 DIABETES MELLITUS |
1. DIABETES MELLITUS GENERAL CONSIDERATION
Clinical diabetes mellitus represents a syndrome with disordered metabolism and inappropriate hyperglycemia due to either an
absolute deficiency of insulin secretion or a reduction in its biologic effectiveness or both. The national institutes of health in 1979
decided to defer a "functional" classification of diabetes that based upon insulin secretion characteristics or insulin sensitivity. It
recommends classifying diabetes mellitus into 2 major types.
A. Type I. Insulin-Dependent Diabetes Mellitus (IDDM). This severe form is
associated with ketosis in the untreated state. It occurs most commonly in juveniles
but also occasionally in adults.
B. Type II. Non-Insulin-Dependent Diabetes Mellitus (NIDDM). This represents a heterogeneous group comprising milder
forms of diabetes that occur predominantly in adults but occasionally in juveniles. Two subgroups of patients with Type
II diabetes are currently distinguished by the absence or presence of obesity.
a. Nonobese NIDDM patients. These patients generally show an absent or blunted early phase of insulin release in response to
glucose.
b. Obese NIDDM patients. This form of diabetes is secondary to extrapancreatic
factors that produce insensitivity to endogenous insulin.
In traditional Chinese medicine, the modern term for the condition is "emaciation-thirst disease," but in ancient Chihese
medicine, it is called "Shi Yi" or "Xiao Dan." The diagnosis is mainly based on symptoms such as thirst, polydipsia,
polyphagia, emaciation and polyuria.
CLINICAL MANIFESTATIONS
The classic symptoms of polyuria, thirst, recurrent blurred vision, paresthesias and fatigue are manifestations of hyperglycemia
and thus are common to both major types of diabetes, likewise, pruritus vulvae and vaginitis are frequent initial complaints of adult
females with hyperglycemia and glycosuria due to either absolute or relative deficiencies of insulin. Weight loss despite normal or
increased appetite is a feature of IDDM, whereas weight loss is unusual in obese patients with NIDDM who have normal or
increased levels of circulating insulin. These latter patients with the insulin-insensitive type of diabetes may be relatively
asymptomatic and may be detected only after glycosuria or hyperglycemia is noted during a routine examination. Diabetes should
be suspected in obese patients, in those with a positive family history of diabetes, in patients presenting with peripheral neuropathy
and in women who have delivered large babies or had polyhydramnios, preeclampsia, or unexplained fetal losses.
DIAGNOSIS
• The classic symptoms of polyuria, thirst, recurrent blurred vision, paresthesias and fatigue are manifestations of
hyperglycemia.
• The fasting plasma glucose is over 140mg/dl on more than one occasion,
further evaluation of the patient with a glucose challenge is unnecessary.
• Fasting plasma glucose is less than 140mg/dl in suspected cases. A standardized oral glucose tolerance test may be done.
• The National Diabetes Data Group recommends giving a 75-g glucose dose
dissolved in 300ml of water for adults (1.75 per kg ideal body weight for children)
after an over-night fast in subjects who have been receiving at least 150-200g of
carbohydrate daily for 3 days before the test.
• Normal glucose tolerance is considered to be present when the 2-hour plasma
glucose is less than 140mg/dl, with no value between zero time and 2 hours exceeding
200mg/dl. However, a diagnosis of diabetes mellitus requires plasma glucose levels
to be 200mg/dl both at 2 hours and at least twice between zero time and 2 hours.
• Insulin levels during glucose tolerance test. Normal immunoreactive insulin
levels range from less than 10 to 25µV/mL in the fasting state and 50 to I30µV/mL
at 1 hour and usually return to levels below 100µV/mL by 2 hours. A value below
50µV/mL at 1 hour and less than 100 µV/mL at 2 hours in the presence of sustained
hyperglycemia implicates insensitivity of B cells to glucose as the cause of hyperglycemia, whereas levels substantially above 100µ
V/mL at these times suggest tissue unresponsiveness to the action of insulin.
TREATMENT
I. Treatment in Western medicine.
A. Diet. Caloric restriction for obese patients and regular spaced feeding with a bedtime snack for patients receiving
hypoglycemic agents, especially insulin.
A well-balanced, nutritious diet remains a fundamental element of therapy.
However, in more than half of cases, diabetic patients fail to follow their diet. The reasons for this are varied and include
unnecessary complexity of the prescription as well as lack of understanding of the goals by both the patient and the physician. In
prescribing a diet, it is important to relate dietary objectives to the type of diabetes. In obese patients with mild hyperglycemia, the
major goal of diet therapy is weight reduction by caloric restriction. Thus, there is less need for exchange lists. Emphasis on
timing of meals, or periodic snacks, all of which are so essential in the treatment of insulinrequiring nonobese diabetics.
Because of the prevalence of the obese mild diabetic among the population of diabetics receiving therapy, this type of patient
represents the most frequent and thus one of the most important challenges for the physician. Treatment requires an energetic,
vigorous program directed by persons who are aware of the mechanisms
by which weight reduction is known to effectively lower hyperglycemia and who are
convinced of the profoundly beneficial effects of weight control on blood lipid levels as well as on hyperglycemia in obese
diabetics. Weight reduction is an elusive goal that can only be achieved by close supervision of the obese patient.
B. Oral hypoglycemic drugs.
