Diabetes mellitus can cause complications in almost all the systems of the body if it is poorly controlled. Our main aim is to keep blood glucose and HbA1c at levels equal to that of normal population in order to prevent development of complications. Almost all the complications of diabetes are due to ‘’microangiopathy’’ that is damage to small blood vessels reducing blood supply to different organs of the body.
After 10-15 years of poorly controlled diabetes, eye complications tend to develop. Eye complications are more common in type 1 than in type 2 diabetes. These include:
1. InfectionsHigh blood glucose level makes the eye prone to bacterial over growth and infections including stye ( infection of eye lashes and lids) or conjunctivitis ( infection of conjunctiva- the membrane covering the eye)
2. Glaucoma: In urdu it is known as ‘’ kalamotia’’. It is increased pressure in the eyeball due to excessive fluid production or inadequate drainage of this fluid. If untreated it can lead to blindness. At initial stage it is treated with various eye drops. At later stages surgery may be required to drain excess fluid.
Patient should have periodic eye examination and measurement of eye pressure.
3. Cataract: It is known as ‘’sufaidmotia’’ in urdu. It is disease of lens of the eye which becomes opaque due to protein deposits. It will cause obstruction of vision. At initial stages it can be handled by wearing anti-glare lens spectacles or sunglasses. but when lens is completely effected by cataract, surgery is done to remove the lens and place an artificial lens in its place.
4. Retinopathy: Retina is the inner most layer of the eyeball. It is most important for vision. In almost all diabetics some changes occur in blood vessels of retina gradually. Initial stage is called ‘’background or non-proliferative retinopathy’’ in which blood vessels balloon up or form pouches. It causes no symptoms, it can be detected by ophthalmologist on routine visit.
Later stage is proliferative retinopathy in which blood leaks from weak blood vessels, and new fragile blood vessels are formed which are more prone to hemorrhage. At this stage patient may feel diminishing vision. The best treatment for this stage is laser photocoagulation that seals the blood vessels to prevent further bleeding. There may be transient blurring of vision after laser surgery for few days, and there can be permanently decreased peripheral vision after surgery.
Kidneys are vital organs for excretion of all the toxic waste from the body. They have a very rich blood supply which helps in filtering all the wastes from the blood. Poorly controlled and long standing diabetes cause damage to these blood vessels that is break down of this filter. As a result toxins are not properly filtered out and useful substances like proteins are lost in the urine. High blood pressure along with high glucose level further aggravated the kidney damage. There are following stages of progression of kidney disease.
1. Microalbuminuria: The initial stage when small sized proteins leak out of urine. It causes no symptoms and can be treated with tight blood glucose control and medicines like ACE inhibitors
2. Macroalbuminuria: The second stage in which large size proteins are also filtered out in urine. It can rapidly progress to end stage renal disease. Low protein diet and good control of blood pressure and blood glucose is required. Frequent urine and blood test to check levels of toxins, urea and creatinin in the blood. Consult a nephrologist at this stage.
3. End-stage renal disease: The stage when the kidneys fail to function. There will be edema (swelling) of feet and whole body due to water retention. Urea and creatinin will rise in the blood giving rise to symptoms of uremia like nausea, vomiting, headache, agitation, confusion, drowsiness or coma. At this stage patient is referred to nephrologist for dialysis or transplant. At end stage blood sugar usually tends to be low and dose of insulin will have to be reduced.
- At initial stage control of blood glucose and blood pressure
- Restriction in dietary protein and fluids
- ACE inhibitors and ARB group of medicines, these medicines lower the blood pressure and prevent damage to kidney membranes and filter.
- Dialysis, peritoneal or hemodialysis is a process to remove toxic wastes from the blood by passing through a filtering machine twice or thrice a week.
- Kidney transplant is the last stage when kidney has completely failed, a new kidney can be transplanted but it has its own problems and risks. (discussed in transplant section)
Diabetes is an independent risk factor for heart disease, coronary artery disease. Presence of other risk factors will increase the chance of heart attack. These include
- High cholesterol LDL level
- High blood glucose
- Sedentary life style
Diabetics usually feel no warning sign or pain during heart attack. So it is better to take precautions. Keep blood pressure and blood glucose in control, low dose aspirin to keep the blood thin, lower cholesterol with medication, quit smoking, exercise regularly, and consult cardiologist.
Neuropathy Diabetes causes damage to the nerves. There is reduction in the blood supply of the nerves. These nerves relay messages to and from the brain and spinal cord to various parts of the body.
Neuropathy can be of two types:
Peripheral neuropathy: Damage to the nervesof the extremities like hands and feet. The first to be effected are the nerves of the feet. As a result of nerve damage there is loss of sensation of touch, pain, pressure, temperature and vibration. Symptoms are:
- Pins and needles in feet and hands
- Numbness of feet and hands
- Pain in the effected parts
- Inability to feel hot or cold can lead to burns.
- Minor cuts and blisters go unnoticed due to numbness
Neuropathy can be prevented by maintaining normal blood glucose level and HbA1c. Regular checkup by doctor.Use of pain reliever medicines.
Autonomic neuropathy: It is the damage to nerves supplying various internal organs. It can lead to many symptoms:
- Gastroparesis, leading to nausea, abdominal fullness, bloating, constipation alternating with diarrhea.
- Postural hypotension, Blood pressure falls down if a patient suddenly gets up or changes posture and patient can faint.
- Resting tachycardia, heart rate is too fast even at rest
- Sexual problems, mostly seen in men as erectile dysfunction
- Urinary symptoms like lack of bladder control, incontinence
- Lack of sweating causing dry skin, or too much sweating while sleeping or eating
- Eyes don’t adjust when they move from bright light to darkness
- Hypoglycemia unawareness, patient can no longer feel symptoms of hypoglycemia like shaking, trembling or sweating.
- Charcots joints: when joints get deformed or damaged due to neuropathy, usually foot joints are effected.
- Entrapment neuropathy: median nerve gets entrapped at the wrist joint, it will cause pain and tingling in the palm and fingers
- Cranial neuropathy: diabetes can effect cranial nerves supplying the eye, damage to this nerve leads to double vision.
- Femoral neuropathy: pain and muscle wasting in front of thigh.
Diabetic patients are very prone to getting foot problems, including infection, blisters, ulcers etc. The reason for this is:
- Neuropathy: feet are numb and they don’t feel the pain or pressure when they get hurt, so small wounds tend to enlarge before they get noticed. Loss of temperature sensation can cause burns by walking on hot surfaces or washing feet with hot water.
- Microangiopathy and peripheral arterial disease: decreased blood flow to the feet will cause dry cracked skin more prone to infections, and less blood supply will also delay the process of healing.
- High blood glucose can increase chance of bacterial and fungal over growth leading to infection. Infection starting from minor cut or blister can sometime progress to involve the bones. Unfortunately it can sometimes lead to amputation.
Easy steps to take care of your feet daily:
- Examine your feet: At least once daily, ideally before going to bed.
- Use a mirror: To examine the under surface of your feet to look for cracks, blisters or corns.
- Inspect in between the toes: To look for fungal infections, athelete’s foot.
- Wash your feet: Daily with soap and water. Dry them after washing especially between toes.
- Cut your nails carefully: Cut them straight and file the edges. If you cut your nails too short you may cut the skin without even feeling the pain. In case of ingrown nail, get professional help to cut it.
- Don’t put your feet in very hot water: As hot water can burn your skin and you won’t even notice the pain due to loss of sensation. Don’t use hot water bottles for your feet.
- Don’t walk barefoot: You may hurt your feet by a stone or sharp object, or burn your feet by walking on hot sand in summers.
- Avoid dryness: As cracks on heels can harbor infectious bacteria. Apply moisturizer daily on upper and under surface of your feet but not between toes.
- Exercise regularly: To improve circulation of your feet. Keep wiggling your toes and ankles whenever you are sitting for long time.
- If you cannot bend to examine your feet yourself then let someone else do it for you.
- Wear comfortable shoes: At all times. Before wearing shoes check the inside for any sharp points or nails that might hurt your feet. Wear loose cotton socks and change them daily.
- Consult your doctor: If you notice even a small wound on your feet, because early treatment can prevent progression to serious problems.
- Quit smoking: As it further decreases the blood supply to the feet.
Diabetic patients present with repeated skin infections, boils, delayed healing of small wounds, or pruritis (itching) and during routine testing they are diagnosed as having diabetes. Why are skin problems so common in diabetics? Very high sugar level serves as a good culture medium for bacteria and fungus, microangiopathy (narrowing of small blood vessels due to diabetes) causes decreased blood supply to the skin thereby delayed healing of wounds. The cause of some skin problems is decreased immunity and autoimmune conditions in which antibodies present in the body react to skin and subcutaneous tissue.
Common bacterial infections in diabetics include: stye (infection in eyelids), boils, carbuncles, nail infections and diabetic foot. Common causative bacteria are staphylococcus. Antibiotics are needed for treating bacterial infections.
Fungal infections caused by candida albicans are common in warm and moist areas of body like armpits, groin, in between fingers and toes. Fungal nail infections are also common in diabetics. Another common fungal infection is ring worm. These are treated with antifungal medicines.
Pruritis or itching can be a common presentation of diabetes. It is caused by dry skin and decreased blood flow to the skin. It can be controlled by using moisturizer for dry skin and keeping blood sugar under control.
Painless small blisters sometimes erupt in diabetics on hands or feet. They heal when blood sugar comes in control.
Black velvety appearance of skin around the neck or armpits is often an indication of diabetes. It commonly occurs in overweight people and it is an indication of an underlying disease.
Raised red or brown areas appearing on shins are seen in some diabetics even before the diagnosis of diabetes. This is due to decreased blood flow to the skin.
Coin shaped, raised, reddish or skin coloured lesions seen on hands or feet. Their cause is not known; they are painless and need no treatment.
Small yellow bumps on back of elbows, knees or buttocks. They are seen in diabetics and may indicate high blood cholesterol level.
Due to decreased blood flow to the skin, oval brownish scaly patches develop especially on front of the legs. They are harmless and need no special treatment.
A raised bump or depression may develop at the site of insulin injection. It can be prevented by changing the site of insulin injection every time. Almost all of these conditions are preventable by keeping tight control of blood sugar. Once diagnosed, most of these problems can be reversed by proper diabetes treatment.
A certain degree of hearing loss is associated with diabetes. It increases with age. Hearing loss is twice as common in people with diabetes as compared to people of same age who don’t have diabetes. The reason for hearing loss is the damage to small blood vessels supplying the inner ear. People with hearing loss usually don’t recognize their problem till others point out. Common complaints are:
- Repeating same question again
- Difficulty in hearing in a crowded noisy place
- Difficulty in hearing low volume sounds like voices of children
- Turning up volume of TV and radio too high.
How to diagnose hearing loss? Examination by ENT specialist who will order hearing tests (Audiometry). This test will identify the type and intensity of hearing loss.
- Conductive deafness: where the problem is in the hearing passage e.g earwax causing blockage
- Sensory-neural deafness: problem with the nerves supplying the inner ear. This is the type commonly seen in diabetics
Sensory neural hearing loss is managed by hearing aids. Nowadays hearing aids are very effective, they are small in size, can fit inside the ear or attached behind the ear, and they make you hear clear sound without background noise and muffling.
Stroke or brain attack occurs when blood supply to a certain part of brain is stopped. Diabetics have 2-3 times increased risk of having a stroke. It presents as weakness of one half of body, difficulty in speech or swallowing, memory problems, and emotional problems.
- High blood pressure
- High cholesterol level
- Physical inactivity
- Family history of strke
- Past history of TIA (transient ischemic attack) paralysis that recovers within 24 hours.
Warning signs: If you feel dizzy, unusual headache, blurred or double vision, heaviness numbness or tingling in one arm or leg, difficulty in speech. It means you might be developing a stroke. Immediately call emergency help to reach a hospital
Treatment: The sooner you reach the hospital the better. After brain CT scan or MRI scan. The neurologist can administer medicines to dissolve the blood clot blocking your brain blood supply. Further management includes:
- Maintaining blood pressure and blood glucose level
- Hydration and nutrition support
- Physical therapy
- Speech therapy
- Psychotherapy for emotional support
- Control blood pressure
- Control blood glucose level
- control cholesterol level
- quit smoking
- aspirin and lipid lowering medicines
Stress can be physical or mental. Both types of stress can upset the blood glucose level. Body considers both types of stress as ‘DANGER’. As a response to danger there is a “FIGHT OR FLIGHT RESPONSE’ of the body. For this fighting or fleeing away, body releases stress hormones that mobilize stored fat and glucose into the blood to be utilized by muscles to fight or run away from danger. In diabetics, insulin is deficient so this extra glucose mobilized to the blood cannot be taken up by muscles. This results in high blood glucose level.
How to cope with stress There are two types of strategies to cope with stress. Either accept the problem as it is or make changes to stop the stress.
- Avoid stress: change of job to avoid job related stress or change of timings to avoid stress due to traffic jams are some examples
- learn to relax: one can learn various relaxation techniques like deep breathing, yoga, stretching, music, meditation
- Group therapy: counseling or psychotherapy is very useful in stress management. The importance of group therapy is that patient sees other people like him and feels that he is not alone, learns from experiences of others.
- Diabetic Institute Pakistan is holding special group sessions for diabetic patients to teach stress management and relaxation techniques.
Ketoacidosis: Diabetic ketoacidosis is an acute emergency that needs hospitalization. Ketones are formed in the body as a result of fat metabolism when body cannot utilize glucose for energy. These ketones when in excess are excreted in urine. Ketoacidosis is more common in type 1 diabetes.
- Blood glucose more than 300mg/dl
- Inter-current illness like fever ,flu
- Too much exercise
- Not taking insulin
Symptoms and signs
- Nausea, vomiting, abdominal pain
- Rapid shallow breathing
- Fruity smell in breath
- Fast pulse rate
- Fever, dry hot skin
- Drowsiness or coma
- Ketones present in blood and urine
Treatment: Do not exercise if ketones are present in urine or blood. Best Treatment is possible in hospital under supervision of doctors and nurses.
- Rehydration with drips of normal saline
- Insulin according to blood glucose level
- Blood glucose monitoring hourly
- Electrolyte replacement
- Blood tests, urine test and x-ray to look for infection
- Antibiotics to treat infection