DIABETES 101 – Understanding diabetes

Dr. Jean-Paul Kanyik, Internal Medicine Specialist at Melomed Mitchells Plain Hospital

A bit of History
Many ancient civilizations recognised an ailment which they called differently such as “honey urine” by a Egyptians. Around 6BCE, the Hindu physician Sushrata described a disease called ‘honey urine’. It was named not so much for the colour of the patient’s urine, but for the taste. He observed that ants were attracted to the urine because of its characteristically sweet taste.

The term diabetes came to us from the ancient Greeks, although it was not a common disease for them. In the first century CE, a Greek physician described an illness characterized by intense thirst and melting down of flesh and limbs into urine, he called it diabetes from Greek “Siphon”. Galen (129-210CE) focused on another symptom – excessive urination – and regarded diabetes as a kidney disease. He graphically referred to it as ‘diarrhoea of the urine’. The condition was very familiar to the Islamic physician Ibn Sina (980-1037CE), who provided a comprehensive list of symptoms. Among them he noted that, when evaporated, the urine left a sweet residue like honey.

Diabetes is a condition where the amount of glucose in the circulating blood exceed certain limits. It is associated with multiple complications, some studies have shown that, the risk of dying is almost double in diabetics than in non-diabetics, hence public health problem. Statistics speaks by themselves: over 463 million affected Worldwide, in South Africa the number of adults with diabetes was 4.6 million in 2019 (12.7%), with more than 90 000 diabetes related deaths.

Types
• Type 1 diabetes generally starts at a young age and is caused by a complete lack of insulin production by the insulin producing cells in the pancreas. Those cells may have been destroyed by the body’s own immunity.
• Type 2 diabetes starts later in life and is caused by insufficient insulin production and/or resistance. There is a familial predisposition to develop type 2 diabetes and being overweight plays an important role.
• Gestational diabetes mellitus is diagnosed in pregnancy and was not clearly overt prior to gestation.
• Diabetes due to other diseases (such as pancreatitis) or medications (such as prednisone).

Symptoms
• Thirst
• Polyuria (increased urination)
• Nocturia (increased nocturnal urination)
• Hyperphagia
• Tiredness and fatigue
• Weight loss
• Other symptoms: Nausea, headaches, blurred vision, irritability, difficult in concentrating.

Diagnosing diabetes
Blood glucose level is the mainstay of diagnosis, this can be done either fasting or random.
A fasting blood glucose of 7 mmol/l or more and random glucose of 11 mmol/l or more are usually diagnostic. When the diagnosis is not clear, doctors normally perform what is called glucose tolerance test, this entails ingestion 75 g of glucose then testing blood glucose after 2 hours.
HbA1c is a useful test, it is not only used to monitor patient’s glucose control but also to make diagnosis of diabetes mellitus.

Complications
In type 1 diabetes, insulin production is lacking, patients usually present with what we call diabetic ketoacidosis. When the body is not able to use glucose for energy production, whilst using lipids as alternative source of energy, glucose level builds up in the blood leading to dehydration and accumulation of ketone bodies. Ketones are acidic, just like when we use fossils to generate electricity, there is increase carbon emission with detrimental consequences on the environment. Acidic blood is not good for the body, apathy, confusion, air hunger, cold extremities and signs of dehydration occur.

As opposed to type 1, type 2 diabetes is characterized by slow and progressive insulin deficiency and/or resistance therefore associated organ damage. Diabetes complications are related to changes in blood vessels’ structure. Depending on the location and the size of the blood vessel this may affect the following organs:

Brain: Stroke, dementia
Eyes: blindness, bleeding in the eye, cataract
Heart: Myocardial infarction, commonly called Heart attack
Kidneys: Various stage of Kidney failure
Lower limbs: Pins and needle, numbness, poor blood circulation and Leg ulcers which can lead to amputation.

Living with diabetes
First step and very important in diabetes management is dietary and lifestyle modification. This is achieved with diabetes education which will address issues related to healthy diet, exercise, smoking cessation, alcohol intake and self-glucose monitoring.

The second step is medications, its choice will depend on the type of diabetes and the presence of complications. For type 1 diabetes the treatment is insulin injections, for type 2 it might be oral medications, oral medications with insulin injections or insulin alone.

In parallel to diabetes treatment, doctors will treat other cardiovascular risk factors such as high blood pressure and high cholesterol.

Diabetes is a common illness and has devastating complications therefore public awareness is important. Lifestyle modification and good glucose control will reduce complications.

Diabetic Ketoacidosis (DKA)
Poor blood glucose control can eventually lead to diabetic ketoacidosis (DKA), which is a medical emergency.

Did you know?
• DKA is a serious diabetes complication and occurs when your body produces high levels of blood acids called ketones
• This happens when your body cannot produce enough insulin to carry blood sugar into your muscle cells. The body then starts to breakdown fat as fuel for energy.
• This process produces a build-up of acids (ketones) in the bloodstream, eventually leading to DKA if untreated.

DKA signs and symptoms often develop quickly, sometimes within 24 hours:
Excessive thirst, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity-scented breath and confusion.

Seek emergency care if:
• Your blood sugar level is consistently higher than 16.0 millimoles per liter (mmol/L)
• You have ketones in your urine and can't reach your doctor for advice
• You have multiple signs and symptoms of DKA - excessive thirst, frequent urination, nausea and vomiting, abdominal pain, shortness of breath, fruity-scented breath, confusion

Medical Dictionary
• Glucose: Breakdown product of starch, it is the major source of energy
• Lipid: Breakdown product of fat
• HbA1c (Glycated haemoglobin): Protein that bind free glucose on the red blood cells. HbA1c can be used to monitor glucose control in the last 3 months.
• Insulin: Produced in the Pancreas, insulin promote glucose uptake by tissues

References:
1. Hussain A, Bhowmik B, Cristina do Vale Moreira N. COVID-19 and Diabetes: Knowledge in Progress. Diabetes Res Clin Pract [Internet]. 2020 Apr 9;108142. Available from: http://www.ncbi.nlm.nih.gov/pubmed/32278764
2. Ma RCW, Holt RIG. COVID-19 and diabetes. Diabet Med [Internet]. 2020 Apr 3; Available from: http://doi.wiley.com/10.1111/dme.14300
3. Zhou J, Tan J. Diabetes patients with COVID-19 need better blood glucose management in Wuhan, China. Vol. 107, Metabolism: Clinical and Experimental. 2020. p. 154216.
4. Gosmanov AR, Gosmanova EO, Dillard-Cannon E. Management of adult diabetic ketoacidosis. Vol. 7, Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2014. p. 255–64.
5. American Diabetes Association. Coronavirus COVID-19 FAQ | ADA [Internet]. 2020 [cited 2020 Apr 17]. Available from: https://www.diabetes.org/covid-19-fa