Diabetes mellitus

In Germany around 10m people are sick with diabetes. 7m are being treated for it, the other 3m are not even aware they have the disease, or they have not yet been tested for it. There are four key signs which may indicate the impending onset of diabetes and which physicians call metabolic syndrome, or, more graphically, “the deadly foursome”.

The deadly foursome consists of hypertension, impaired fat metabolism, visceral obesity (apple-shaped obesity) and impaired sugar metabolism. The main problem here is the abdominal fat that is located between the intestinal loops and the liver. The markedly increased blood sugar levels in type-2 diabetics are the consequence of insulin resistance which is caused by this abdominal fat.

Type-1 diabetes is different in that it is characterised by a progressive destruction of the insulin-producing beta cells in the pancreas and occurs at an early age. Affected children and adolescents have markedly increased blood sugar levels that may cause severe ketoacidosis which can result in a coma.

Large studies have proven that a change in lifestyle can prevent diabetes. Dropping 5 – 10 % of your original weight, 4 hours of exercise per week, and a change in diet (fewer fats and more wholemeal products) will restore the cells’ insulin sensitivity and thus reduce your risk of developing diabetes.
Only about 25 % of the people with a predisposition for diabetes do not succeed in completely eliminating their risk of getting diabetes with the above measures. And there is no preventive pill.

In type 1 diabetes, it is not excessive weight and insulin resistance that causes diabetes, but the fact that the body’s dysfunctioning immune system produces antibodies which attack the insulin producing pancreatic cells.

Please use the diabetes questionnaire to assess your own diabetes risk. If your score is higher than 12 points, you should take preventive action immediately. A score of more than 15 or 20 points indicates that you are at an acute risk of developing diabetes.

The figure of 3m of as yet undiagnosed diabetics shows that symptoms are almost imperceptible in the early stages of diabetes. Markedly elevated blood sugar levels result in a loss of concentration and increasing dehydration due to frequent urination. The blood sugar is being excreted in the urine, which makes the urine taste sweet. Sometimes, high blood sugar levels accompanied by frequent urination at night are a symptom for diabetes. Due to insulin deficiency, type-1 diabetics may quickly develop ketoacidosis (DKA = diabetic ketoacidosis) characterised by symptoms such as lethargy and even coma. In the absence of such symptoms, diabetes is often diagnosed as a result of the secondary disorders it causes, eg stroke or myocardial infarction (heart attack).

The most reliable method to diagnose diabetes are measuring the fasting blood sugar or making a glucose tolerance test. Any 2-hour samples showing blood sugar levels above 200 clearly indicate the presence of diabetes. Any 2-hour samples showing levels ranging from 140 to 200 mg/dL indicate an impaired glucose tolerance, which is called prediabetes.
In order to manage a diabetic’s glucose metabolism, the long-term serum glucose concentration, the HbA1c level, is measured. It should be taken every three months, and levels should not exceed 6.5 in diabetics with good blood sugar control. Other methods to measure insulin resistance are the HOMA index and the proinsulin index.

There are three pillars to the therapy of type-2 diabetes:
1. Exercise therapy
2. Food therapy and a change in diet
3. Drug therapy, including insulin injections.

Among the many anti-diabetic drugs available for treatment Metformin has been known and proven effective for years. It is the basic therapy for overweight diabetics because it effectively reduces insulin resistance.

Other anti-diabetic drugs that have been in use for years are so-called sulfonyl ureas. This class of drugs induces the pancreatic beta cells to secrete more insulin. Then there a so-called insulin sensitisers. Two known insulin sensitisers are rosiglitazone and pioglitazone. Both drugs are designed to increase the body’s insulin sensitivity and thus lower the blood sugar levels. Since May this year two new anti-diabetic drugs have been available on the German market. These drugs are the first ones to act on the incretin system, a group of hormones that are produced in the intestines during meals.

These new drugs lower blood sugar levels specific to the type of food eaten. In most type-2 diabetics, the pancreatic insulin production fails 3-5 years after onset of the disease so that anti-diabetic drug therapy is no longer sufficient and they need insulin therapy instead. In Germany, there are currently 1.9m diabetics who need to inject insulin.

Thanks to modern injection devices and ultra-short action insulins that can be injected immediately before meals, most diabetics can lead a completely normal life. Especially type-1 diabetics depend on insulin injections from the very beginning. Their insulin therapy today is more rigorous than in previous times. The patient injects a long-acting basal insulin and a so-called short-acting food insulin immediately before each meal. Many examples show that diabetics can do sports and even run a marathon. The expression “healthy as a diabetic” is not a hollow phrase, and a good diabetes disease management prevents many secondary diseases which diabetes can cause.

Diabetes significantly increases the risk of suffering a myocardial infarction, stroke and progressive kidney damage. More than 50 % of all dialysis patients today are diabetics. Diabetic neuropathy (nerve damage) caused by poor blood circulation in the peripheral nerves does not only cause pain and discomfort, it can lead to diabetic foot syndrome. In Germany alone up to 20,000 leg amputations go down to diabetic foot syndrome. These amputations could have been avoided with systematic blood
sugar control, thorough wound care, and multi-disciplinary disease management involving diabetologists, surgeons, podologists, angiologists.

Due to the rather high cardiovascular mortality rates (= increased probability of suffering a heart attack) anti-diabetic treatment cannot afford to focus only on blood sugar control but has to manage other risk factors such as cholesterol and hypertension. The necessary medical check-ups follow the guidelines of the “Blauer Diabetespass” (Blue Diabetes Passport) issued by the “Deutsche Diabetes Gesellschaft” (German Diabetes Association) and include check-ups of metabolic parameters, blood pressure and body weight every three months as well as a comprehensive evaluation of the vascular status and fundus of the eye once every year.