| |
Content
|
Modern Medicine and Traditional Chinese
Medicine - Diabetes Mellitus
Complications or Sequelae of Diabetes
Sometimes a complication of diabetes may give a clue to the presence of the
disease. The principle complications or sequelae associated with diabetes are
retinopathy, neuropathy, nephropathy and arteriosclerosis. Whether these are the
unavoidable consequences of the diabetic state over time or whether they may be
influenced by controlling the diabetes through aggressive monitoring, treatment
and life-style management, including diet and supplements, remains a central
topic.
One of the largest, most comprehensive diabetes studies conducted to date2
showed that keeping blood sugar levels as close to normal as possible through
aggressive management slows the onset and progression of eye, kidney and nerve
diseases caused by diabetes. In fact it demonstrated that any sustained lowering
of blood sugar helps, even if the person has a history of poor control.
Specifically it found that lowering and maintaining more constant blood sugar
levels reduced the risk of eye disease by 76%, kidney disease by 50%, nerve
disease by 60% and cardiovascular disease by 35%.
Since the discovery of insulin nearly 70 years ago, the patterns of morbidity
from diabetes have changed. Where the major causes of death were ketoacidosis
and infection, they are now the microvascular and cardiovascular complications
of diabetes (renal failure and myocardial infarction).
These complications are responsible for a reduction in the life expectancy of a
newly diagnosed insulin dependent diabetic by about one-third. The basis of
managing diabetes in the 90s is an improvement in the life-style of the
diabetic and prevention of complications responsible for morbidity and mortality
in diabetes.
Neuropathy (nerve disease)
Diabetic neuropathies are among the most frequent complication of long-term
diabetes. It is estimated that 60% to 70% of diabetics have mild to severe forms
of nervous system damage. The femoral nerve is commonly involved giving rise to
symptoms in the legs and feet. Pain is the chief symptom and tends to worsen at
night when the person is at rest. It is usually relieved by activity and
aggravated by cold. Paraesthesias are a common accompaniment of the pain.
Cramping, tenderness and muscle weakness also occur but atrophy is rare.
Advanced femoral nerve disease is a major contributing cause of lower extremity
amputations. Nerves in the arms, abdomen and back may also be affected. Symptoms
may include impaired heart function, slowed digestion, reduced or absent
perspiration, severe oedema, carpal tunnel syndrome, alternating bouts of
diarrhoea and constipation, bladder atony, urinary and faecal incontinence and
impotence.
With respect to sexual impotence, diabetes is probably the single most common
disease associated with erectile failure (termed neurogenic impotence in the
diabetic). Since diabetes is a metabolic disease with vascular and nervous
system complications and an erection involves all levels of the nervous system
from the brain to the peripheral nerves, lesions anywhere along the path may be
responsible for erectile failure. It has been estimated that close to 50% of
diabetic males have some degree of erectile dysfunction. Neuropathies usually
improve with the control of the diabetes. Severe or chronic changes may require
several weeks or months to show maximum improvement.
Retinopathy (eye disease)
Changes occurring in the eye which are distinctive of diabetes involve the
narrowing, hardening, bulging, haemorrhaging or severing of the veins and
capillaries of the retina. This is a serious complication known as retinopathy
and may lead to loss of vision. Visual changes in the earlier stages may include
diminished vision, contraction of the visual field, changes in the size of
objects or photophobia. In the more advanced stage, termed 'proliferative
retinopathy', haemorrhages, retinal detachment and other serious forms of
deterioration are observed. When the disease progresses to this late stage total
blindness may occur.
It usually takes between 10-13 years for diabetic retinopathy to develop and it
is present in some degree in most diabetics who have had the disease for 20
years. In only about half of the diabetics who develop it however, is vision
markedly impaired and blindness occurs in only about 6%. Still, diabetes is the
leading cause of blindness in adults 20 to 74 years old and is estimated to
cause from 12,000 to 24,000 new cases each year. Two other complications of
diabetes, cataracts and glaucoma, can also lead to loss of vision
The development of laser therapy will probably reduce the prevalence of
diabetes-induced blindness, however this therapy is not without occasional side
effects (haemorrhage, retinal detachment and loss of visual field) and is
therefore indicated only for the more serious conditions.
Arteriosclerosis (vessel disease)
The diabetic state is associated with earlier and more severe vascular changes
than normally occur at a given age. Cardiovascular- renal disease is the leading
cause of death among diabetics. Atherosclerosis can be accurately described as
the end stage of Type 1 and Type 2 diabetes, since the vast majority of diabetes
patients will die from an atherosclerotic event. Most commonly these events are
cardiovascular in nature (an estimated 60% to 65% of diabetics have high blood
pressure) although 20-25% of atherosclerotic events may be cerebrovascular or
microvascular.
The incidence of coronary occlusion in persons with clinical diabetes has been
estimated at from 8-17% with diabetic adults having heart disease death rates
about 2 to 4 times as high as the general population. The risk of stroke is also
found to be 2 to 4 times higher in people with diabetes. Arteriosclerosis
obliterans in the lower extremities, a form of peripheral vascular disease, may
produce disturbances in sensation, decrease in muscular endurance, intermittent
claudication on effort, absence of peripheral pulses in the lower legs and feet
and gangrene, and ultimately lead to amputation of the extremity. Diabetic
gangrene usually involves the toes, heels or other prominent parts of the feet
and is precipitated by trauma, infection or extremes in temperature. Needless to
say, careful attention to proper foot care, avoidance of injury and consistent
use of methods to improve peripheral circulation, including withdrawal from
tobacco use in any form, are critical for the diabetic. The aetiology of large
vessel disease is multi-factorial in the diabetic as well as the non-diabetic
population with lipoprotein metabolism, hypertension, physical activity,
obesity, cigarette smoking, stress, personality and genetic and racial factors
all playing a part.
Nephropathy (kidney disease)
Nephropathy is a common and important accompaniment of diabetes and one that in
young diabetics takes precedence over heart disease as a cause of illness and
death. As with eye changes, there is a wide variation in the type and degree of
renal damage. Nephropathy is less frequent than retinopathy and where it occurs
is also a development of long standing diabetes. Nevertheless, diabetes is the
leading cause of end-stage renal disease in the US, accounting for about 40% of
new cases. In 1995, a total of 98,872 people with diabetes underwent dialysis or
kidney transplantation and 27,851 developed end-stage renal disease.
One study reported that among 200 juvenile diabetics who survived 20 years after
onset, one half had evidence of renal disease. Another study found that the
majority of these patients have hypertension and two thirds show significant
albuminuria, but the fully developed nephrotic syndrome of hypertension,
proteinuria and oedema occurs in less than 10% and renal function is impaired in
only one half to three quarters of those patients.
Like other long-term complications, good blood glucose control goes a long way
towards reducing the risk of diabetic nephropathy. In addition to monitoring the
blood sugar levels, periodic monitoring of a diabetic patients kidney function
(blood urea nitrogen, uric acid, creatinine and creatinine clearance) is
important.
Hypoglycaemia
If there is too much insulin in the body compared to the amount of blood sugar,
and the blood sugar falls below normal levels, a condition known as
hypoglycaemia occurs. This problem of hypoglycaemia due to insulin or oral
hypoglycaemic drugs is much more common in Type 1 than Type 2 diabetes since the
Type 1 diabetic is directly injecting insulin. If too much insulin is
administered, or the person misses a meal or over-exercises, hypoglycaemia may
result. In this condition, commonly referred to as insulin shock, the brain is
deprived of an essential energy source. The first sign is mild hunger, quickly
followed by dizziness, sweating, palpitations, mental confusion and eventual
loss of consciousness. Before the condition reaches emergency proportions, most
diabetics learn to counteract the symptoms by eating a sweet or drinking a glass
of orange juice. In some cases, the only effective measure is an intravenous
injection of glucose.
Digestive Disorders
Based on the 1989 US National Health Interview Survey, diabetics are more likely
than the general population to report a number of digestive conditions,
including ulcers, diverticulitis, symptoms of irritable bowel syndrome,
abdominal pain, constipation, diarrhoea and gallstones.
Oral Complications
Periodontal disease, which can lead to tooth loss, occurs with greater frequency
and severity among diabetics. Periodontal disease has been reported to occur
among 30% of people aged 19 years or older with Type1 diabetes.
Infections
Studies in clinic, community and hospital populations indicate that diabetic
subjects have a higher risk of some infections, including asymptomatic
bacteriuria, lower extremity infections, re-activation tuberculosis, infections
in surgical wounds and group B streptococcal infection. Populationbased data
suggest a probable higher mortality from influenza and pneumonia.
Complications of Pregnancy
The rate of major congenital malformations in babies born to women with
pre-existing diabetes varies from 0% to 5% among women who receive preconception
care, to 10% among women who do not receive preconception care. Between 3% to 5%
of pregnancies among women with diabetes result in death of the new-born; the
rate for women who do not have diabetes is 1.5%4.
Ketoacidosis
Another acute complication more likely to occur in the IDDM is ketoacidosis, a
condition caused by a lack of insulin leading to a build-up of ketoacids.
Chemical compounds called ketones are one of the natural by-products of fat
metabolism. Excessive ketone bodies are formed by the biochemical imbalance in
uncontrolled or poorly managed diabetes. The condition known as diabetic
ketoacidosis can directly cause an acute life-threatening event, a diabetic
coma.
The possibility of ketoacidosis is suggested by:
Confusion or coma, the patient almost always appearing extremely ill.
Air hunger - an attempt to compensate for metabolic acidosis.
Acetone odor (fruity) invariably on the breath.
Nausea and vomiting almost always present.
Abdominal tenderness which may mimic viral gastroenteritis.
Extreme thirst and dry mucous membranes.
Diabetic history (present in about 90% of cases).
Weight loss.
Before the discovery of proper treatment by insulin and other intravenous
injections, acidosis was the chief cause of death among diabetics. Today
diabetics can use a simple urine dipstick at home to measure the level of
ketones (excreted ketoacids) in the urine.
|
|
