are at risk for obesity and, later, adults who are at risk for Pre- and Type 2 Diabetes. Pre-Diabetes is a reversible condition that occurs when a person’s blood glucose levels are higher than normal but not in the range of irreversible Type 2 Diabetes.

 

How to prevent GDM ?

 

The best way of preventing Gestational Diabetes is to have a more active lifestyle and not be overweight before pregnancy. But if it does develop, early treatment is required because the disorder can hurt both mother and baby. The treatment aims to reduce and maintain normal blood glucose levels to those of pregnant women. It includes special meal plans and scheduled physical activity, though pregnancy is not a good time for rigorous exercise.

 

Treatment for Gestational Diabetes helps lower the risk of a cesarean section birth that very large babies may require. While the disorder usually goes away after pregnancy, your chances are 2 in 3 that it will return in future pregnancies.

 

In a few women, however, pregnancy uncovers Type 1 or reversible Pre-Diabetes, which, if left unchecked, can lead to Type 2 Diabetes, a disorder that must be managed throughout one’s lifetime and may require daily insulin. It is sometimes difficult to diagnose whether these women have Gestational Diabetes or have just started showing their Diabetes symptoms during pregnancy.

 

Gestational and Type 2 Diabetes – is there a A Link?

 

As mentioned, many women who have Gestational Diabetes go on to develop Type 2 Diabetes years later. There seems to be a link between the tendency to have Gestational and to develop Type 2 Diabetes, both of which involve Insulin Resistance.

 

Once Gestational Diabetes has disappeared after giving birth, some basic changes in lifestyle can help prevent the later onset of Insulin Resistance. If neglected, this latter condition may lead to Pre-Diabetes and a severely increased risk of Type 2 Diabetes. These lifestyle changes are:

 

Losing weight – if you’re 20% over your ideal body weight, you’re at risk. Losing even a few pounds can help you avoid developing Type 2 Diabetes. ♦ Making healthy food choices – follow simple daily guidelines, ♦ like eating a variety of foods including fresh fruits and vegetables, avoiding refined carbohydrates (e.g. sugar, bread, bagels, pasta, cookies, crackers, chips, soda and candy), minimizing intake of complex carbs (e.g. brown rice, whole wheat pasta and whole wheat bread) and keeping a close eye on your portion size. Healthy eating habits can help prevent Type 2 Diabetes and a host of other Insulin-Resistance-related health problems like the cluster of cardiovascular diseases called Metabolic Syndrome (Syndrome X) and Polycystic Ovarian Syndrome (PCOS), a hormonal imbalance which is a leading form of female infertility. All Insulin Resistance-related conditions are increased risk factors for Cardiovascular Disease, which can lead to a heart attack or stroke in both sexes. ♦ Exercising – regular exercise allows your body to use glucose without extra insulin. This helps combat Insulin Resistance, a root cause of Pre-Diabetes leading to Type II Diabetes. But always check with your doctor before starting an exercise regime. Pregnancy is not a good time to either start or pursue strenuous exercise. The ideal aim should be to lose weight and reach a healthy level through regular exercise before becoming pregnant.

 

Managing The Problem of GDM

 

 

STAGE ONE:

  • Identify High Risk Cases
  • (i) All Asians,
  • (ii)Multiparous
  • (iii) With Family History
  • (iV) Twin Pregnancy
  • (v) Obese,Age >25 yrs’ past history of GDM
  • (vi) PCOS,prev. large babies
  • (vii) IntraUterineDeaths
  • (viii) Abortions
  • Low Risk• White race AND • Age < 25 years AND • Weight normal before pregnancy AND • No history of abnormal glucose metabolism AND • No history of poor obstetric outcome- You can see that practically all Indian Females are High Risk cases for GDM

 

STAGE TWO:

1. Screen and Diagnose:
a. All women (other than those at special risk) have a 50 g non-fasting glucose challenge test (GCT) performed at 24 - 26 weeks. If the 1-hour plasma glucose is = 140 mg%, they will be recalled to have an oral glucose tolerance test. I place the cut-off at 130 mg % for Indian females.

 

b. The GTT is performed after a 10-12 hour fast. The fasting plasma glucose measured, and then 75g glucose solution is drunk in not more than 5 minutes, and then 1 hourly plasma glucose is measured.

 

Patients may not smoke, eat nor drink anything other than water during the test, and should not perform any exercise.

Gestational diabetes (GDM) is defined by any of the two levels above the limits given below:
Abnormal Values:
At F : > 092 mg/dl;
At 1H: >180 mg/dl;
At 2H: >153 mg/dl;

 

OR with or without fasting if a pregnant lady shows Blood Glucose of more that 140 mg % TWO hours after ingestion of 75 G of Glucose,one can assume that Gestational Diabetes is present.

 

. Also note that ½ Hrly Testing is no more recommended.

 

STAGE THREE :CLINICAL INTERVENTION :

D. First Visit After Diagnosis1. Education- most crucial. a. All the women with GDM are seen initially by the diabetes educator and receive the following information:
I. Importance of GDM
II. Education in home glucose monitoring
III. Initial diet and exercise advice
IV. Long-term follow-up

NOTE: Women at special high risk of should be tested with a GTT in the first instance. If a GTT is performed before 24 weeks and if normal, should be repeated at 28 weeks. E. )Insulins To be Used : Human insulin (Regular/Pre-Mixed) Aspart and Lispro all three can be used ,as different combinations ,depending upon the glycemic profile of your patient Insulin Levemir is also now favored as basal Insulin

 

At the Diabetes Clinic

a. All women with GDM are seen at the diabetes clinic by an obstetrician
b. All women with GDM will be seen by the dietitian and have appropriate dietary advice.
C. Till the glycaemic control is made, women will also be seen by the diabetologist.
3. Investigations: Routine 
a. HbA1c 
b. Urea, creatinine, uric acid and electrolytes LFT,TFT. c. Random plasma glucose.
d. Ultrasound examination at diagnosis & at 30 weeks for growth. This should be repeated as clinically indicated, or at 36 weeks if the initial estimated fetal weight is > 80th percentile.

 

STAGE FOUR:

G.)Achieving Glycaemic Control & Defining TARGETS 
a. All women with GDM will perform home blood glucose monitoring (SMBG), initially 4 times each day before breakfast and 2 hours after each meal. This may be reduced if the values are normal.
b. The target levels are = 90-95 mg % fasting and < 120 mg% at 2 hours after meals. or < 140 mg% at 1 Hr after meals. ; c. ASSESS WEEKLY ; d.Occasionally, it may be appropriate to commence insulin on the basis of developing fetal macrosomia. 

H.) Subsequent Visits & Follow-up :

1.Frequency of visits
a.Three-weekly until 28 weeks, then 2-weekly until 38 weeks then weekly until delivery if not on insulin. Women receiving insulin should be seen weekly from 34 weeks. 
b.IMP: Visit frequency should be increased if there are other complications, such as: 
i.Hypertension pre-existing or pregnancy-induced.Retinal or Renal Problems also need more frequent visits,
ii.Fetal macro-somia 
iii.Intrauterine growth restriction.
iv.Poor glycaemic control 
v.Smokers.
2.Fetal surveillance
a.Ultrasound examination for growth as above. More frequent ultrasound examination, including umbilical artery blood flow measurement, may be indicated with the above complicating factors.
b.Cardiotocography should be performed weekly from 40 weeks gestation in the absence of complicating factors.
c.Earlier and more intensive (more frequent CTG, Doppler flow studies, biophysical profiles) fetal monitoring may be indicated in the presence of the above complications

 

STAGE FIVE: In close association with your Diabetologist & Obstetrician

I. Delivery
1. Timing 
a. In patients with optimal glycaemic control and no complicating factors (see above) delivery should be considered at 40-41 weeks, with the method depending on obstetric factors. Insulin by itself is not an indication for earlier delivery. If an elective Caesarean section is to be performed, this should be at 39 weeks. 
b. Patients with one of the complicating factors mentioned above should be delivered at 38-39 weeks, or earlier if indicated. 
c. A very tight control around delivery saves the new born from landing in an ICU. 
2. Method-Suggested is: 

a.If the estimated fetal weight at the time of delivery is < 4,000 g, vaginal delivery is usually appropriate unless there are other obstetric indications for Caesarean section.


b.If the estimated fetal weight at the time of delivery is > 4,250 g, elective Caesarean section should be strongly considered because of the risk of shoulder dystocia. c. If the estimated fetal weight at the time of delivery is 4,000 - 4,250 g, the decision about the route of delivery should be discussed with the patient taking into account the risks for the particular patient.

J.)Follow-up <- As much as 47- 50 % cumulative risk of developing Diabetes at 5 yrs and 16 – 20 % yearly risk of developing Impaired Fasting Glucose /Impaired Glucose tolerance after GDM, makes the follow-up GTT a very important tool to screen out patients who may develop DM type 2. 
1.GTT : 
a.This GTT should be performed 6-8 weeks postpartum. The GTT is a standard 75 g GTT using WHO, non-pregnant criteria. 
b.Women with an abnormal GTT (diabetes, impaired glucose tolerance or impaired fasting glycaemia) should be reviewed by the diabetes physician. They should have annual GTTs thereafter. 
e.Women with a normal postnatal GTT should be advised about a healthy lifestyle, and to have a GTT every 2 years.
MNT: Medical Nutrition therapy for GDM is a mandatory component.

Polycystic Ovaries & Fertility

PCOD /PCOS :

 

A woman with Insulin-Resistance-linked to Pre-Diabetes> is also at greater risk of developing the hormonal imbalance known as Polycystic Ovarian Syndrome (PCOS), a major cause of infertility. This condition is also known as polycystic ovaries, Sclerocystic Ovarian Disease, Stein-Leventhal Syndrome and Polycystic Ovarian Disease.

 

State of IR or Insulin Resistance creates an excess of glucose and insulin in the blood stream, which, as well as increasing the risk of Pre-Diabetes, can also create a situation for an upset in the delicate balance of a woman's hormones.

 

♦ PCOS is a Health Hazard and is clearly linked to:
♦ Infertility & Menstrual abnormalities
♦ Hirsuitism-abnormal and excessive Body Hair
♦ Male pattern Baldness
♦ Increased Risk For Atherosclerosis-Heart attacks, stroke, Peripheral Vascular Disease
♦ Dyslipidemia-High TG and Low HDL-C
♦ PCOS patients may require help from different medical specialists at different times in their life.

 

As adolescents obesity, excess hair, acne, irregular menses may bring them to Internists, Cosmetologists, Dermatologists and Gynecologists in that order. Later in life infertility and lack of Menses remain main focus.

 

Insulin Resistance and Development of Diabetes brings them to Diabetologist and if not managed properly they land up with Interventionalists- with clogged arteries! And all of this is reversible and treatable, of-course by appropriate attention to the root cause of the problem

 

INSULIN RESISTANCE IS THE ROOT CAUSE OF PCOS

 

Are you one of the millions of women with PCOS who have failed to reverse the symptoms of this condition no matter what you've tried? It may not be due to lack of willpower.

 

Instead, you could be Insulin Resistant, the root cause of PCOS.

 

 

Insulin Resistance, a biochemical condition that causes excessive weight gain and PCOS.

 

You need to understand this link in order to reverse IR.
Your doctor may use Metformin, Pioglitazone, Aldosterone or one of the Hormonal pills to regulate/ control PCOD.
Different grades of Hormone imbalance at different 
times in a patient may require different strategies of treatment.

 

 

Ultra sound image of How a Polycystic Ovary appears to be !

Frequently Used Terms

ADRENALINis a hormone released by the body in reaction to stress. It prepares the body for 'flight or fight.'

 

ADULT-ONSET DIABETES is the former term for non-insulin dependent, or type 2 diabetes. This term is no longer in use because, although type 2 diabetes usually occurs after 40 years of age, it may develop at younger ages..

 

ALPHA CELLS are found in the Islets of Langerhans within your pancreas. They are responsible for producing glucagon, a hormone which causes an increase in the blood sugar level.

 

AMPUTATION is the surgical removal of a limb or part of a limb. People with diabetes may be at increased risk for gangrene due to nerve damage in the legs and feet, which may require amputation.

 

ANIMAL INSULIN is the original form of insulin derived from the pancreas of cows and pigs.

 

ANTIBODIES are proteins that the body produces to fight off foreign substances such as bacteria, viruses and transplanted organs.

 

ANTIOXIDANTS are chemicals that are added to foods containing fat to prevent oxygen from combining with the fatty molecules. Oxidation would cause the fatty food to become rancid.

 

ARTERIOSCLEROSIS is the hardening and narrowing of the arteries. This condition often occurs with aging, in hypertension and diabetes.

 

AUTOIMMUNE DISEASE is a disorder in which a person's own antibodies destroy body tissues, such as the beta cells in the pancreas.

 

BEEF INSULIN was a form of insulin derived from the pancreas of cows and is no longer readily available.

 

BETA CELLS are found in the Islets of Langerhans in the pancreas. Their function is to produce insulin.

 

BLOOD PRESSURE refers to the pressure exerted by blood flow on artery walls. People with diabetes should aim for a bllod pressure of 130 / 80 or lower. High blood pressure (hypertension) can cause health problems such as heart attacks, strokes and kidney problems.

 

BODY MASS INDEX (BMI) is a unit of measurement to describe weight in relation to height for people 20 to 65 years of age (kg /m2) Classifications include-Underweight (<18.5), Normal Weight (18.5 - 24.9), Overweight (25 - 29.9),Obese(>30).For Indian BMI of23 is the upper limit and over weight is 23.1to 28.

 

BUNION is a bulge on the first joint of the big toe caused by swelling under the skin as a result of chronic irritation and pressure from poorly fitting shoes.

 

CALLUS is a common, usually painless, thickening of the skin on the feet or hands, at points of external pressure or friction.

 

CALORIE is a measurement of the energy provided by food. The sources of calories in a diet are carbohydrate, protein, alcohol and fat.

 

CAPILLARY is the smallest blood vessel. Capillary walls are so thin that oxygen and glucose can pass through them and enter the cells. Waste products, such as carbon dioxide, pass back into the bloodstream via the capillaries to be carried away and expelled from the body.

 

CARBOHYDRATE one of the major sources of calories in the diet. It comes primarily from sugar (found in refined fruits and vegetables) and starch (found in grains and legumes). Carbohydrate breaks down into glucose during digestion and raises blood glucose levels.

 

CATARACTS are a grey-white film that can cover the lens of the eye, obscuring vision. They tend to occur in people over 50 years of age, but can occur at a younger age and advance more rapidly in the presence of diabetes. If left untreated, cataracts can cause blindness.

 

CHIROPODIST is a health professional who diagnoses and treats disorders of the feet.

 

CHOLESTEROL is a type of fat which occurs naturally in our bodies and is also found in animal fats. Too much saturated fat and dietary cholesterol may be associated with arteriosclerosis.

 

CHRONIC refers to a disease or disorder that is present over long periods of time often the remainder of a lifetime of an individual.

 

COMA is a state of unconsciousness. In diabetes, it may result from a variety of causes including severe Hypoglycemia or severe ketoacidosis.

 

C-PEPTIDE is formed in the beta cells of the pancreas therefore a test of C-peptide levels indicates the amount of beta cell function occurring in the pancreas.

 

CREATININE is a compound present in the muscles and blood that is passed in the urine. A 'creatinine clearance test' is a diagnostic test for kidney function.

DEHYDRATION is a state in which there is excessive loss of water from body tissues. It can occur when the blood sugar levels are high for long periods of time. It can also result from inadequate water intake, or excessive sweating, vomiting or diarrhea. Symptoms of dehydration can include extreme thirst, irritability, confusion and flushed, dry skin.

 

DIABETIC RETINOPATHY is a disease in which the small blood Vessels (capillaries) in the back of the eye (retina) may bleed or form new Vessels. This condition usually occurs in people with long-standing diabetes. Regular eye examinations are an important part of diabetes management.

 

DIABETES is a condition in which the body either cannot produce insulin or cannot effectively use the insulin it produces. (see Gestational Diabetes, type 1 Diabetes, type 2 Diabetes)

 

DIABETES CONTROL AND COMPLICATIONS TRIAL (DCCT) was a nine year study during the 1990s designed to test whether persistently high blood sugar levels are related to the development of complications in people with type 1 diabetes. The results demonstrated that intensive treatment of individuals with type 1 diabetes can delay the onset and progression of long-term complications in people.

 

DIABETLOIGIST Doctor who specializes in treatment of Diabetes and all its Complications.

 

DIALYSIS is a method of removing waste products and excess water from the body when the kidneys no longer function adequately.

DIETITIAN is an expert in nutrition who can assist people plan the kinds and amounts of foods that promote a healthy lifestyle.

 

EDEMA is the swelling or puffiness caused by fluid collecting in the tissues.

ENDOCRINOLOGIST is a medical doctor who specializes in treating people who have problems related to their endocrine system, which includes diabetes.

 

EPIDEMIOLOGY is the study of the occurrence, distribution and causes of diseases in mankind.

 

FAMILIAL OCCURRENCE refers to the pattern of a disease within a family. Family and twin studies have shown that type 2 diabetes is far more likely to run in families than type 1 diabetes.

 

FAT is the most concentrated source of calories in a diet. Saturated fats are found primarily in animal products and unsaturated fats come from plants. Excess intake of fat, especially saturated fat, can increase the risk of heart disease and stroke.

 

FIBRE is a type of material within foods mainly found in vegetables, fruits and cereals that adds bulk to the diet aiding digestion.

 

GANGRENE is the death of body tissues usually due to loss of blood supply to the affected area, followed by bacterial invasion.

 

GESTATIONAL DIABETES develops during pregnancy due to a deficiency of insulin during pregnancy that disappears following delivery. Women who have had gestational diabetes are at a high risk of developing type 2 diabetes later in life.

 

GLUCAGON is a hormone produced by the pancreas that stimulates the liver to produce large amounts of glucose. It is given by injection for Hypoglycemia & SMBG and generally restores blood sugar within five to ten minutes.


 

GLUCOSE is a simple form of sugar that acts as fuel for the body. It is produced during digestion of carbohydrate and carried to the cells in the blood.

 

GLYCOGEN is the main carbohydrate storage material, which is stored in the liver and muscles for use when energy is required.

 

GLYCOSURIA refers to an increased amount of sugar in the urine. It is usually an indication of an elevated blood glucose level.

 

GLYCOSYLATED HEMOGLOBIN (A1C) is a measure of your average blood glucose level over the past 2 - 3 months.

 

HONEYMOON PERIOD is the period of time after the diagnosis of type 1 diabetes when the dose of insulin may need to be reduced due to remaining or recovered insulin secretion from the pancreas. This period can last weeks, months or years.

 

HORMONES are the substances released into the bloodstream from a gland or organ. Hormones control growth and development, reproduction, sexual characteristics, blood sugar levels and influence the way the body uses and stores energy.

 

HUMAN INSULIN is a bio-synthetic insulin created in the 1990s using recombinant-DNA technology.

 

HYPERGLYCEMIA (also HYPERGLYCAEMIA) is a condition caused by greater than normal levels of glucose in the blood. Symptoms include thirst, frequent urintation and fatigue.

 

HYPERLIPOPROTEINEMIA is the presence in the blood of greater than normal amounts of certain lipids and other fatty substances in the blood.

 

HYPERTENSION is the medical term for high blood pressure.

 

HYPOGLYCAEMIA (also HYPOGLYCAEMIA) is a condition in which blood glucose levels drop too low. Symptoms may include sweating, trembling, hunger, dizziness, moodiness, confusion blurred vision and hunger.

 

IMPOTENCE is a form of sexual dysfunction in which a man is unable to obtain an erection.

 

INSULIN is a hormone produced by the beta cells of the pancreas in response to increased levels of glucose in the blood.

 

INSULIN LIPODYSTROPHY is the loss of fatty tissue that can occur as a result of repeated insulin injections in the same area.

 

INSULIN PUMP is a portable, battery-operated device that delivers a specific amount of insulin through a small needle inserted under the skin. It can be programmed to deliver constant doses throughout the day and / or deliver extra insulin as required throughout the day.

 

INSULIN RECEPTORS are areas on the outer walls of a cell that permit insulin to bind to the cell. When cells and insulin bind together, the cell is able to take glucose from the bloodstream and use it for energy.

 

INSULIN SHOCK is another term used for Hypoglycemia & SMBG or low blood sugar (see Hypoglycemia )

 

ISCHEMIA is an inadequate supply of blood to body tissues or organs. It can occur if blood Vessels are narrowed or constricted.

ISLETS OF LANGERHANS are clusters of cells in the pancreas that produce insulin, glucagons and pancreatic polypeptide.

 

JUVENILE-ONSET DIABETES is the former term for insulin-dependent, or type 1 diabetes.

 

KETONES are chemicals produced by the liver when the body cannot use glucose and must break down fat for energy. Ketones can poison and even kill body cells. When ketones build up, the body gets rid of them in the urine. Ketones that accumulate in the body over long periods of time can lead to serious illness and coma.

 

KETOACIDOSIS is a severe complication of diabetes that is the result of high blood sugar levels and ketones often associated with poor control of diabetes or as a complication due to other illnesses.

 

LASER TREATMENTS are a recognized treatment for retinopathy that involves a source of intense radiation that targets damaged areas of the retina.

 

mg/dL is the abbreviated form of milligrams per decilitre, a term used to describe how much glucose is present in a specific amount of blood. To convert mg/dl readings to the mmol/L, divide by 18.

 

MORBIDITY RATE is the number of cases of a particular disease occurring in a single year often expressed as 'x cases per 1000'.

 

MORTALITY RATE is the rate of people who die from a specific illness in relation to the total population. Mortality rates are usually expressed as the number of deaths per 1,000, 10,000 or 100,000 persons.

 

NEPHROLOGIST is a medical doctor who specializes in the care and treatment of people with kidney diseases.

 

NEPHROPATHY is any disease of the kidneys.

 

NEUROPATHY is inflammation or degeneration of the peripheral nerves.

 

OBESITY is an abnormal increase in the proportion of fat cells. Obesity may be accompanied by other signs of poor health and is a risk factor for type 2 diabetes.


OPHTHALMOLOGIST is a medical doctor who specializes in treatment and care of the eyes.


ORAL AGENTS are medications, taken by mouth, for the treatment of type 2 diabetes.


ORAL GLUCOSE TOLERANCE TEST (OGTT) is a test of the body's ability to metabolize carbohydrate. It is performed by giving a standard dose of glucose and measuring the blood and urine for glucose at regular intervals.


PANCREAS A fish-shaped grayish-pink nodular gland that stretches transversely across the posterior abdominal wall in the epigastric region that secretes various substances such as digestive fluid, insulin and glucagons. It is divided into a head, a body, and a tail, and is about 13cm long in adults.


PEDIATRICIAN (also PEDIATRIST) is a medical doctor who specializes in the care and treatment of children.


PODIATRIST is a health professional who diagnoses and treats disorders of the feet.


PORK INSULIN - is a form of insulin available in Canada that is derived from the pancreas of pigs


POST-PRANDIAL means 'after mealtime'.


PROTEIN is one of the major sources of calories in a diet. Found in meats, eggs, milk and some vegetables and starches, protein provides the body with material for building blood cells, hormones and body tissue.


SUGAR is a simple form of carbohydrate that provides calories and raises blood glucose levels.


TYPE 1 DIABETES (or insulin-dependent diabetes) occurs when the pancreas no longer produces any or very little insulin. The body needs insulin to use sugar as an energy source. Type 1 diabetes usually develops in childhood or adolescence and affects 10% of people with diabetes.


TYPE 2 DIABETES (or non-insulin-dependent diabetes) occurs when the pancreas does not produce enough insulin to meet the body's needs or the insulin is not metabolized effectively. Type 2 usually occurs later in life and affects 90% of people with diabetes.


ULCER is a crater-like lesion of the skin or mucous membrane often as a result of inflammatory process.


URINE TESTS measure substances, such as blood glucose or ketones, present in the urine.


VASCULAR DISEASE is a disease of the blood Vessels.