SUGAR DIABETES (syn.: Sugar disease, diabetes mellitus) is an endocrine disease caused by a deficiency of the hormone insulin in the body or its low biological activity; characterized by a violation of all types of metabolism, damage to large and small blood vessels and manifests itself as hyperglycemia. Diabetes is the most common endocrine pathology: in most countries of the world, approximately 3% of the population suffers from it. In the development of the disease, a hereditary predisposition and exposure to adverse environmental factors play a significant role.
Insulin is formed in the beta cells of the islets of Langerhans of the pancreas in the form of a precursor - proinsulin, which has practically no hormonal activity. Under the action of a specific proteolytic enzyme, C-peptide is cleaved from proinsulin, resulting in the formation of an active insulin molecule. Violation of the process of conversion of proinsulin to insulin is one of the mechanisms for the development of diabetes.
There are insulin-dependent (type I) and non-insulin-dependent (type II) diabetes mellitus. Type I diabetes mellitus is relatively rare (children and adolescents are more likely to suffer from it), since its occurrence is associated with genetically determined autoimmune destruction of beta cells and a decrease in insulin production on this soil. Type II diabetes affects up to 85% of all patients with diabetes mellitus, mainly people over 50 years old (especially women). Overweight patients are characterized by this type of diabetes: over 70% of these patients are obese. Hyperglycemia in type II diabetes mellitus occurs due to dysregulation of insulin secretion depending on the level of glucose, as well as due to a decrease in its biological activity. In addition, diabetes mellitus arising from a number of diseases and pathological conditions, for example, with Itsenko-Cushing's disease, diffuse toxic goiter, pheochromocytoma, acromegaly. Pancreatitis and some other diseases of the pancreas can lead to diabetes; a number of hereditary diseases are accompanied by diabetes. Long-term and uncontrolled intake of high-dose corticosteroids, hormonal contraceptives and diuretics can cause diabetes.
The group of people who have a significant risk of developing diabetes, for example, includes people in whom both parents have diabetes; identical twin of a patient with diabetes; women; in which during pregnancy a violation of tolerance (resistance) to glucose was detected or who gave birth to a child weighing (at birth) more than 4500 g.
Severe diabetes is preceded by a period of impaired glucose tolerance, during which there are no clinical signs of it, the fasting blood glucose concentration is normal, however, an glucose tolerance test reveals an excessive (compared to normal) increase in its blood concentration after 1-2 hours after glucose loading. The test is carried out on an empty stomach: take blood for sugar, then give a glass of water in which 75 g of glucose is dissolved, then after 30 minutes, 1 and 2 hours, the blood glucose is determined. Normal glucose is less than 5.5 mmol / L on an empty stomach and 11.1 mmol / L 2 hours after exercise. It has been established that diabetes mellitus develops in 9 - 10% of individuals with impaired glucose tolerance, which is ascertained with glycemia of 7.8-11.1 mmol / l 2 hours after exercise.
The clinical manifestations of the disease are determined by the degree of insulin deficiency. Symptoms include thirst (polydipsia), dry mouth, weight loss (or obesity), weakness, and increased urine output (polyuria). The amount of urine allocated per day to patients can reach 6 liters or more. There is a significant decrease in performance.
In the mild course of the disease, the clinical picture of diabetes is not pronounced; diabetic retinopathy can only be detected using sensitive specific methods. Compensation is achieved by diet, without drug treatment.
With moderate diabetes, ketoacidosis is very rare (sometimes it develops after severe stress or a sharp diet violation); diabetic retinopathy is diagnosed by examination of the fundus, but it does not affect the function of vision; damage to the small vessels of the kidneys develops (microangionephropathy), which at this stage of the disease rarely affects kidney function. Compensation is achieved by prescribing sugar-lowering (antidiabetic) drugs or insulin, usually at a dose of up to 60 units per day.
In severe cases of the disease, ketoacidosis often develops, up to a kstoacidotic coma. Severe diabetic retinopathy leads to impaired vision function, microangionephropathy - to renal failure. Compensation is often impossible, the used doses of insulin often exceed 60 PIECES a day.
With decompensation of diabetes mellitus in patients, increased thirst, polyuria, dry skin, slow healing of wounds, and a tendency to pustular and fungal skin diseases are noted. Gingivitis and periodontitis are often observed. Muscular atrophy associated with diabetic polyneuropathy and circulatory disorder develops. Metabolic disorders can contribute to osteoporosis and osteolysis. With a long course of the disease, sexual dysfunction often develops: impotence in men and menstrual irregularities in women.
The defeat of large blood vessels (macroangiopathy) in decompensated diabetes mellitus is expressed in progressive atherosclerosis of large arteries, chronic coronary heart disease, obliterating atherosclerosis of the vessels of the lower extremities, atherosclerosis of the vessels of the brain, etc. Blood circulation of the lower extremities is especially disturbed, one of the first symptom of this process is one of the first symptom intermittent claudication. Diabetic retinopathy
accompanied by a decrease in visual acuity, sometimes up to complete blindness, microangionephropathy leads to acute renal failure. Patients with diabetes mellitus often develop cataracts , glaucoma often occurs.
The diagnosis of diabetes mellitus in the presence of fasting hyperglycemia, glucosuria and the corresponding clinical symptoms is beyond doubt. However, in practice, there are often situations when, for the diagnosis of diabetes, it is necessary to conduct a test with a load of glucose.
Treatment of diabetes is aimed at eliminating metabolic disorders caused by insulin deficiency (primarily for the correction of hyperglycemia), preventing diabetic coma and eliminating the complications of diabetes - primarily blood vessel damage. Depending on the type of diabetes mellitus, patients are prescribed insulin or oral administration of drugs that have a hypoglycemic effect. Patients should follow a diet, the qualitative and quantitative composition of which also depends on the type of diabetes. For about 20% of patients with type II diabetes mellitus, the diet is the only and quite sufficient method of treatment to achieve compensation. In patients with type I diabetes, especially in obesity, therapeutic nutrition should be aimed at eliminating excess body weight. . After its normalization or decrease, the need for the use of sugar-lowering drugs decreases and sometimes completely disappears.
The ratio of proteins, fats and carbohydrates in the diet of a patient with diabetes should be physiological. It is necessary that the proportion of proteins is 16 - 20%, carbohydrates - 50 - 60%, fats - 24 - 30%. The diet is calculated on the basis of the so-called ideal, or optimal, body weight, taking into account the growth and nature of the work performed by the patient, as well as the type of diabetes. With type I diabetes, the energy intake should correspond to its consumption, with type II diabetes, the diet should be low in calories. So, if, when doing light physical work, the body needs to get 30 - 40 kcal per 1 kg of ideal weight, then with an actual body weight of 70 kg, an average of 35 kcal per 1 kg is needed, i.e. 2500 kcal. Knowing the content of nutrients in food products, it is possible to calculate the number of kilocalories per unit mass of each of them.
The regimen of fractional nutrition is recommended (eating 5-6 times a day). Patients are prohibited from sugar, sweets, preserves, honey and other sweets, fruits rich in easily digestible carbohydrates (grapes, persimmons, figs, melons), spices, and alcohol. Sugar substitutes (sorbitol, xylitol, etc.) can be included in the diet in an amount of not more than 25-30 g per day. Depending on the type of diabetes and the patient’s body weight, the consumption of bread is from 100 to 400 g, flour products - up to 60 - 90 g per day. Potatoes are limited to 200 - 300 g per day, animal fats (butter, lard, pork fat) to 30 - 40 g, they are recommended to be replaced with vegetable oils or margarines. Vegetables - white cabbage, cucumbers, lettuce, tomatoes, zucchini are practically unlimited. The use of beets, carrots, apples and other unsweetened fruits should not exceed 300 - 400 g per day. Low-fat meats and fish should be included in the daily diet in an amount of not more than 200 g, milk and dairy products - not more than 500 g, cottage cheese - 150 g. A moderate (up to 6-10 g) restriction of table salt is necessary. The daily diet of patients should contain a sufficient amount of vitamins, in particular vitamins A, C, B vitamins. The nature of the culinary processing of products is equally important, which should also be carried out taking into account concomitant diseases, for example, cholecystitis, gastritis, peptic ulcer.
Non-observance of a patient’s diet leads to an aggravation of the condition. Therefore, the most important task of medical workers is to monitor the proper nutrition of a patient with diabetes. Such control is simplified by using special meters of balanced nutrition, which the patient himself can use.
Insulin treatment is given to all patients with type I diabetes. In type II diabetes, indications for insulin are the lack of effect of the use of sugar-lowering drugs, ketoacidosis and a precomatous state, prolonged infectious diseases (tuberculosis, chronic pyelonephritis), as well as liver and kidney failure .
The doctor prescribes insulin, insulin therapy is carried out under the control of glucose in blood and urine. Insulin preparations by the nature and duration of action are divided into three main groups: drugs of short, intermediate and prolonged (prolonged) action. When the patient receives one injection of insulin per day, it is necessary to combine insulin preparations of various durations of action. However, the use of long-acting insulin preparations does not always make it possible to compensate for diabetes. Therefore, often patients with type I diabetes mellitus require fractional administration of simple insulin 3-4 times a day or two subcutaneous injections of an intermediate insulin preparation before breakfast and dinner in combination with a short-acting insulin preparation.
The most common complications of insulin therapy include hypoglycemic conditions that occur during the period of maximum insulin action in those cases when the patient does not follow a diet or is experiencing increased physical activity. One of the complications of insulin therapy is an allergy to insulin , in which the patient must be hospitalized for treatment in a specialized endocrinological department. Allergic reactions can be local (redness, pain and swelling at the injection site of insulin) and general, characterized by varying degrees of severity, up to anaphylactic shock (see Anaphylaxis). Another complication of insulin therapy - lipodystrophy - is manifested by the formation of “dips” or “pits” at the injection sites of insulin, which requires special treatment.
Sugar-lowering drugs are used orally for type II diabetes mellitus and diet therapy inefficiency. These include sulfonylureas, which stimulate insulin secretion by pancreatic islet cells and promote glucose uptake by tissues, and biguanides, which reduce intestinal glucose uptake and promote peripheral tissue uptake. Derivatives of sulfanylureas are used - bukarban , chlorpropamide , glibenclamide (maninyl), glurenorm. Treatment begins with minimal doses of drugs, the dose is gradually increased to stabilize the level of glucose in the blood at an acceptable level (not higher than 8 mmol / l). The use of these drugs requires constant monitoring of the concentration of glucose in the blood, since they can cause severe hypoglycemic conditions, up to a hypoglycemic coma. Biguanides are prescribed less frequently. This is due to the fact that they can cause an increase in the content of lactic acid in the blood and lead to a serious complication - lactic acidosis in patients older than 60 years old, in patients with renal and hepatic insufficiency, as well as in chronic infections, etc., i.e. in all those cases when a deficiency in the supply of oxygen to tissues can occur. Therefore, treatment with biguanides (adebit, etc.) is advisable for type II diabetes mellitus in relatively young patients with severe obesity.
An important role is played by training the patient in basic techniques for monitoring his condition. It is necessary that the patient’s family members have an idea about this disease, and if necessary (development of a coma or precomatosis state) can help the patient.
The prognosis for well-organized treatment and observation of the patient is favorable for life. "In the presence of vascular lesions of the kidneys and eyes, the prognosis is unfavorable for work and serious for life. All patients with diabetes mellitus are under constant observation by an endocrinologist.
Ketoacidotic diabetic coma occurs with acute insulin deficiency and the associated sharp decrease in glucose use by the body, increased formation of ketone bodies and their accumulation in the blood. The cause of decompensation of diabetes can be an unreasonable decrease or cancellation of hypoglycemic agents, dietary disorders, infection, intoxication. The concentration of glucose in the blood rises to 27.8-38.9 mmol / l (500-700 mg / 100 ml) or more. Pronounced glucosuria is detected; the release of large amounts of fluid leads to dehydration, which is manifested by dry skin and mucous membranes, hypotension, tachycardia. With urine, a lot of sodium, potassium, phosphorus and other mineral substances are excreted from the body, which leads to an imbalance in the balance of electrolytes and mineral metabolism in general. A shift in the acid-base balance to the acid side (acidosis) is observed; the associated severe intoxication and dysfunction of the central nervous system are the main causes of diabetic coma.
Diabetic coma develops gradually, it is preceded by the appearance of general weakness, lethargy, loss of appetite, the occurrence of intense thirst, polyuria , headache , nausea , often vomiting , abdominal pain. If you do not take the necessary measures, these phenomena increase, patients become apathetic, a strong smell of acetone is felt in the exhaled air, the skin and visible mucous membranes become dry, the tongue is covered with a grayish-white coating. The pulse rate increases, blood pressure begins to decline. The abdomen is painful on palpation, there are no symptoms of peritoneal irritation. With the progression of the pathological process, patients fall into a soporous state (they do not respond to verbal treatment, only reactions to pain stimuli remain). With the growth of coma, consciousness and reaction to any stimuli completely disappear. Signs of ketoacidotic diabetic coma and hypoglycemic coma are shown in the table.
Hypoglycemic coma occurs as a result of a sharp decrease in blood sugar (hypoglycemia) and is more often caused by a violation of the diet, increased physical activity or an overdose of insulin. A rapid decrease in the concentration of glucose in the blood is clinically expressed in the appearance of profuse sweat, trembling of the limbs, feelings of hunger, anxiety, irritability, unmotivated behavior, convulsions, and loss of consciousness. It usually develops with a decrease in the concentration of glucose in the blood to 3.3 mmol / L (below 60 mg / 100 ml).