Diabetes

Glucose is the most basic energy source our body uses. The concentration of glucose in the blood is called “blood sugar,” which is maintained at a constant level by two substances, the insulin and glucagon produced by the pancreas.

Two hormones that regulate blood sugar

1) Insulin

Produced from beta (β) cells on the island of Langerhans in the pancreas
Serves to lower blood sugar

2) Glucagon

Produced from alpha (α) cells on the island of Langerhans in the pancreas
It plays a role to raise blood sugar

Diabetes is a metabolic disorder characterized by hyperglycemia caused by the secretion or dysfunction of insulin, which is necessary for blood sugar control in the body. Chronic hyperglycemia caused by diabetes leads to damage and dysfunction of each organ. In particular, it causes microvascular complications in the retina, kidney and nerves, and giant vascular complications such as arteriosclerosis, cardiovascular and cerebrovascular diseases, and mortality. To increase. Studies on the incidence and course of diabetes have shown that a thorough control of blood sugar can reduce the incidence of complications and prevent diabetes by weight loss or medication.

Prediabetes

High blood sugar is an abnormally high blood sugar level. Even if it is normal, blood sugar rises temporarily after a meal, but an increase in blood sugar levels outside the normal allowable range may increase your chances of already having diabetes or progressing to diabetes in the future.

In the pre-diabetes stage, blood sugar level is higher than normal, but it does not meet the diagnosis criteria of diabetes and can be classified into fasting glucose disorder and impaired glucose tolerance.

Fasting Glucose Disorders: Glucose levels measured after 8 hours of fasting are higher than normal but lower than the standard for diabetic diagnosis (100-125mg / dL)
Impaired glucose tolerance: 2 hours after oral glucose intake after fasting, blood sugar level is higher than normal range but lower than diabetic criteria (140-200mg / dL)

The risk of developing diabetes for people with normal blood sugar is about 0.7% a year, but people who have impaired fasting glucose or impaired glucose tolerance are as high as 5-10%. In the prediabetes stage, the transition to diabetes is about 10 times higher than in normal people, and the incidence of cardiovascular disease is doubled.

If screening results are normal, retests are performed at least every three years, and prediabetes or patients diagnosed with diabetes are additionally tested for risk factors associated with cardiovascular disease and appropriate action.

Risk Factors and Prevention Methods in Prediabetes

According to the 2009 American Diabetes Association (ADA), lifestyle corrections such as weight loss of 5-10% and moderate exercise of at least 150 minutes per week in patients with impaired fasting glucose, impaired glucose tolerance, or 5.7-6.4% of glycated hemoglobin It is recommended to be treated.

If: 1) under 60 years old, 2) obesity (BMI≥35 kg / ㎡, 3) complex blood glucose disorders (fasting glucose disorders / impaired glucose tolerance) and other risk factors (HbA1c > 6%, hypertension, decreased HDL cholesterol, high neutrality) If you have at least one of them, it is recommended to treat lifestyle correction and medication together.

Symptoms

When the blood sugar rises, the urine escapes the sugar. At this time, the glucose draws a lot of water, so you get a lot of urine. Therefore, lack of water in the body is thirsty and drink a lot of water. In addition, the food we eat can’t be used as energy because it escapes into the urine, and the feeling of hunger becomes worse and we try to eat more and more.

Diabetes has several symptoms. However, diabetes can be asymptomatic, so you may not know you are diabetic and may be diagnosed later.

Diagnoses

1. Types

Diabetes is classified according to the physiological and clinical characteristics of the condition. Most cases belong to type 1 diabetes and type 2 diabetes, and other diabetes mellitus and gestational diabetes.

Type 1 diabetes mellitus: occurs mainly in children, but can also occur in adults Acute onset, severe symptoms, followed by symptoms such as polyuria, weight loss, and ketoacidosis due to absolute deficiency of insulin. Insulin therapy is essential to control hyperglycemia and prevent death from ketoacidosis.

2) Type 2 Diabetes: Depending on the weight of the body is divided into two types of obesity and obesity. Increasing standard of living results in excessive calorie intake or relatively reduced exercise and exposure to high stress, which leads to a decrease in insulin’s ability to develop diabetes. Most often after age 40, more than half of people are overweight or obese. Compared to type 1 diabetes, the clinical symptoms are less pronounced and tend to be familial.In other cases, weight loss and muscle growth can be improved initially by diet and exercise therapy without causing acute complications such as ketoacidosis. a lot.

3) Other Diabetes: Pancreatic disease, endocrine diseases, certain drugs, chemicals, insulin or insulin receptor abnormalities, and genetic syndromes can cause secondary diabetes.

4) Gestational Diabetes: refers to glucose control abnormalities that were first discovered during pregnancy or occurred at the beginning of pregnancy, and are distinct from diabetes diagnosed before pregnancy. 2-3% of pregnant women develop, most of them normalize after childbirth. However, during pregnancy, if the degree of blood sugar control is outside the normal range, the fetal mortality rate and the morbidity of hearing deformity are high. If you have a family history of diabetes, or have calving births that gave birth to giant, deformed or stillborn children, and if you are obese, have high blood pressure, or have urine sugar, you should usually have a simple gestational diabetes screening at 24-28 weeks of pregnancy.

2. Diagnostic Criteria

Diagnosis criteria for diabetes in general adults are as follows:

Glycated hemoglobin (HbA1C) 6.5% or more, fasting blood glucose 126 mg / dl or more after an 8-hour fast, blood glucose is 200 mg / dl or more after 2 hours on a 75g oral glucose load test, or 200 mg / dl or more on a random glucose test, and high blood sugar In patients with typical symptoms of diabetes, diabetes is diagnosed when one or more of them are satisfied.

Diagnosis of gestational diabetes

The risk assessment for gestational diabetes should be made at the first prenatal visit. The high-risk group requires oral glucose tolerance tests for mothers with severe obesity, a history of gestational diabetes, urine detection in urine tests, and a family history of diabetes. High-risk mothers who have a negative first visit test should have their glucose screening tested again at 24-28 weeks of pregnancy.

The glucose load test is performed immediately after a 100g oral glucose load test with fasting for more than 8 hours, or a 5g glucose load test first, and a 100g glucose load test is given to mothers whose plasma glucose is greater than 140 mg / dL after 1 hour.

The diagnostic criteria for gestational diabetes after 100g glucose load test presented by the American Diabetes Association

Fasting blood glucose ≥ 95 mg / dL
1 hour blood sugar ≥ 180 mg / dL
2 hours blood sugar ≥ 155 mg / dL
3 hours positive for two or more of blood sugar ≥ 140 mg / dL

Low-risk mothers do not need to be tested for glucose load, in which case they are 25 years of age or younger, have a normal weight before pregnancy, have a low incidence of gestational diabetes, have no diabetes in their immediate family, or have a history of abnormalities in glucose-load tests. This is the case when the mothers who do not have a mother and the mother who had no difficulty in giving birth in the past meet the criteria.

Because mothers diagnosed with gestational diabetes are at high risk of developing type 2 diabetes after birth, they should be screened for diabetes 6-12 weeks after birth and then periodically tested for early detection of diabetes.

Treatments

Recent studies show that microvascular damage caused by diabetes is directly related to the level of hyperglycemia and the duration of diabetes. Therefore, the latest guideline for the treatment of diabetes is to control strict blood sugar levels to suppress the occurrence and progression of complications. Achieving these treatment goals is important when you consider that diabetes is the number one cause of blindness, kidney dialysis, and lower extremity amputation. To do this, early diagnosis of diabetes, as well as self-care practices, methods, patient supervision, and various treatment policies, must be developed to ensure that most patients achieve this goal.

1. Glucose Control Evaluation Methods and Goals

Self blood glucose measurement is very important for strict blood sugar control. Therefore, autologous glucose measurement should be recognized as a very important part of a comprehensive strategy for the treatment and management of diabetes. It is a rule to take insulin measurements three to four times a day for patients using insulin, but the most appropriate blood glucose measurement for patients with type 2 diabetes using oral hypoglycemic drugs is not yet known. Even in people with high postprandial blood sugar levels, post-prandial self-blood glucose measurements can be a useful way to maintain a target blood sugar level. However, in order to improve the accuracy of self blood glucose measurements, medical staff must regularly train and supervise patients.

How to measure auto glucose

1) Wash hands thoroughly with soap and running water under warm water before drying. If you can’t wash your hands, use an alcohol swab to disinfect the blood collection area, dry it thoroughly, and take a measurement to get accurate results.
2) The hand to be drawn is lowered below the heart for about 10 to 15 seconds, and this pressure is swept from the shoulder to the tip of the finger with the opposite hand to compress the blood at the tip of the finger.
3) Pinch the edge of the finger (the middle part is more painful) with a lancet and gently press the fingertips to bleed enough.
4) Drop a sufficient amount of blood into the test strip reaction site.

The glycated hemoglobin test can give you an approximate average of your blood sugar over the last 2-3 months. That is, you can easily see the effectiveness of the treatment. Therefore, the glycated hemoglobin test should be taken at least twice a year for patients who maintain the target blood sugar level and every two to three months if the target blood sugar level is not met or recent treatment changes. Glucose control can be better judged by a combination of self blood glucose measurement and glycated hemoglobin test.

Recent large studies have shown that maintaining an average of 7% or less of glycated hemoglobin levels significantly reduces microvascular complications and reduces complications in proportion to levels of 6% or less. However, strict blood sugar management requires attention because it increases the risk of developing severe hypoglycemia.

However, it is advisable to set individual glycemic control goals because each patient has individual differences in the incidence of hypoglycemia, weight gain, or other complications. Fasting blood sugar is within the target range, but when glycated hemoglobin is high, glycemic hemoglobin is lowered by measuring post-prandial blood glucose levels and keeping them at or below 180 mg / dL.

2. Meal Therapy

The primary goal of dietary therapy is to maintain blood sugar, lipid levels, and blood pressure at target levels. However, dietary therapy is not easy to implement, even though it is the basis for the treatment of diabetes, because it is complex, difficult to implement strictly in daily life, and doctors or patients lack understanding of dietary therapy. For this reason, a well-trained, dedicated dietitian is needed for patient education and care.

In overweight or obese patients, short-term, low-calorie meals can be effective for weight loss, recommend adequate intake of essential nutrients such as vitamins and minerals, limit intake of saturated fatty acids, and increase physical activity. In obese people with diabetes, blood sugar can often be normalized by weight control alone, so be sure to know your standard weight.

Man: Standard weight (kg) = [height (m)] ² x 22
Female: Standard weight (kg) = [height (m)] ² x 21

Calorie recommendations in diabetes vary widely among researchers, but usually 36 kcal / kg in men and 34 kcal / kg in women are recommended. In recent years, different dietary guidelines are recommended based on the individual patient’s condition and personal goals. For example, patients who need to lose weight may be able to limit their carbohydrate delivery time and type by taking into account glycemic index (GI) according to protein limitations, fasting and post-prandial blood sugar levels, and fiber, fruits, vegetables and low-fat dairy products. Your child should be instructed to eat properly according to their nutritional balance. The total calories you need to consume per day depends on the standard weight and activity of each patient. Calculate as follows:

Patients with little physical activity: standard weight x 25-30 (kcal / day)
Patients with normal activity: standard weight x 30 ~ 35 (kcal / day)
Patients with severe physical activity: standard weight x 35-40 (kcal / day)

Protein intake requirements are no different from the general population, and make about 10-20% of your total calorie intake. Complications are recommended to limit to 0.8 g / kg per day of kidney disease and to 0.6 g / kg per day when glomerular filtration rate (GFR) begins to decrease. Fatty acid intake should be about 25-30% of total calories and reduce saturation to within 10%.

Cholesterol intake should not exceed about 10% of total calories. Fructose in the fruit is effective in raising blood sugar, but eating too much can increase the level of triglycerides, a type of cholesterol, so you should eat only the right amount.

It is recommended to take 20-35g of fiber per day, and water-soluble fiber inhibits the absorption of sugar, which helps control blood sugar and improve blood lipid concentration.

Alcohol intake is recommended for men two glasses per day (about 10-15 grams of alcohol). Alcohol inhibits glucose diogenesis. As a result, people taking insulin or oral hypoglycemic agents can cause hypoglycemia if they consume alcohol without food.

3. Exercise Therapy

Exercise not only increases insulin sensitivity, lowers blood sugar, lowers the incidence of diabetes in type 2 diabetes risk groups, and reduces the rate of cardiovascular disease. The effect lasts for 1-3 days, so it’s best to do it at least every 2-3 days, 30-40 minutes a day, 3-5 times a week or 150 minutes a week. One study found that regular exercise reduced glycated hemoglobin by about 0.66% without weight loss.

Regular exercise is necessary and beneficial in type 1 diabetes, but sometimes it can cause problems when hormone regulation is lost. In other words, if you do not receive insulin treatment properly and exercise at a very low insulin level, your blood sugar may increase dramatically, leading to ketoacidosis. On the contrary, if you exercise with an excess of extra insulin supply, hypoglycemia may occur. In addition, patients with proliferative diabetic retinopathy should be careful because excessive exercise may cause bleeding or retinal detachment. If you have nephropathy, you may not be able to exercise too vigorously. And patients with diabetic peripheral neuropathy lack protection for their feet and should avoid weight-bearing exercises. Autonomic neuropathy can lead to tachycardia and orthostatic hypotension, which can lead to sudden death or myocardial infarction. Excessive exercise such as jogging and hiking should be avoided. If you need exercise test before starting exercise, if you are 35 years old or older, if your history of diabetes is more than 10 years, if you have risk factors for coronary artery disease, if you have microvascular disease or peripheral vascular disease, If you have autonomic neuropathy.

When you start exercising, we recommend that you choose the exercise that suits your preferences and do 30 or more days a week for 30 minutes at 50-85% of your maximum heart rate. Patients should be familiar with the symptoms of hypoglycemia and it is advisable to prepare candy, chocolate, etc. in preparation for hypoglycemia. If your blood sugar is too low, below 100 mg / dL, try eating a snack that contains carbohydrates. When you exercise in hot summer, make sure you get enough fluids to avoid dehydration.

4. Drug Therapy

1) Selection of oral hypoglycemic agents

In general, the most important treatment for the first-diagnosed type 2 diabetes is lifestyle improvement. However, the treatment of lifestyle changes is rarely normalized by monotherapy alone, and it is often difficult to maintain it. Therefore, treatment with Metformin is usually started at the time of diagnosis. Metformin is the first choice drug in the absence of special contraindications, especially in obese patients. If you do not reach your target glycated hemoglobin with the maximum dose of Metformin, you will need to add other drugs (Sulfonylurea, alpha-glucosidase inhibitor, Thiazolidinedione, DPP-IV inhibitor, GLP-1 agonist, etc.) within 2-3 months of treatment. Patients with more than 9% glycated hemoglobin often use two or more hypoglycemic agents.

2) insulin therapy

In type 2 diabetes, if your glycated hemoglobin is higher than 8.5% or you have symptoms caused by hyperglycemia, or if two oral hypoglycemic agents fail to control your blood sugar, you should consider combining insulin. Furthermore, as type 2 diabetes progresses, beta-cell dysfunction occurs, and many patients find that the oral glucose-lowering agent alone reaches the target level of 7% of glycated hemoglobin.

Early incorporation of insulin in patients using oral hypoglycemics can safely maintain glycated hemoglobin up to 7% during the first year after diabetes is diagnosed.

5. Hypertension Treatment

According to the American Diabetes Association, approximately 73% of people with diabetes have high blood pressure. And when first diagnosed with diabetes, about 50% of people already have high blood pressure. In diabetics, high blood pressure promotes progression to kidney and cardiovascular complications.

Thorough blood pressure management is important to prevent kidney and vascular complications, one of the chronic complications of diabetes. The target blood pressure for diabetics is less than 130/80 mmHg. If you have proteinuria, it should be kept below 120/75 mmHg.

6. Hyperlipidemia Treatment

In diabetes mellitus, there is abnormal lipid metabolism. Characteristically, low-density lipoprotein cholesterol is not different from the general population, but triglyceride is elevated and high-density lipoprotein cholesterol is decreased. In 30-40% of people with diabetes, triglycerides are above 200 mg / dL and in 10% they are above 400 mg / dL.

Targeted lipid levels in people with diabetes are less than 100 mg / dL of low-density lipoprotein cholesterol, less than 150 mg / dL of triglycerides, and more than 40 mg / dL in men and 50 mg / dL in women. However, the low-density lipoprotein cholesterol target for people with cardiovascular disease or high risk is less than 70 mg / dL.

Therefore, in people with type 2 diabetes who are 40 years of age or older, statins should be used to reduce low-density lipoprotein cholesterol levels by 30-40% of baseline or to lower low-density lipoprotein cholesterol by 100 mg / dL. Patients under 40 years of age who have cardiovascular risk factors and who do not improve their diet to lower LDL cholesterol to 100 mg / dL should also consider drug therapy.