DIABETES (. Syn: diabetes, sugar diabetes) - endocrine disorder caused by lack of the hormone insulin in the body or its low biological activity; characterized by the violation of all types of metabolism, the defeat of the large and small blood vessels, and is manifested by hyperglycemia. Diabetes - the most common endocrine pathology: in most countries they are sick of about 3% of the population. In the development of the disease play an important role genetic predisposition and exposure to environmental factors.
Insulin is produced in beta cells of the pancreatic islets of Langerhans as a precursor - proinsulin, which has virtually no hormonal activity. Under the action of specific proteolytic enzyme is cleaved from the proinsulin C-peptide, thereby forming the active insulin molecule. Violation of the transformation process of proinsulin into insulin is one of the mechanisms of diabetes.
There are insulin-dependent (Type I) and non-insulin dependent (Type II) diabetes mellitus. Diabetes mellitus type I is relatively rare (often it affects children and teenagers), as it has been associated with genetically caused by autoimmune destruction of the beta cells and the reduction on this basis insulin. Type II diabetes affects up to 85% of all patients with diabetes, especially those over 50 years of age (especially women). For patients with this type of diabetes is characterized by excess body weight more than 70% of these patients are obese. Hyperglycemia in diabetes mellitus type II is caused by dysregulation of insulin secretion depending on the blood glucose levels as well as in connection with a reduction in its biological activity. In addition, allocate diabetes, occurs when a number of diseases and pathological conditions, such as pituitary -Kushinga, diffuse toxic goiter, pheochromocytoma, acromegaly. It can cause diabetes pancreatitis and some other diseases of the pancreas; a number of hereditary diseases accompanied by diabetes. Call diabetes can long and uncontrolled intake of drugs in high doses of corticosteroids, hormonal contraceptives and diuretics.
The group of persons having a valid risk of diabetes, includes, for example, people who have both parents have diabetes; Identical twins patient with diabetes mellitus; women; who during pregnancy to detect violations of tolerance (sustainability) glucose or weight (at birth), given birth more than 4500 g
Expressed period precedes diabetes impaired glucose tolerance, in which it no clinical signs in fasting blood glucose concentration is correct, but when a sample glucose tolerance is detected excessive (above normal) increasing its concentration in blood in 1-2 hours after the glucose load. Fasting sample performed: taking blood sugar, then allowed to drink a glass of water in which is dissolved 75 g of glucose, and then after 30 minutes, 1 hour and 2 determine blood glucose. Normal glucose is less than 5.5 mmmol / l fasting and 11.1 mmol / L 2 hours after the load. It was found that diabetes develops in 9 - 10% of people with impaired glucose tolerance, which states when glucose 7,8-11,1 mmol / L 2 hours after the load.
The clinical manifestations of the disease are determined by the degree of insulin deficiency. The characteristic symptoms are thirst (polydipsia), dry mouth, weight loss (or obesity), weakness, and increased excretion of urine (polyuria). The amount of urine per day selected patients may be 6 liters or more. There has been a significant decrease in performance.
In less severe disease clinical picture of diabetes expressed mild; Diabetic retinopathy can only be detected using sensitive methods specific. Compensation is achieved by diet, without medication.
In diabetes, the average severity of ketoacidosis say very rarely (sometimes develops after severe stress or abrupt diet violations); diabetic retinopathy is diagnosed by fundus examination, however, a function of view, it has no effect; developing kidney damage small blood vessels (mikroangionefropatiya), which at this stage of the disease rarely affects kidney function. Compensation is achieved by the appointment saharoponizhayuschih (antidiabetic) drugs or insulin are usually at a dose of 60 units per day.
In severe disease often develops ketoacidosis, coma until kstoatsidoticheskoy. Severe diabetic retinopathy leads to dysfunction of view, mikroangionefropatiya - kidney failure. Compensation is often not possible, the dose of insulin used often exceed 60 units per day.
When decompensation of diabetes in patients noted increased thirst, polyuria, dry skin, slow wound healing, susceptibility to fungal and pustular skin diseases. Often there are gingivitis and periodontitis . Develops muscular atrophy associated with diabetic neuropathy and circulatory disorder. Metabolic disorders may contribute to osteoporosis and osteolysis. With long-term course of the disease often develop sexual dysfunction: impotence in men and menstrual irregularities in women.
The defeat of the large blood vessels (macroangiopathy) with decompensated diabetes is expressed in progressive atherosclerosis of large arteries, chronic ischemic heart disease, obliterating atherosclerosis of the lower extremities, cerebrovascular and other. Very often blood circulation of the lower limbs, one of the first symptoms of this process is intermittent claudication. Diabetic retinopathy
accompanied by a decrease in visual acuity, and sometimes even blindness, mikroangionefropatiya leads to acute renal failure. In patients with diabetes more likely to develop cataracts , often a glaucoma .
The diagnosis of diabetes in the presence of fasting hyperglycemia, glycosuria and clinical symptoms is not in doubt. However, in practice there are often situations where for diagnosing diabetes is necessary to load the sample with glucose.
The treatment of diabetes is aimed at eliminating the metabolic disorders caused by insulin insufficiency (primarily at correcting hyperglycemia), diabetes prevention and elimination com diabetic complications - primarily vascular lesions. Depending on the type of diabetes patients administered insulin preparations or ingestion, having hypoglycemic action. Patients should follow a diet, qualitative and quantitative composition of which also depends on the type of diabetes. Approximately 20% of patients with type II diabetes diet is the only one and it is sufficient to achieve the compensation of treatment method. In patients with type I diabetes, particularly in obesity, nutritional therapy should be directed at eliminating excess body weight. . After its normalization or reduction reduces and sometimes completely eliminates the need for a sugar-reducing drugs.
The ratio of proteins, fats and carbohydrates in the diet of patients with diabetes should be physiological. It is necessary that the proportion of protein was 16 - 20%, carbohydrate - 50 - 60% fat - 24 - 30%. The ration is calculated from the so-called ideal, or optimum, body weight, given the nature of the growth, and ill work and the type of diabetes. In diabetes type I energy intake must match its consumption in type II diabetes diet should be low-calorie. Thus, if performing work light physical body needs to obtain 30 - 40 kcal per 1 kg ideal weight, the actual body weight at 70 kg must be an average of 35 kcal per 1 kg and 2500 kcal ie... Knowing the content of nutrient in food, we can calculate the number of calories per unit weight of each.
Recommended fractional diet (eating 5 - 6 times a day). Patients forbid sugar, candy, jam, honey and other sweets, fruits rich in carbohydrate (grapes, persimmons, figs, melons), spices, and alcohol intake. Sweeteners (. 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 the patient's body weight and the consumption of bread is 100 to 400 g, pastry - 60 - 90 g per day. Potatoes are limited to 200 - 300 g per day, animal fats (butter, lard, lard) 30 - 40 grams, they are recommended to be replaced with vegetable oils or margarines. Vegetables - cabbage, cucumbers, lettuce, tomatoes, zucchini practically not limited. Use beets, carrots, apples and other fruits savory should not exceed 300 - 400 g per day. Lean meat, fish should be included in the daily diet in an amount of not more than 200 grams, milk and dairy products - not more than 500 g, cottage cheese - 150 g should be moderate (6-10 g) the restriction of salt. Daily diet of patients must contain a sufficient amount of vitamins, particularly vitamins A, C, B vitamins No less important is the nature of the culinary processing of products, which also shall be subject to co-morbidities, such as cholecystitis, gastritis, peptic ulcer disease.
The most common condition leading to the weighting of non-compliance patients diet, therefore the most important task of health workers is to monitor the proper nutrition of the patient with diabetes. Such control is simplified by using special counters nutrition, which can use the patient himself.
Insulin treatment is carried out in all patients with diabetes mellitus type I. In diabetes type II Indications for insulin are the lack of effect of the sugar-reducing drugs, ketoacidosis and prekomatosnoe state, long infectious diseases (tuberculosis, chronic pyelonephritis), as well as liver and kidney failure .
Insulin is prescribed by the physician, insulin therapy is performed under the control of glucose in the blood and urine. Insulin preparations on the nature and duration of action are divided into three main groups: Preparations short, intermediate and extended (extended) action. When a patient receives an injection of insulin per day, it is necessary to combine different insulin products the duration of action. However, the use of insulin preparations of prolonged action is not always possible to achieve compensation of diabetes. So often patients type I diabetes need insulin fractional introduction of a simple 3 - 4 times a day or in two subcutaneous injections of intermediate-acting insulin before breakfast and dinner in conjunction with the preparation of short-acting insulin.
The most common complications of insulin therapy are hypoglycemic conditions arising in the period of maximum insulin action in cases where the patient does not keep to a diet or experiencing increased physical activity. One of the complications of insulin therapy is allergic to insulin, in which the patient has to be hospitalized for treatment in specialized endocrinology department. Allergic reactions may be local (redness, pain and swelling at the site of insulin) and general characterized by varying degrees of severity up to anaphylactic shock (see. Anaphylaxis). Another complication of insulin therapy - lipodystrophy - manifested form "gaps" or "holes" in the field of insulin injections, which require special treatment.
Hypoglycemic drugs administered orally in diabetes mellitus type II and poor diet. These include sulfonylureas that stimulate insulin secretion of pancreatic islet cells and tissues promoting absorption of glucose and biguanides which reduce the absorption of glucose in the intestines and promoting its assimilation by peripheral tissues. Use sulfonylurea derivatives - bucarban, chlorpropamide, glibenclamide (maninil) glyurenorm. Treatment started with a minimum dosage of drugs, the dose is gradually increased until the stabilization of blood glucose level to an acceptable level (not higher than 8 mmol / l). The use of these agents requires continuous monitoring of the concentration of glucose in blood, as they can cause severe hypoglycemic condition until hypoglycemic coma. Biguanides administered less frequently. This is due to the fact that they may be responsible for elevated levels of lactic acid in the blood and lead to severe complications - lactic acidosis in patients older than 60 years, in patients with renal and hepatic failure, as well as chronic infections, etc., ie. in all those cases where there may be a shortage in the supply of oxygen to tissues. Therefore, treatment biguanides (Adeb et al.) It is advisable for patients with diabetes type II in relatively young patients with severe obesity.
An important role is played by the patient learning the basic techniques of control over their condition. It is essential that the patient and family members have an idea about this disease, may if necessary (the development of a coma or prekomatosnoe state) to help the patient.
Forecast at a well-organized treatment and monitoring of patients for life-friendly. "In the presence of vascular lesions of the kidneys and eyes prognosis is unfavorable for employment and for life is serious. All patients with diabetes are at a constant dispensary observation at the endocrinologist.
Ketoatsidoticheskaya diabetic coma occurs in acute insulin deficiency and its associated sharp decline in the use of glucose by the body, increasing the formation of ketone bodies and their accumulation in the blood. The cause of diabetes decompensation may be unjustified reduction or elimination of hypoglycemic agents, violations of diet, joining infections, intoxication. The concentration of glucose in the blood rises to 27,8-38,9 mmol / L (500-700 mg / 100 ml) or more. Detected pronounced glycosuria; the allocation of large amounts of fluids leads to dehydration, which is manifested by dryness of the skin and mucous membranes, hypotension, tachycardia. The urine excreted displayed much sodium, potassium, phosphorus and other minerals, which leads to an imbalance of electrolytes and mineral metabolism in general. There is a shift in the acid-base balance in the acid side (acidosis); the associated severe intoxication and violation 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 emergence of strong thirst, polyuria , headache , nausea , sometimes vomiting , abdominal pain. If you do not take the necessary measures, these phenomena increase, patients become lethargic, breath there is a strong smell of acetone, the skin and visible mucous membranes become dry, the tongue is covered with a grayish-white bloom. The pulse quickens, blood pressure starts to drop. The stomach tenderness, symptoms of irritation of peritoneum absent. With the progression of patients fall into the pathological process in soporous state (unresponsive to verbal appeal only saved reactions to painful stimuli). With an increase in coma completely disappear consciousness and response to any stimuli. Symptoms ketoatsidoticheskaya diabetic hypoglycemic coma and coma are shown in the table.
Hypoglycemic coma is the result of a sharp decline in blood sugar levels (hypoglycemia) and more frequently due to the violation of diet, exercise, or enhanced insulin overdose. The rapid decrease in the concentration of glucose in the blood is clinically manifested in the appearance of the patient profuse sweat, trembling limbs, hunger, anxiety, irritability, unmotivated behavior, seizures, loss of consciousness is possible. Typically develops in reducing blood glucose concentration to 3.3 mmol / l (below 60 mg / 100 ml).