2 TOPICS What is Diabetes? Diabetes Epidemic Risk Factors Complications of DiabetesPreventing Diabetes ComplicationsWonder herbs
3 Where Medical Ethics Began Hippocrates & the Hippocratic Oath (by all MDs)“First Do No Harm”Today: most Conservative, Least InvasiveHippocrates is the Greek father of modern medicine: The Hippocratic Oath, to which all physicians subscribe, bases all treatments of a patient on the ’first do no harm’ principle. In other words begin treatment of a condition with the treatment option that has the least negative impact on the patient.Hippocrates is the Greek father of modern medicine: The Hippocratic Oath, to which all physicians subscribe, bases all treatments of a patient on the ’first do no harm’ principle. In other words begin treatment of a condition with the treatment option that has the least negative impact on the patient.
7 DIABETES What is Diabetes? The body does not produce or properly use insulin.Insulin is a hormone that allows the body to use glucose for energy. The body produces glucose from the food you eat.Insulin allows glucose (sugar) to enter body cells to convert it into energy. Insulin is also needed to synthesize protein and store fats. In un controlled diabetes, glucose and lipids (fats) remain in the blood stream and, with time damage the body’s vital organs and contribute to heart disease.
8 Blood sugar and health Sugar (glucose) is an important source of energyInsulin is producedby the pancreas whenblood sugar is highWhat is eaten isabsorbed intothe bloodInsulin keeps bloodsugar level withinthe normal rangefor health8
9 Islet of Langerhans:Pancreas contains insulin-making cells in “islets”Insulin b-cells9
11 TYPES OF DIABETES Type 1 diabetes Usually diagnosed in children and young adultsType 2 diabetesMost common formMost often diagnosed in adults
12 Classification Diabetes is classified into three main types: Type 1 previously called insulin-dependent diabetes mellitus (IDDM)Type 2 previously called non-insulin-dependent diabetes mellitus(NIDDM)Gestational Diabetes Mellitus(GDM)
13 Type 1 Diabetes Occurrence: Autoimmune disease wherein the immune system attacks B-cells of pancreas and destroys them. The pancreas then produce little or no insulin.Scientists do not know exactly what causes the body’s immune system to attack the B-cells, but they believe that both genetic factors and environmental factors and possibly viruses, are involved.
14 Type 1 Diabetes: Characteristics: Often develops in children and young adults, but the disorder can appear at any age.Symptoms usually develop over a short period, although B-cell destruction can begin year earlier.If not diagnosed and treated with insulin, a person can lapse into a life-threatening diabetic coma, also known as diabetic ketoacidosis.
15 Type 2 diabetes Occurrence: The most common form of diabetes. Due to reduce insulin secretion or peripheral resistance to action of insulin.The result is the same as for Type 1 diabetes, glucose builds up in the blood and the body cannot make efficient use of its main source of fuel.
16 Differences between type-1 and type-2 Diabetes Mellitus Young ageNormal BMI, not obeseNo immediate family historyShort duration of symptoms (weeks)Can present with diabetic coma (diabetic ketoacidosis)Insulin requiredType 2Middle aged, elderlyUsually overweight/obeseFamily history usualSymptoms may be present for months/yearsDo not present with diabetic comaInsulin not necessarily requiredPrevious diabetes in pregnancyThese differences are not absolute
17 Symptoms of DiabetesPeople with diabetes often have typical complaints (symptoms):Thirst and frequent drinkingMore frequent urination, particularly at nightUnexplained weight lossFatigueBlurred visionFrequent infections : skin, genital
19 PREDIABETES What is Prediabetes? Comes before type 2 diabetes Pre-diabetes RangesA1C%Fasting Plasma Glucose Testmg/dlOral Glucose Tolerance Testmg/dlWhat is Prediabetes?Comes before type 2 diabetesBlood glucose are higher than normal, but not yet diabetesMost people with prediabetes don’t know they have it
20 A random Plasma glucose value (taken any time of day) of 200mg/dl or more, along with the presence of diabetes symptoms.A plasma glucose value of 126/mgdL or more, after a person has fasted for 8 hours
21 Glycated Hemoglobin (HbA1c) Test Indicates blood glucose control over a period of approximately 3 months.Normal range varies depending on the method the lab uses: usually 4-7%, correlating to average blood glucose of mg/dl ( mmol/l)
22 THE SCOPE OF DIABETESRecent estimates project that as many as 1 in 3 adults will have diabetes in 2050 unless we take steps to Stop Diabetes.
23 DIABETES IS COSTLY$ Diagnosed diabetes costs $174 billion each year (an increase of 32 percent since 2007).$ Including gestational diabetes, prediabetes and undiagnosed diabetes, the total diabetes-related costs exceed $218 billion.$ 1 out of every 10 health care dollars is attributed to direct diabetes care$ 1 out of every 5 health care dollars is spent caring for someone with diabetes
24 Reason for increasing prevalence of type-2 diabetes The disease is reaching epidemic proportions because:Rates of overweight/obesity have increasedWe have become a physically inactive speciesOur diets are increasingly unhealthy
26 Risk factors for type 2 diabetes Physical inactivityOverweight and obesityHigh-fat and low-fiber dietAgeUrbanisationWhile some risk factors are fixed (such as age, gender and genetic background), many others are modifiable. The more risk factors a person has, the greater their likelihood of developing type 2 diabetes. Given that risk factors often occur together, all should be treated to gain the most benefit in terms of reducing type 2 diabetes.Modified from the IDF publication: ‘Diabetes and Obesity’, p.12; and ‘Time to Act’, p.53Family historyLow birth weightEthnicity
27 YOU ARE AT INCREASED RISK FOR DIABETES IF You are overweight.A parent, brother or sister has diabetes.You have high blood pressure.You have low HDL (good cholesterol).You have high triglycerides.
28 Complications of Diabetes Short term:Symptoms of diabetesDehydrationDiabetic ComaInfectionsLong term:KidneyEyeHeartCirculationAmputation
29 Treatment of Type-2 Diabetes Diet/ exerciseOral monotherapyOral combinationOral +/- insulinInsulinDiet and exercise may control condition for some timeVariety of tablets available when diet exercise no longer workTablets can be used in combination with each other or with insulinInsulin can also be used aloneStepwise approachThe traditional stepwise approach aims primarily to control acute symptoms.Dietary measures and exercise are not usually sufficient to control glycemia beyond the first year of therapy.If oral monotherapy proves inadequate, combination therapy is usually started. If this also proves unsuccessful, conversion to insulin is the next step, either alone or in combination with an oral agent.In the majority of cases, the stepwise approach does not lead to sustained control.Many physicians intensify treatment only when symptoms of poor glycemic control become apparent, rather than when glycemic targets are not reached.Early, aggressive approachThis approach to type 2 diabetes management avoids the risk of early treatment failure by adopting an intensive therapeutic strategy immediately upon diagnosis.Combinations of agents with complementary modes of action targeting the dual defects underlying type 2 diabetes (insulin resistance and b-cell dysfunction) are most likely to support tight, long-term glycemic control.Furthermore, combination therapy should be considered earlier in the regimen to provide additional glycemic control.Campbell IW. Br J Cardiol 2000; 7:625–631.29
30 Management: Diet Exercise Education Insulin for Type 1 and OHAs or insulin in Type 2Monitoring blood glucose and therapy
31 Goals Of Treatment Control high blood glucose (hyperglycemia) Avoid low blood glucose (hypoglycemia).Treatment of associated conditions, such as high blood pressure, cholesterol disorder and obesity.Prevent or retard the progression of complications of diabetes such as blindness, kidney failure, heart disease, stroke and amputation of legs.
32 Treatment Plan Management of Blood Glucose: Target Blood Glucose values:(as recommended by the American Diabetes Association)Pre-meal blood glucosemg/dlBedtime blood glucosemg/dl*HbA1cLess than 7%
33 Macro-vascular Complications Ischemic heart diseaseCerebrovascular diseasePeripheral vasculardiseaseDiabetic patients have a 2 to 6 times higher risk for development of these complications than the general population
34 Macro-vascular Complications The major cardiovascular risk factors in the non-diabetic population (smoking, hypertension and hyperlipidemia) also operate in diabetes, but the risks are enhanced in the presence of diabetes.Overall life expectancy in diabetic patients is 7 to 10 years shorter than non-diabetic people.
35 Effect of Hypertension The combination of hypertension and diabetes is a serious situation, posing increased predisposition to cardiovascular morbidity and mortality.There is no doubt that hypertension occurs more commonly in diabetic patients, and confer a greater prospect of development of complications, it should therefore be taken as seriously as glycemic control when planning treatment strategies
36 Why worry about Hypertension in Diabetic patients Treating hypertension can reduce the risk of:Death 32%Microvascular disease 37%Stroke 44%Heart failure 56%UKPDS BMJ 1998;317:
37 Management of cholesterol: Target Cholesterol Levels(as recommended by the American diabetes association)LDL CholesterolLess than 100 mg/dlHDL CholesterolGreater than 45 mg/dlTriglyceridesLess than 200 mg/dl
38 Effect of CholesterolHyperlipidemia can occur as result of poorly controlled diabetes, or may occur as a independent risk factor for macrovascular disease. About 25% of patients attending a diabetes clinic will have elevated lipid levels
40 Eye Complications Cataracts Non enzymatic glycation of lens protein and subsequent cross linkingSorbitol accumulation could also lead to osmotic swelling of the lens but evidence of involvement in cataract formation is less strong
46 Advanced Diabetic Eye Disease Retinal detachment with or without retinal tearsRubeosis iridisNeovascular glaucoma
47 Screening for Neuropathy 128 Hz tuning fork for testing of vibration perception10g Semmers monofilamentThe main reason is toidentify patients at riskfor development ofdiabetic foot
48 DIABETES COMPLICATIONS Heart Disease and StrokeOn diabetes-related death certificates among people aged 65 years or older:Heart disease was noted 68 percent of the time.Stroke was noted 16 percent of the time.The risk for stroke and death from heart disease is 2 to 4 times higher among people with diabetes.
49 DIABETES COMPLICATIONS Kidney DiseaseDiabetes is the leading cause of kidney failure, accounting for 44 percent of new cases in 2008.In 2008, 48,374 people with diabetes began treatment for end-stage renal disease.
50 DIABETES COMPLICATIONS AmputationsMore than 60 percent of nontraumatic lower-limb amputations occur in people with diabetes.In 2006, about 65,700 nontraumatic lower-limb amputations were performed in people with diabetes.
51 DIABETES COMPLICATIONS BlindnessDiabetes is the leading cause of new cases of blindness among adults aged years.In , 4.2 million (28.5 percent) people with diabetes aged 40 years or older had diabetic retinopathy, and of these, 655,000 (4.4 percent of those with diabetes) had advanced diabetic retinopathy that could lead to severe vision loss.
52 BEWARE OF YOUR BLOOD PRESSURE High blood pressure raises your risk for heart attack, stroke, eye problems and kidney disease.Get your blood pressure checked at every visit.Target BP for people with diabetes = less than 130/80
53 CHECK YOUR CHOLESTEROL Several kinds of blood fats:LDL (“bad”) cholesterol - can narrow or block blood vessels.HDL (“good”) cholesterol - helps remove cholesterol deposits.Triglycerides - can raise your risk for heart attacks/stroke.
54 ADA GOALS FOR CHOLESTEROL Target LDL = less than 100Ideal HDL = above 40 (men)above 50 (women)Target triglycerides = less than 150
55 Do’s of diabetic dietsConsistency in diet and meal timings according to medicines.Multivitamin containing an antioxidant such as vitamin ,beta-carotene, vitamins C and E.Minimum of 1200 kcal/day for women and 1500 kcal/day for men.
56 KEY STEPS FOR MANAGING CHOLESTEROL Eat less saturated fat and trans fat.Foods high in saturated fat and trans fat: fatty meats, hot dogs, high fat dairy products like cream and cheese, baked products and snacks with hydrogenated vegetables oils in the ingredients.Eat foods high in fiber.Examples: oatmeal, beans, peas, citrus fruitsTake cholesterol-lowering medication prescribed by your doctor.Exercise regularly.
57 MEAL PLANNINGWork with a dietitian to develop your own, personalized meal plan to help you:Lose weight, if needed.Choose foods low in fat.Include variety in your food choices (whole grains, vegetables, fruits, meats and dairy).
58 EXERCISE A little bit goes a long way: Try being more active throughout the day.Examples: work in the garden, play with the kids, take the stairsWalk - work up to at least 30 minutes of walking on most days; you can even split this into three 10-minute walks when it’s convenient.
59 OTHER STRATEGIES Get help to quit smoking. Talk to your health care provider about taking aspirin and other medications to reduce your risk for heart disease and stroke.
60 MANAGING MEDICATIONSAsk when to take each medicine; make sure instructions and labels are clear.Link as many medicines as possible to recurring daily events – getting up, eating, brushing teeth, bedtime.Set your watch, computer or a kitchen timer as a reminder.Make a chart showing when each medicine should be taken.Talk to your health care provider about what you should do if you miss a dose.Use a daily or weekly pill box.Put a reminder note where you’ll see it.
62 Reasons for diet Weight control Blood glucose control Prevention and management of short-term and long-term complications of diabetes
63 Foods to avoid or take in reduced amounts for diabetics SALT: You get enough salt from vegetables in inorganic form, so reduce the intake of extra salt.SUGAR: Sucrose, a table sugar, provides nothing but calories and carbohydrates. Substitute sucrose with natural sugar, like honey, jaggery (gur), etc.FAT: Excessive fat intake is definitely not a good habit. Try and exclude fried items from the diet But, remember, a small quantity of oil is needed to absorb fat-soluble vitamins, especially vitamin E.WHOLE MILK AND PRODUCTS: Try to switch to low fat milk and its products like yogurt (curd).WHITE FLOUR (MAIDA) AND ITS PRODUCTS: Replace these with whole grains, whole wheat (ATTA) or soya breads and unpolished rice.FOODS WITH A HIGH CARBOHYDRATE (SUGAR) CONTENT: Avoid white rice, potatoes, carrots, breads and banana – they increase the blood-sugar levels.
67 Eat more fruit and vegetables FreshFrozenTinnedDriedJuice
68 Choose more high fibre foods To help maintain blood glucose levels and cholesterol levelsFruitVegetablesPulsesOatsHelps to maintain a healthy gutWholegrain cerealsWholemeal breadWholewheat pastaBrown rice
69 Reduce animal or saturated fat intake Use low fat milkUse low fat spread instead of butterUse oil high in unsaturated fat, eg olive oil, rapeseed oil
70 Use less fat in cookingGrillDry-roastMicrowaveSteam
71 Cut down on sugary foods Not a sugar free dietCut out sweetsCut out sugary drinks
72 Choose low sugar products Use diet or low calorie, sugar free drinks
77 Slimming tips Be realistic about your target weight Aim to lose weight graduallyEat regular mealsMake small changes you can stick to
78 Say “No” to diabetes Avoid the causative factors Maintain good dietary habitsRestrict sugar intakeDo proper exerciseRelax/ de-stressIf there is hereditary factor- take preventive herbal medicines
79 Oral Hypoglycemic Agents OHAs are primarily used in type 2 diabetes adjunct to nutrition therapy and exercise.Oral agents are broadly classified as follows:
80 First generation sulfonylureas Generic nameDosage range per dayDuration of actionSide effect of classChlorpropomidemg6-2 hrsProlonged hypoglycemia, cholestatic jaundice, Hypersensitivity; alcohol flushTolbutamidemgHypoglycemia, hypersensitivityTolazamidemg12-24 hrsAceohexamidemg
81 Second generation sulfonylureas Generic nameDosage range per dayDuration ofactionSide effectsOf classGlipisidemg12-24 hrsHypoglycemia, hypersensitivityGlibenclamide5-20 mgGlymeperide1.8 mg24 hrsGliclazidemg
82 Agents enhancing effects of insulin Generic nameDosageRangePer dayDuration of actionSide effects of classMetformin(Obimet)mg6-8 hrsGi upset; diarrhea; possible resumption of ovulation in premenopausal anovolvutary patients; acidosis (if renal, liver, heart impairment present).
83 Agents enhancing effects of insulin Generic nameDosageRange per dayDuration of actionSide effects of classRosiglitazone4-8 mgVery longRenal and liver function studies should be done to monitor liver dysfunction, salt and water retention, edema, congestive heart failure.
84 Agents enhancing effects of insulin Generic nameDosage range per dayDuration of actionSide effects of classPioglitazone15-45 mgVery longRenal and liver function studies should be done to monitor liver dysfunction, salt and water retention, edema, congestive heart failure
85 Other Oral agents Generic name Dosage range per day Duration of action Side effects of classRepaglinide(NovoNorm)mg2-6 hrsHypoglycaemia, arthralgia, leukopeniaAcarbosemg< hrsDiarrhoea,abdominal discomfort, flatulenceMiglitol<4 hrsDiarrhoea, abdominal discomfort, use not recommended when significant renal dysfunction present
89 Gymnema’s (Meshashringi) principal constituent is gymnemic acid, which has antidiabetic properties. It reduces excessive blood sugar. It also has a regenerative effect on pancreatic beta cells and is insulinotropic, which means that it stimulates the production and activity of insulin.Gymnema temporarily abolishes the taste for sugar and helps decrease sugar cravings.It increases the activity of enzymes responsible for glucose absorption and utilization.
90 Phenolic-linked biochemical rationale for the anti-diabetic properties of Swertia chirayita (Roxb. ex Flem.) Karst. Phoboo S, Pinto Mda S, Barbosa AC, Sarkar D, Bhowmik PC, Jha PK, Shetty K.The crude extract of Swertia chirayita, an important medicinal plant of Nepal, is locally used for many diseases including type 2 diabetes. In this study, crude aqueous and 12% ethanol solution extracts of S. chirayita collected from nine districts of Nepal were analyzed for anti-diabetic-linked anti-hyperglycemia potential using in vitro biochemical assays. There was moderate-to-high positive correlation between antioxidant activity and total phenolic content of both extracts and moderate-to-high α-glucosidase inhibitory activity. Although the anti-diabetic property of S. chirayita is mainly attributed to the phytochemical swerchirin present in its hexane fraction, we propose that the crude extract of this plant used in local healing also has anti-hyperglycemia potential. The crude extracts indicated the presence of three main phytochemicals mainly mangiferin, swertiamarin, and amarogentin and their derivatives. Among the standard compounds (mangiferin, swertiamarin, and amarogentin), mangiferin showed α-glucosidase and 2,2-diphenyl-1-picrylhydrazyl radical inhibitory activity indicating anti-hyperglycemia potential.Source:Department of Plant, Soil and Insect Sciences, University of Massachusetts, Amherst, MA 01003, USA.
91 Berberis aristataJ Ethnopharmacol. 2009 May 4;123(1):22-6. doi: /j.jep Epub 2009 Mar 5.Antihyperglycemic and antioxidant effect of Berberis aristata root extract and its role in regulating carbohydrate metabolism in diabetic rats.Singh J, Kakkar P.Source:Herbal Research Section, Indian Institute of Toxicology Research (Council of Scientific & Industrial Research), Post Box No. 80, Mahatma Gandhi Marg, Lucknow , UP, India.
93 The pentacyclic triterpenoids in herbal medicines and their pharmacological activities in diabetes and diabetic complications. Alqahtani A, Hamid K, Kam A, Wong KH, Abdelhak Z, Razmovski-Naumovski V, Chan K, Li KM, Groundwater PW, Li GQ.Source:Faculty of Pharmacy, University of Sydney, NSW 2006, Australia.A large number of bioactive pentacyclic triterpenoids have shown multiple biological activities with apparent effects on glucose absorption, glucose uptake, insulin secretion, diabetic vascular dysfunction, retinopathy and nephropathy.
95 U.S.P. reduces hyperglycemia in individuals with NIDDM. It significantly reduces fasting and post-prandial blood sugar levels.reduces serum cholesterol, low-density lipoprotein and triglycerides and increases serum high-density lipoprotein levels.controls changes in early diabetic retinopathy.increases plasma insulin and C-peptide levels.Microalbuminuria (a sign of kidney damage in which a large amount of the protein albumin is found in the blood) is improved in individuals with NIDDM.
96 Antibitis Combats diabetes: The natural ingredients increase insulin secretion in the body by reducing the glycated hemoglobin level (form of hemoglobin used to measure glucose content in the blood)normalizing microalbuminuria (a condition which is an important prognostic marker for kidney disease in diabetes mellitus)modulating the lipid profile,minimizes long-term diabetic complications.The drug also increases hepatic and muscle glycogen content, which enhances the peripheral utilization of glucose.
97 Indications:Antibitis is For non-insulin-dependent diabetes mellitus (NIDDM/type II), as a monotherapy or as an adjuvant to other oral antidiabetic drugsAntibitis is For NIDDM with signs and symptoms of hyperlipidemiaAntibitis is For NIDDM with early retinopathyAntibitis is For NIDDM with microalbuminuriaAntibitis is As an adjuvant in insulin-dependent diabetes mellitus (IDDM/type I)
98 Side effects:Antibitis is not known to have any side effects if taken as per the prescribed dosage.