Diabetes Symptom and Prevention: A Comprehensive Guide

This article provides a comprehensive guide on diabetes symptoms, prevention, epidemiology, types, pathophysiology, and nutrition in diabetic patients. It covers the causes, symptoms, and prevention measures of diabetes, along with its types and pathophysiology. It also discusses the importance of nutrition in diabetic patients and how medical nutrition therapy can help in managing diabetes.

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Diabetes symptom and prevention :
Diabetes is one of the metabolic disorders in which blood sugar level remains elevated for the
prolonged time. Pre prandial glucose level for non-diabetic and diabetic patient should be 4.0
to 5.9 mmol/L and 4 to 7 mmol/L respectively. Post prandial glucose level for non-daiabetic
and diabetic should be under 7.8 mmol/L and 5 to 9 mmol/L respectively. HbA1c in normal,
prediabetes and diabetes patient should be below 6 %, 6 to 6.4 % and above 6.5 %
respectively. Prominent symptoms of diabetes include frequent urination (polyurea),
increased thirst (polydipsia) and increase hunger (polyphagia). In type 1 diabetes, these
symptoms develop very rapidly and in type 2 diabetes these symptoms develop slowly over a
period of duration (Thomas & Philipson, 2015). Diabetic patient particularly in the older age
is mostly associated with acute diabetic complications like diabetic ketoacidosis and
hyperosmolar hyperglycemic state. Few of the symptoms are not associated specifically with
the diabetes; however, these symptoms indicate onset of the disease. These symptoms include
blurry vision, headache, fatigue, slow healing of cuts, and itchy skin. Alteration in the vision
of the diabetes patient occurs due to absorption of glucose in the lens. Rashes on the skin of
the diabetes patient are collectively known as diabetic dermadromes. Diabetic condition also
produces effects like uneasy feeling, sweating, trembling, confusion, aggressiveness, seizures
and unconsciousness (Wiley, 2016; Pippitt et al., 2016).
It is also associated with chronic complications like cardiovascular condition like damage to
the blood vessels, stroke, peripheral artery disease, chronic kidney disease (diabetic
nephropathy), foot ulcers, damage to nerves (diabetic neuropathy) and damage to the eyes
(diabetic retinopathy). Diabetic retinopathy mainly caused due to damage to the blood vessels
of retina and it leads to sustained vision impairment and finally blindness. Older diabetes
patients are more prone to risks like glaucoma and cataracts. Older people are more prone to
eye problems due to anatomical changes in the eye due to older age. In older people, diabetes
nephropathy lead to problems like tissue scarring and protein loss in the urine. Diabetic
neuropathy is most common complication of diabetes and it leads to occurrence of numbness,
tingling, pain, and altered sensitivity to pain. As a result of altered sensitivity to pain, skin
become more susceptible to the injury. Foot problem like diabetic foot ulcer is difficult to
treat.
No effective prevention measures are available for type 1 diabetes and however, type 2
diabetes can be effectively prevented. Due to complex nature of diabetes, medical, physical
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and nutritional interventions need to be carried for the treatment and management of diabetes
(Garrison, 2015). Most prominent interventions to be carried out for the treatment and
management of diabetes include healthy diet, regular physical exercise, a normal body
weight, and avoiding use of tobacco. It is evident that physical activity for more than 90
minutes per day can reduce risk of diabetes in approximately 30 % of the patients.
Appropriate diet can also be useful in the prevention of diabetes. Diet useful for the
prevention of diabetes include whole grains, fibres, and polyunsaturated fat (Li et al., 2014;
ADA, 2015). Prevention of consumption of sugary beverages and food containing saturated
fats can be useful in the prevention of diabetes. Tobacco smoking can increase the
susceptibility of diabetes and its complications; hence prevention of tobacco smoking can be
useful in prevention of smoking (Handelsman et al., 2015).
Epidemiology :
Prevalence of diabetes in adult population above 18 years of age is approximately 10 % and it
is estimated to rise upto 12 % by 2030. It is still higher in people above 65 years of age. In
older people above 65 years of age, prevalence of diabetes is estimated to be 19 %. Diabetes
prevalence increases with increase in the age of the patient. It has been estimated that
diabetes prevalence in approximately 20 % in age group people between 60 – 70 years of age.
It is approximately 22 % in age group people between 70 – 80 years of age and it is
approximately 23.5 % in age group people between 80 – 90 years of age. In age group above
65 years of age, incidence of obesity is estimated to be 14 cases per 1000 adults. It has
estimated that person lose life by approximately 10 years when diagnosed in the middle age
of life. Mortality rate is approximately double in patients with diabetes as compared to the
normal people. Prevalence of diabetes is higher in women as compared to the men (Sánchez
Martínez, 2014)
Types of diabetes mellitus:
Diabetes can be classified in two categories like insulin dependent diabetes mellitus (IDDM;
type 1 diabetes mellitus) and non-insulin dependent diabetes mellitus (NIDDM; type 2
diabetes mellitus). IDDM is more prevalent in children and young people. It can also be
termed as juvenile diabetes. In this type of diabetes, there is occurrence of abrupt onset of
symptoms, it depends on the exogenous insulin and these patients are more susceptible to
ketoacidosis. It can be considered as catabolic disease in which diabetic patient is with
deficiency of circulating insulin, with raised levels of glucagon and pancreatic B cells
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become resistant to insulin stimulation. Autoimmunity plays major role in the development of
IDDM. Infectious and toxic environmental substances affect immune system of people whose
immune system is susceptible to autoimmune response against pancreatic B cell antigens.
Genetic defect also plays important role in the impaired B cell function and replication. These
patients become more susceptible for type 1 diabetes due to failure of B cells development
after viral infection. Specific HLA genes can augment susceptibility to infection by
diabetogenic virus. These HLA genes can also augment susceptibility of autoimmune
destruction of their own islet cells. Hence, immunosuppressive drugs like cyclosporine and
azathioprine are proved to useful in the management of initial stage of type 1 diabetes
mellitus (ADA, 2015).
Approximately 80% of the diabetes patients are of type 2 diabetes. Patients of this type of
diabetes are not reliant on the exogenous insulin source for management of ketonuria and
these patients are not at risk of ketosis. However, these patients can develop ketosis due to
severe stress aggravated by the infection and trauma. Type 2 diabetes patients might require
insulin for the control of fasting hyperglycaemia when it is not controllable by proper diet
and after consumption of oral hypoglycaemic agents. In type 2 diabetes, body can produce
optimum amount of insulin; hence it can not be used effectively by the body. This mainly
occurs because peripheral tissues become insulin resistance. Moreover, insulin receptors and
other intermediate signalling pathways become insensitive to insulin. Hence, glucose can not
enter in the tissues and hence, blood sugar level increases. Both lifestyle and genetic factors
are responsible for the occurrence of type 2 diabetes (Selph et al., 2015).
Type 2 diabetes can be managed by medications which can improve the insulin sensitivity
and reduce the glucose production by the liver. Lifestyle factors play important role in the
development of type 2 diabetes. It includes obesity measured in terms of body mass index,
lack of physical activity, improper diet and stress. Excess body fat is associated with
approximately 50 % cases of the diabetes. Sugary sweetened drinks, saturated fats and trans
fats are responsible for the development of type 2 diabetes. Polyunsaturated and
monounsaturated fats can decrease the risk of development of type 2 diabetes mellitus.
Approximately, 7 % cases of the develop type 2 diabetes due to lack of physical activity (Siu,
2015).
Pathophysiology:
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Insulin is the principal hormone responsible for regulation of glucose uptake from blood into
different cells like adipose tissue and muscle, except smooth muscle. In these tissues, insulin
act through insulin-like growth factor 1 (IGF-1). Hence, deficiency of insulin or insensitivity
of insulin receptors are mainly responsible for the development of diabetes mellitus (Byrne,
2012). There are three different sources of glucose for the body. These include through food
absorption through intestine, glycogen breakdown which is a storage depot of glucose in the
liver and gluconeogenesis which is a production of glucose from the non-carbohydrate
sources present in the body (Ahmadieh & Azar, 2014).
Insulin can control hyperglycaemia by different mechanisms like inhibiting glycogen
breakdown and gluconeogenesis; stimulating glucose transport in the fat and muscle cells and
stimulating glycogenesis in which glucose is stored in the form of glycogen. Islets of
Langerhans in the pancrease contain beta cells which secret insulin in response to increased
levels of glucose after taking food. Approximately, two-third of the body’s cells use insulin
for lowering glucose level, for conversion of glucose into the fuel, for conversion into other
required substances and for storage. Reduced levels of glucose can lead to the reduced insulin
secretion of beta cells which lead to the gluconeogenesis in which glycogen get converted to
glucose. Gluconeogenesis process is controlled by hormone glucagon which exhibits opposite
action to the insulin. Insulin action can be impaired in several ways like insufficient
availability of insulin, poor response of cells to insulin which is termed as insulin resistance
and defective insulin. Due to this impaired action of insulin, glucose will not be absorbed
adequately by the body cells and it will not be stored in required amount in liver and muscles.
It can lead to sustained raised levels of glucose, inadequate protein synthesis and acidosis.
Sustained increase in the glucose level can lead to reabsorption by the kidneys and excretion
in the urine which is called as glycosuria. It leads to raised osmotic pressure of the urine and
inhibition of water reabsorption by the kidneys. It leads to raised urine production which is
termed as polyuria. It leads to increased fluid loss. It leads to dehydration and increased thirst
which is called as polydipsia (Kwak & Park, 2018; Brooks-Worrell & Palmer, 2011).
Nutrition in diabetic patient:
In the recent past, nutritional therapy gain importance for the management of diabetes. Main
goals of this therapy include : promotion and support for maintaining healthy eating pattern,
ensuring diverse nutritional foods in appropriate amount for improvement in the overall
health of the adult, attainment of individual glycaemic, blood pressure, and lipid goals,
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attainment and maintenance body weight, prevent and control diabetic complications, ensure
fulfilment of nutritional goals with respect to personal and cultural preferences and
implementation of suitable diet plan and schedule for the adult diabetic patient. Through
nutritional therapy, goals for different parameters of diabetic patient include Hba1c <7%,
Blood pressure <140/80mmHg, LDL cholesterol <100 mg/dL, triglycerides <150 mg/dL,
HDL cholesterol.>40 mg/dL for men, and HDL cholesterol .>50 mg/dL for women (Khazrai
et al., 2014).
Medical nutrition therapy (MNT) comprises of implementation of both medicinal
intervention and diet plan. Goal of MNT should be to improve glycaemic control and prevent
hypoglycaemia. For patients with type 1 diabetes mellitus, administration of flexible insulin
therapy along with carbohydrate counting meal approach in addition to the education
programme can result in improved glycaemic control. For patients with fixed daily doses,
regular consumption of carbohydrate according to scheduled time and measured amount can
be helpful in the improved glycaemic control with reduced risk of hypoglycaemia. For type 2
diabetes patients and older people meal planning approach can be more useful in controlling
the hyperglycaemia (Gosmanov & Umpierrez, 2012).
Appropriate proportion of combination of carbohydrate, protein and fat can be helpful in
meeting metabolic goals of the adult patient based on the patient’s preference of food. Total
intake of calorie need to be kept in mind while diet planning for adult diabetic patient.
Amount and type of glucose in the food can influence overall glucose level in the patient.
Carbohydrate intake in the form of vegetables, fruits, whole grains, legumes, and dairy
products is advised instead of other forms of glucose. Carbohydrate containing food in
combination with fats, sugars and sodium should be avoided. Carbohydrate counting or
experience-based quantitation can be useful in administering optimum amount of
carbohydrate to the patient. Non-nutritive sweeteners (NNSs) has the possibility to reduce
calorie and carbohydrate intake as compared to the nutritive sweeteners (Evert et al., 2014).
Nutritive sweeteners include sucrose and fructose. In comparison to the starch, sucrose has
negligible effect on the glucose level. Nutritive sweeteners provide excess amount of energy
because these foods provide empty calories and result in the unnecessary weight gain.
Fructose is commonly used monosaccharide present in the fruits, some vegetables and honey.
Fructose present in the form of free fructose which is present in the fruits can exhibit more
glycaemic control over the sucrose and starch consumption. If free fructose consumed in less
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than 12 % quantity, it doesn’t exhibit effect on the triglycerides level (Deed et al., 2015).
Diabetes patients should avoid sugar-sweetened beverages (SSBs) including high-fructose
corn syrup and sucrose to keep body weight in control and limit cardiometabolic risk factors.
Beverages with high level of fructose can have effects on the deposition of ectopic and
visceral fat, lipid metabolism, blood pressure, and insulin sensitivity in comparison to the
glucose-sweetened beverages. Non-nutritive sweeteners can exhibit can add negligible
amount of calorie while providing sweet sensation. It does not exhibit any significant effect
on the blood glucose and insulin concentration. Following are the FDA approved non-
nutritive sweeteners : sucralose, saccharine, Acesulfame K, Neotame, Stevia and Luo han
guo. It is evident that these FDA approved sweeteners do not exhibit effect on the glucose
level and body weight. Sugar alcohols (polyols) are the hydrogenated monosaccharides which
include sorbitol, mannitol, erythritol, xylitol and D-tagatose and hydrogeneated diasacchride
which include isomalt, maltitol, lactitol and trehalose. These polyols are partially absorbed by
the small intestine; hence provide less amount of calorie per gram. From the clinical studies,
it is evident that polyols produce less postprandial glucose level alteration as compared to the
sucrose and glucose. These polyols can produce long term effect in the form of less calorie
intake and control of glucose level (Esposito et al., 2014).
Dietary fibre is the composition of carbohydrate and lignin. These dietary fibres are
indigestible by the stomach and unobservable by the GI tract. It is evident that dietary fibres
can reduce mortality rate in diabetic patients. Fibbers can produce satiety, produce less
calorie, less in fat and sugar content. Hence, it can be helpful in the prevention of obesity and
heart disease. Resistant starches are the starches enclosed inside the intact cell walls. These
comprise of legumes, starch granules in raw potato and retrograde amylose from plants. It is
difficult to digest these resistant starches and these are absorbed as glucose. Fructans like
inulin are indigestible fibres and these can be used to reduce blood glucose level. Diabetes
patients need to be assessed for cardiovascular conditions prior to consumption of fat
containing food because fat can exaggerate both diabetes and cardiovascular disease. Amount
of saturated fat consumption need to be assessed in diabetes patients because it should be
below 7 %. Intake of trans fat need to be minimized because intake of trans fat raise the
levels of LDL cholesterol and reduce HDL cholesterol (Esposito et al., 2015). Consumption
of monounsaturated fatty acid (MUFA) containing food can be helpful in improving glucose
levels in the diabetes patients. There is less evidence available for the role of omega-6
polyunsaturated fatty acids (PUFAs) in diabetes patients. It is not recommended to reduce
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protein consumption below usual intake in patients with diabetes and evidence of diabetic
kidney disease. Protein consumption below the usual intake doesn’t affect glycemia,
cardiovascular condition and glomerular filtration rate (GFR). In type 2 diabetes patients,
protein consumption can improve the sensitivity of insulin action without increasing plasma
blood sugar level. In RCTs it has been demonstrated that reduction in the protein
consumption doesn’t have any effect on the improvement of diabetic nephropathy. Diabetes
is a condition with increased oxidative stress hence vitamins with the antioxidant potential
like vitamin C and E need to be administered to the diabetic older patient.
Glycemic index (GI) and glycemic load (GL) can be used as the assessment parameters for
assessing hyperglycaemia potential and insulin levels in diabetes patients. GI is applicable in
ranking the carbohydrate rich foods with potential to develop hyperglycaemia. It has been
established that foods with higher GI are refined grain products and potatoes; foods with
moderate GI are legumes and whole grains and foods with lower GI are starchy fruits and
vegetables (Kahleova & Pelikanova, 2015). Glycaemic control can be achieved effectively by
replacing high GI food with low GI food. GL is the combined effect of GI and total
carbohydrate content of food per serving of food. It is useful in assessing the effect of food on
blood glucose level and insulin level. GL is more sensitive parameter as compared to the GI
for the selection of food in older diabetic patients. Data obtained from the studies comprising
of GL and GI indicate that both amount and type of carbohydrate can be helpful in assessing
risk of hyperglycaemia development in diabetic patients. Intervention studies indicated that
diets containing low GI exhibited positive effect on the type 2 diabetes and CVD. These
studies also demonstrated that with GI food, insulin sensitivity can be improved and Hba1c
can be controlled effectively (Schwingshackl & Hoffmann, 2013; Mirrahimi, 2014).
The interdisciplinary team:
Management of diabetes can be effectively achieved by providing medical, nutritional and
physical intervention. Hence professionals from different fields like Nurse practitioner,
endocrinology-certified diabetes educator (CDE), podiatrists, optometrists, dental care
professionals, primary care physician, physician assistant, dietician, community health
workers, mental health professional and a pharmacist. Implementation of interdisciplinary
team (IDT) in the management of diabetes can be helpful in control of glycaemia, reducing
cardiometabolic risk factors and reducing risk of diabetes complications. Global Partnership
for Effective Diabetes Management suggested to implement IDT for the management of type
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2 diabetes (Powell et al., 2015). Nurse practitioner plays significant role in assessment of
patient and in providing appropriate intervention to the diabetes patient. Along with the blood
glucose evaluation and Hb 1ac estimation, feet and eye examination and urine test need to be
carried out in the diabetes patient. Hence, medical professionals from different disciplines
like podiatrists, optometrists, diagnostic laboratory head and technician need to be
incorporated in the management of diabetes patient. Diabetes educator can play important
role in the education of patient about healthy lifestyle to manage diabetes and self-
management of blood glucose level. Diabetes educator can provide education to the diabetes
patients based on the stage of diabetes hence diabetes educator can provide education about
prevention, prediabetes and management of diabetes. Dietician can make proper diet plan and
schedule for the diabetes patient. Dietician can identify food with low GI and GI, which can
be helpful in controlling glycaemia (Chatterjee & Davies, 2015).
Community health worker can be helpful in the reducing disparity for accessing health
education. Community health workers can act as connecting link between the healthcare
professionals and patients because older patients have more belief on community workers as
compared to the healthcare professionals; moreover, community workers have more
understanding of the patients in the community. Hence, they can be helpful in providing
holistic care by considering cultural and social aspects of the older people. Psychological and
mental issues can occur in adult diabetes patients due to impaired quality of life, increased
rate of hospitalizations and increased cost of care. Hence, mental health care professional
conduct motivational interview and implement cognitive-behavioural therapy for
improvement of morale of patient. Pharmacist can help patient to select most appropriate
hypoglycaemic strategy based on the individual needs of the patient. Pharmacist can provide
counselling to the patient for monitoring glucose levels on the regular basis and to control
out-of-range glucose levels. Pharmacist can also help patient to follow appropriate care plan
by eliminating risk of hypoglycaemia development. There should be cooperation between the
healthcare professional and specialist healthcare professional (Conley et al., 2014).
There should be regular communication among these members of IDT. IDT need to be
implemented in the people with low and middle class economic class people (Lall &
Prabhakaran, 2014). IDT can be helpful in the minimizing health risk to the adult patient
through assessment, intervention and surveillance. Problems can be identified in the earlier
stage and effective intervention can be implemented in the effective manner.
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Policies, procedures, tools and training for diabetes control :
National Institute for Health and Care Excellence (NICE) policies need to be implemented
for elimination of the unnecessary obstacles and provide safe and effective diabetes care to
the adult patients. Timely action need to be taken for the management of diabetes. Access of
the adult diabetic patients need to be improved for getting better education for the
management of diabetes. Diabetes people need to stay healthy and adapt healthy habits and
behaviours which can be helpful in lifestyle change and improved management of chronic
diabetic conditions in the older age. Diabetes education and management services need to be
provided by the healthcare staff according to their clinical expertise to the diabetic patient.
Policies need to be implemented for adapting updated clinical practice guidelines. Gaps and
needs of the community need to be identified and diabetes education need to be given with
respect to needs of the community and gaps need to be filled (Bloomfield et al., 2015).
Care need to be provided to the diabetes patients at three levels like national, local and
individual level. National organisations and policy makers need to implement national
guideline and policies of NICE, partnerships need to be developed for delivering healthcare
services, develop national workforce strategy, develop leadership from colleges and
universities, develop national framework, develop and implement national incentive
framework like General Practitioner contract and incentive (Haw et al., 2015). At local level,
whole system approach need to be implemented to provide care in terms of more than
medicines. Local guidelines and agreements need to be implemented for cross sector
working, develop stering group to oversee all the operations, develop local workforce and
training strategy, develop multidisciplinary team, develop local clinical leadership, develop
local financial framework, develop and implement local incentives and procurements like
insurance policies and coordinated procurement of medicines. At personal level care need to
be given to provide care by considering needs and requirements of the patients and work in
collaboration with the local authorities to implement required strategies. Details of the
population need to be collected, consultation skills need to be developed in healthcare
professionals, integrated muti-disciplinary team need to be recruited, education need to be
provided according to the needs pf the patient and emotional and psychological support need
to be given (Haw et al., 2015).
Diabetes management can be effectively implemented by applying different tools like
diabetes medical management plan, individualised healthcare plan and emergency care plan
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hyperglycaemia and hypoglycaemia. Diabetes medical management plan should be compiled
by healthcare team and it should contain medical orders which are basis of healthcare and
education needs. In individualised healthcare plans patient’s needs and requirements need to
be considered. Emergency care plans for hypoglycemia and hyperglycemia need to provide
training for identification of the hypoglycemia and hyperglycemia and strategies to control it.
Self-management education and patient-centred care, lifestyle strategies management
including diet and physical activity management and medical therapy with individualised
glycaemic goals need to be given for providing holistic care to the diabetes adults. Evidence
based lifestyle strategies need to be implemented by providing interventions for behaviour
change through counselling and motivational interview. It cab be helpful in improving health
belief of the patient in medication, identifying and overcoming barriers for healthcare access
and prioritising strategies to overcome risk factors. Adult patients need to be educated and
trained for the self-management of the blood sugar level. These patients need to be educated
for use of glucose strips and monitoring of both hyperglycaemia and hypoglycaemia.
Education need to be given to the adult diabetes patients about the healthy diet (Ofori &
Unachukwu, 2014).
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