Diabetes

Diabetes

Diabetes mellitus (DM) or simply diabetes, is a group of metabolic diseases in which a person has high blood sugar.

Diabetes may also refer to a heterogeneous group of diseases that only have in common the presence of excessive urination, necessarily accompanied by the parallel symptom of excessive thirst.

Common types

Rare types

  • Diabetes mellitus type 1, a form of diabetes mellitus that results from autoimmune destruction of insulin-producing beta cells of the pancreas
  • Diabetes mellitus type 2, a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency
  • Gestational diabetes, a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy
  • Insulin-dependent diabetes mellitus (IDDM), a medical term that describes diabetes mellitus that requires insulin therapy to avoid ketoacidosis

 

  • Diabetes mellitus and deafness, a mitochondrial disease associated with the gene “Leu-UUR”
  • Latent autoimmune diabetes (LADA), a term coined to describe slow-onset type 1 autoimmune diabetes in adults
  • Diabetes type 1.5, comprising LADA and ketosis-prone diabetes mellitus type 2
  • Lipoatrophic diabetes, a type of diabetes mellitus presenting with severe lipodystrophy
  • Maturity onset diabetes of the young (MODY), any of several hereditary forms of diabetes caused by mutations in an autosomal dominant gene that disrupts insulin production
  • Neonatal diabetes mellitus, a form of diabetes that occurs in the first 6 months of life
  • Prediabetes, the state in which some but not all of the diagnostic criteria for diabetes are met
  • Steroid-induced diabetes, prolonged high blood sugar due to glucocorticoid therapy for another medical condition

 

Sign and symptoms

 The classic symptoms of untreated diabetes are

  • weight loss,
  • polyuria (frequent urination),
  • polydipsia (increased thirst),
  • andpolyphagia (increased hunger).

Pathophysiology

If the amount of insulin available is insufficient, if cells respond poorly to the effects of insulin (insulin insensitivity or insulin resistance), or if the insulin itself is defective, then glucose will not be absorbed properly by the body cells that require it, and it will not be stored appropriately in the liver and muscles. The net effect is persistently high levels of blood glucose, poor protein synthesis, and other metabolic derangement’s, such as acidosis.

When the glucose concentration in the blood remains high over time, the kidneys will reach a threshold of re-absorption, and glucose will be excreted in the urine (glycosuria). This increases the osmotic pressure of the urine and inhibits re-absorption of water by the kidney, resulting in increased urine production (polyuria) and increased fluid loss. Lost blood volume will be replaced osmotically from water held in body cells and other body compartments, causing dehydration and increased thirst (polydipsia).

Diagnosis

Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by demonstrating any one of the following:

  • Fasting plasma glucose level ≥ 7.0 mmol/l (126 mg/dl)
  • Plasma glucose ≥ 11.1 mmol/l (200 mg/dL) two hours after a 75 g oral glucose load as in glucose tolerance test
  • Symptoms of hyperglycemia and casual plasma glucose ≥ 11.1 mmol/l (200 mg/dl)
  • Glycated hemoglobin (Hb A1C) ≥ 6.5%

WHO diabetes diagnostic criteria

Condition 2 hour glucose Fasting glucose HbA1c
mmol/l(mg/dl) mmol/l(mg/dl) %
Normal <7.8 (<140) <6.1 (<110) <6.0
Impaired fasting glycaemia <7.8 (<140) ≥ 6.1(≥110) & <7.0(<126) 6.0–6.4
Impaired glucose tolerance ≥7.8 (≥140) <7.0 (<126) 6.0–6.4
Diabetes mellitus ≥11.1 (≥200) ≥7.0 (≥126) ≥6.5

Complications

 

Acute

Chronic

  • Diabetic coma, a reversible form of coma, a medical emergency, found in people with diabetes mellitus.
  • Diabetic ketoacidosis, a potentially life-threatening complication in patients with diabetes mellitus characterized by nausea, vomiting and abdominal pain, the smell of acetone on the breath, deep breathing known as Kussmaul breathing, and in severe cases a decreased level of consciousness.
  • Hyperosmolar nonketotic state  a rare but equally severe possibility which is more common in type 2 diabetes and is mainly the result of dehydration

 

  • The major long-term complications relate to damage to blood vessels
  •  Diabetes doubles the risk of cardiovascular disease,  and about 75% of deaths in diabetics are due to coronary artery diseas. Other “macrovascular” diseases are stroke, and peripheral vascular disease

The primary microvascular complications of diabetes include damage to the eyes, kidneys, and nerves.

  •  Diabetic retinopathy : Hyperglycemia-induced intramural pericyte death and thickening of the basement membrane lead to incompetence of the vascular walls. These damages change the formation of the blood-retinal barrier and also make the retinal blood vessels become more permeable An over accumulation of glucose and/ or fructose  damages the tiny blood vessels in the retina which leads to changes in its shape known as macular edema, resulting in vision changes and can result in gradual vision loss and potentially blindness. Blurred vision is a common complaint leading to a diabetes diagnosis.
  • Diabetic nephropathy : Damage to the kidneys, known as diabetic nephropathy, can lead to tissue scarring, urine protein loss, and eventually chronic kidney disease, sometimes requiring dialysis or kidney transplant.
  •  Diabetic neuropathy :  Damage to the nerves of the body, is known as diabetic neuropathy, is the most common complication of diabetes. The symptoms can include numbness, tingling, pain, and altered pain sensation, which can lead to damage to the skin.
  • Diabetes-related foot problems (such as diabetic foot ulcers) may occur, and can be difficult to treat, occasionally requiring amputation.
  • Additionally, proximal diabetic neuropathy causes painful muscle wasting and weakness.
  • There is a link between cognitive deficit and diabetes. Compared to those without diabetes, those with the disease have a 1.2 to 1.5-fold greater rate of decline in cognitive function.
  • Diabetic Dermadromes : A number of skin rashes that can occur in diabetes are collectively known as diabetic dermadromes.

 

Definition of prameha

Tatravilprabhutmutralakshanah Sarva eva Prameha

(Sushruta, Nidan 6/6)

Samanyam lakshanam tesham prabhutavilmutrata

Doshadushyavisheshepi tatsamyog visheshatah,

Mutravarnadibheden medo meheshu kalpate.

(Ashtanghridaya Nidan 10/7)

In ayurvedic texts Prameha is defined to be characterized with excessive urination (both in frequency & quantity) and turbidity. The nature of the turbidity may vary depending upon the body reaction with the doshas

Premonitory symptoms of prameha

  • Excessive sweating with foetid odour,
  • obesity and flabbiness,
  • inclination to lie down,
  • sedentary habits,
  • excessive mucosal discharge,
  • rapid growth of hairs and nails,
  • thirst,
  • sweetness of mouth,
  • burning sensation in hands & feet,
  • swarming of ants on the urine

Etiological factors

Asyasukham swapnasukham dadhini

gramyodakanuprasah payansi,

Navannapanam gudvaikratam ch

Pramehahetuh kaphakrichh sarvam.

(Charak, Chikitsa 6/4)

Addiction to the pleasures of lounging and sleeping, the excessive use of curds, meat juice of domestic, aquatic and wet-land animals, milks, new grains and drinks & products of gur and all things that increase kapha are the causative factors of Prameha.

Classification of prameha (diabetes Mellitus)

 

Etiological Classification (Sushrut)

clinico-pathological classification

Therapeutic classification based on body constitution (charak)

Prognostic classification

1. Sahaja Prameha (Growth onset/Juvenile/IDDM)

  • Family history
  • Early onset
  • Asthenic constitution
  • Prone to complications

2. Apathyanimittaja Prameha (NIDDM)

  • Over nutrition
  • Sedentary habits
  • Obese
  • Manageable with diet control and Herbo-mineral treatment (ApatarpanaChikitsa)

1. Kaphaja Prameha -10 (Early Diabetes)

  • Overweight with Mild Hyperglycemia
  • Polyuria/Glycosuria

2. Pittaja Prameha -6 (Acute Diabetes)

  • Loss of weight
  • Hyperglycemia and Glycosuria
  • Urinary Tract Infection

3. Vataja Prameha -4 (Chronic Diabetes)

  • Severe Hyperglycemia with Glycosuria
  • Cachexia
  • Nephropathy,
  • Neuropathy
  • Retinopathy
  • Cardio Respiratory Complication,
  • Gangrene

 

  1. Sthul Pramehi (Obese- NIDDM)
  • Manageable with diet control and Exercises
  1. Krisha Pramehi (Asthenic- IDDM)
  • Not manageable with diet control alone rather requires nutritive treatment (Bringhana chikitsa)

1. Sadhya (Manageable)

  • Apathyanimittaja Prameha (NIDDM)
  • Kaphaja Prameha (Early Diabetes)
  • Sthula Pramehi (ObeseDiabetics)

2. Yapya (Palliative)

  • Pittaja Prameha(Acute Diabetes)

3. Asadhya (Unmanageable)

  •  Sahaja Prameha (IDDM)
  • Vataja Prameha (Chronic Diabetes)
  • Krisha Pramehi ( Asthenic Diabetics)

Clinico-pathological classification of prameha

 

Early diabetes (kaphaj prameha)

Acute diabetes (pittaja prameha)

Chronic diabetes (vataj prameha)

Udakameha- Clear urine in larger quantity without odour, feels cold sensation while passing urine.Ikshuvalikameha – Very sweet urine, cold, slightly turbid due to slimy substances and like crushed cane sugar.Sandrameha – Precipitate is deposited in the pot, if urine is kept overnight.

Sandra Prasadmeha- Described as Surameha by Sushruta & Vagbhata. Literally, sandraprasad means -some portion of urine is turbid & some is clean like un-distilled alcohol (Sura).

Shuklameha – Urine seems to be mixed with some paste. While passing urine patient feels erection of body hairs. Itis described as Pistameha by Sushruta.

Shukrameha, – Patient passes urine similar to quality of semen or semen itself may be mixed with urine.

Sheetameha–Urine is very sweet & enormous with low temperature.

Siktameha – Patient start passing small particles like sand in urine.

Sanairmeha- Flow of urine becomes slow & patient feels difficulty in passing urine.

Lalameha –Quality of urine is turbid & slimy. It is sticky & threads may be demonstrated like gum.

Kalameha –Urine is blackish.

Nilameha –Urine is bluish.

Lohitameha –Urine contains blood and saltish in taste with putrid odour. It is described as Shonitmeha by Sushrata & Raktameha by Vagbhata & Madhava.

Manjishthameha –Urine is pink like decoction of Manjishta having putrid odour.

 Haridrameha- Urine is turmeric yellow, pungent & associated with severe burning sensation.

Ksharmeha –Not named on the basis of colour. Urine is like an alkali (ash) solution, in smell, colour and touch.

Vasameha- Urine contains fat (vasa).

Majjameha –Urine contains bone marrow (majja) It is described as Sarpimeha by Sushruta.

Hastimeha –Lymph (lasika) is passed in the urine. Flow & frequency of urine is almost continuous (incontinence). Simile of such patients is given with adult elephant as regards passes of urine.

Madhumeha –Essence of body – Oja, is passed in urine and its taste is sweet & little astringent like honey.

Prameha-correlation with diabetes, metabolic syndrome and obesity

 

Understanding of prameha is not merely related only to the patho physiology and clinical picture of Diabetes mellitus. From the etio pathology to the state of complications prameha has much in common to share with obesity and metabolic syndrome

Prameha

Diabetes

Metabolic syndrome

Obesity

  1. Involvement of meda, kleda ,kapha, vata and agni
  2.  Ama (toxic intermediary products of digestion and metabolism) – A contributing factor to obesity, metabolic syndrome and diabetes
  3. Hyperinsulinemia and Insulin resistance
Diabetes mellitus is a chronic disorder of carbohydrate, fat, and protein metabolism, with a relative or absolute deficiency in insulin secretory response resulting in hyperglycemia. Insulin resistance is a major factor in the development of Type 2 diabetes, which is seen in obese patients.
  1. Central obesity
  2. High cholesterol
  3. High triglycerides
  4. Low HDL cholesterol
  5. Hypertension
  6. Insulin resistance
  7. Hyperglycemia.
Obesity is a state of increased body weight, due to adipose tissue accumulation, that is of sufficient magnitude to produce adverse health effects. Central or visceral obesity is associated with a much higher risk for several disorders and diseases, including diabetes, hypertension, hypertriglyceridemia, decreased high-density lipoprotein (HDL) cholesterol, proteinuria, osteoarthritis, pancreatitis, gallstones, fatty change in the liver, hypoventilation syndrome,etc.

Different types/stages of prameha and diabetes mellitus

 

Diabetes Mellitus

NIDDM(Kaphaja, Pittaja Prameha) IDDM(Vataja Prameha/Madhumeha)

 

Early diabetes  Acute diabetes Chronic diabetes
↑ G.H.  ↑ Catecholamine Cortisol ↓ Insulin
Kaphaj Prameha      Pittaja Prameha    Vataj Prameha
↑ Kapha ↓ Kapha ↓ Kapha
↑ Pitta ↑ Pitta ↓ Pitta
↓ Vata ↓ Vata ↑ Vata
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