What is being done here is an attempt to present the how and why of some of the complications of Diabetes mellitus with the hope that patients and those who bear the burden of caring for them will understand one or two things that will give them grace and hope to persevere.
Young diabetic patients sometimes argue that, their parents or close relatives, smoked cigarettes, took as much alcohol as they could without developing any of the complications they see around. Reason is that God created us equal in the big sense of creation, but there are differences at levels too numerous to mention; it is important also to note that, the natural chemicals known as enzymes which speed up biochemical reactions in the body are not only inherited, but are also specific. Moreover, there are people with gene types , such that they ican drink two cartons of beer, or six bottles of Gin or Whisky with only minimal damage because thye have these enzymes that can very quickly neutralize the toxic degradation products of ethanol. The same goes for cigarettes and Ciga. So people have these specific enzymes that operate to reduce or prevent some people from going down with the twenty or more recognized diseases that can be caused by smoking. These enzymes in some individuals undergo changes in many ways(mutation). In a family of fat people for instance, one person may be thin and healthy because the enzyme responsible for transfer of cholesterol and lipids from the Liver and intestine to the tissues may have undergone changes. Even in Hiv/Aids, mutation in the Chemokine cellular receptors CCR5 and CXR4 which are required as coreceptors by the virus for successful infection explains why some people can have repeated receptive sexual intercourse with Hiv positive partners and remain seronegative
For chronic complications which may be classified as, vascular, or non vascular, micro vascular, when the small and tiny blood vessels are involved or macro vascular when the large blood vessels, arteries and veins are involved, patients tend seek medical help long after they have had the problem, as Doctors call it present late, and so what we see are combinations of these complications , and it becomes difficult to draw a clear line
Deposits of unutilized sugar forming complex molecules with proteins to generate Advanced Glycosylated End products (AGE) as has been discussed are largely responsible for most of the complications of diabetes mellitus
On the other side of the problem, the presence of hyperglycemia, gives rise to increased production of diacylglycerol. This results in activation of protein kinase C . Excessive phosphorylation through these pathways alters the transcription of genes responsible for a number of proteins including those responsible for the structural integrity of many cells, tissues and organs throughout the body, such as the brain, heart, skeletal muscles.etc
We may recall that under normal conditions, the metabolism of glucose occurs by pathways that result in the formation of energy and water to drive most of the activities necessary for the cells to function normally, as well as in the production of pyruvates which go into the krebs cycle for more energy, but in conditions of excess glucose, alternative pathways are employed, which result in the production of oxygen coupled molecules. These then react with others in the body to damage cell membranes and related structures. There is also increased movement of reactants through the Hexosamine pathway. This favours the generation of fructose-6-phosphate(F6P), and consequently the excessive production of growth factors and alteration of endocrine properties of vascular endothelium; reflex stimulation of the Renin Angiotensin System (RAS) for instance is translated to increased resistance at the renal arterioles. Renal hypertension then creates a vicious cycle that may eventually cause irreversible kidney damage, which is seen as a major complication of Diabetes mellitus
Abnormal bleeding pattern is another complication of Diabetes Mellitus that may declare itself as a serious emergency; it may be due to excessive production of platelet-derived growth factor, increased platelet aggregation or decreased activity of fibrinolysins. Diabetic patients particularly those who are also hypertensive are therefore usually advised to exercise extreme caution when asked to take blood thinners such as vitamin E, Aspirin or herbal products known to affect blood clotting system
Especially for type 2 Dm, with Chronic complications, problems may begin very softly, with, few non specific warning signs of tiredness and loss of strength, heart beat may be faster than normal even when the patient is resting.
Frequent micturition, and especially nocturia, when a patient who had never been woken up by the urge to urinate finds himself or herself getting up four to five times in the night to do so, though a common symptom may also herald serious onset of an acute or chronic complication. This should be different from not being able to hold urine or urinating frequently accompanied with some sweet pain which occurs in urinary tract infection or UTI. As was discussed, excess glucose in blood draws water from the cells so that two things can happen; to dilute the excess glucose with the water, remove the excess glucose through urine formed in the kidneys, this starves the cells of water and those cells passing through a center in the Brain sends signals to the patient to drink more water leading to polydypsia and then more urine is made in a cycle that leaves him weak, dry and thin.
Microvascular complications
Retinopathy and Neuropathy.
The eyes are often used by physicians as windows to the brain, and in many cases, by the time the eyes begin to show signs of damage, they are likely to search for similar tissue damage in other parts of the body. Blurred vision, seeing shadows, or black spots, all due to involvement of the light sensitive retina at the back of the eye may appear for the first time in a patient with advanced stage of the disease. An eye specialist may then discover damaged blood vessels in the eye. He could use the shape and pattern of bleeding to tell whether bleeding was as a result of hypertension(hypertensive retinopathy )or diabetes mellitus as in diabetic retinopathy.
Another piece of equipment in the office of the eye physician or general practice Physician, Tonometer can measure the pressure in the eye ball and draw attention to the condition called glaucoma, another complication of uncontrolled high blood sugar. What ever the manifestation, the mechanisms may include the following;
•direct damage to the tiny blood vessels of the vascular portion of the eye
•dumping of abnormal proteins, protein products, fibrin residues and fibrin degradation products blocks regular flow of free fluid between the chambers of the eye leading to abnormal increase in the pressure of the eye ball. In addition, similar deposits of fats, sugar, calcium and protein complexes along the inner walls of blood vessels cause narrowing of the caliber of the small vessels, and also cause them to break when they try to expand to accommodate blood.
•attempt by the body to repair the damage by issuing signals for growth of new blood vessels(angiogenesis)
•obliteration of the bipolar paraneurones , and their supporting cells in the light sensitive back of the eye ball, the retina
• disorganization , and disruption of the flow of fluid across the chambers of the eye as result of blockade of canals(schlem) etc, all these will manifest in several different patterns and that is why you must seek medical advice from appropriate quarters . There you will receive additional information, and will know what you can safely do for yourself and others you shouldn’t attempt.
Peripheral arterial disease Again , the presence of a blister in the foot that refuses to heal may for the very first time force a patient to the hospital . For others it may be troublesome electric shock type of feeling along parts of the distal upper and lower limbs where gloves and stockings are usually worn .
Diabetic patients who also have other conditions of the musculoskeletal system such as, knock knee(valgus deformity), bow legs(varus deformity), flat feet( pes planus), anatomically significant leg length inequality, bent spine(scoliosis, kyphosis, kyphoscoliosis) are at increased risk for diabetic foot ulcer, in this conditions, there is alteration in the normal biomechanics of the spine in weight transmission and distribution from the lumbar vertebrae(lower backbone) through the sacrum (holy bone) to the waist , thigh, leg and arches of the feet . More weight than is allowed is borne by one foot at the expense of the other
It is believed that inflammatory and apoptotic events occasioned by AGE occurring at different levels incuding the vasa nervorum are responsible for these abnormal sensation , progression to complete loss of sensation occur with the passage of time and persistence of hyperglycemia.
Under these conditions, a patient loses the ability to feel pain in the feet and legs. He may step on a mounted nail and be pierced without knowing it, There very many spaces in the plantar area of the foot where infection and pus can spread and within a short period ,the whole foot is nothing but a bag of pus up to the ankle, a situation that will definitely involve amputation of one or both feet. Simple avoidance behavior such as good personal hygiene with emphasis on foot care , wearing loose fitting shoes, and regular monitoring of blood glucose will prevent or reduce these problems
A diabetic patient may have striking pains in the limbs when he tries even mild physical activity ,the pains disappears when he rests the affected limb( intermittent claudication). In some people this may pass without further problems, but may be the first symptom that the limbs are about to develop serious problems
The risk of developing diabetic foot ulcer increases under the following settings;
. a parent , auntie, uncle , brother or sister had a similar problem
. the patient is a male adult older than 35 years
.the patient is obese with BMI ,30 and above, particularly gyenoid or pear type where fat is distributed around the buttocks, waist, thigh, and legs
He ( patient) smokes;diabetic patients who smoke are at a particular risk of developing end arteritis obliterans(obliteration of end arteries) usually followed by gangrene
patient has had diabetes for over 10years and control of blood sugar has been erratic , despite good medical supervision
patient has abnormal musculoskeletal deformities
patient habitually wears tight fitting shoes
Impotence(Erectile dysfunction) in Diabetes Mellitus requires special attention, because it is quite capable of resulting in marital disharmony especially if couples had been very sexually active before illness began. Sexual activities involve the central, and the autonomic arms of the Nervous system . Even without any chronic disease conditions, the interest and stamina for sex decline as early as age 25, and earlier in some men and women. Diabetes mellitus more common in middle age , is commonly seen in association with hypertension and the drugs used in the treatment of both conditions reduce libido and cause impotence. These issues when added to the primitive idea that the man should at all times initiate sexual intercourse place the man in a position of disadvantage and hopelessness. The symptoms range from weak to flaccid appearance , but can hopefully be completely reversed with a loving, patient , reasonable and understanding wife with the supervision of the family physician. Decreased synthesis of nitrous oxide(NO) due to advanced gycosylated end products which also alters the elastic properties of vascular endothelium account for 60% of the etiology, apart from other psychosomatic issues . Excessive sweating and anxiety make the situation worse, because in that condition, the blood vessels in the penis are actually collapsing instead of dilating, or opening ,return of venous blood to the heart is reduced , making it difficult for the Heart to supply blood to itself so it can sustain life, for this reason, attempt to use a performance enhancing drug to force the heart to pump more blood to where it is mostly needed , will create a physiological crisis for the body . When blood is shunted from a heart that is already battling to supply itself, the rest can be worked out.
Obesity and Diabetes Mellitus:- diabetic patients who are obese are more likely to have poor wound healing abnormal orientation of the feet , anatomically significant leg length inequality, and abnormal weight bearing during activities of daily life poor spine, hip and foot muscle alignment , ulcers form as a result of the loss of the sense of pressure, pain , two point discrimination and touch .
Macrovascular complications
Coronary artery disease:- Lipids especially the bad cholesterol low density and very low density lipoproteins(LD&VLD) are elevated where as the good cholesterol ,high density cholesterol (HDL)is low. Moreover, Diabetes Mellitus is associated with narrowing of the coronary vessels, wasting and loss of cardiac muscle tissue. Because signs of small heart attacks (micro infarcts) are commonly absent, sudden death may occur without the warning symptom of left sided chest pain radiating to the inner left arm and inner left neck
Cerebrovascular disease(CVD)
Stroke may occur after minor arguments ,minor physical exertion or even while sleeping. One side of the body may be paralyzed with or without loss of consciousness. Deposits of AGE in the walls of arteries in the brain, causes them to lose elasticity, and become plastic . They are liable to rupture at any moment of agitation, slight increase in blood pressure or sudden large drop in blood pressure(law of Laplace). Diabetic patients with congenital or acquired blood filled outpocketting of the blood vessel wall(aneurysms) in the arterial circle of Willis are particularly vulnerable
FATTY LIVER IN DIABETES MELLITUS
Fatty liver and hypertension are both included in the entities that constitute the metabolic syndrome. The liver is like a factory in the human body ,and as such is the main site of storage of unutilized glucose as well as the breakdown of glycogen . In diabetes mellitus increased deposits of triglycerides and increased need for increased production of glucose from non carbohydrate sources may result in fatty liver. The matter is not yet settled as to which one comes first ,since there are very many other alternative pathways involved, but it is enough to stress that the appearance of fatty liver in type 2 Diabetes mellitus should be taken seriously .
NON VASCULAR COMPLICATIONS
Gastroparesis
may develop in the older patient with type 2 diabetes mellitus, mainly from abnormalities in the parasympathetic chain of the ANS. Hyperglycemia on its own causes delayed gastric emptying, bloating and easy fullness with small meals
How ever many people live with diabetes mellitus for years without complications, but are few.
Infections
When blood sugar remains persistently high, the body becomes a living reservoir for small organisms inside and outside the body, outside the body, fungal infections with candidisis of the skin , bacteria infections with staph aureus can take the form of recurrent boils, and can even appear as badly smelling infection of the outer ear(otitis externa), offensive vaginal itching with or without abnormal discharge, Escherichia coli,(ecoli), can colonize the urinary bladder(cystitis with frequency, urgency and strangury) , the urethra in women (shorter in women, 3or 4 cm compared to 10-11cm in men), and can climb up to cause ascending pyelonephritis , or even frank kidney infection
Dermal complications;
Skin complications are usually coincidental with those just described, with little differences, protracted wound healing and skin ulcerations are common features of Diabetes mellitus , but can be so bad as to cause wound dehiscence or wound break down forcing the surgical team to go back into the theatre several times for the same surgery, each successive surgery carrying a higher risk .Sometimes Typhoid perforation may occur in a diabetic as a complication with very challenging consequences for the surgical team
Type 1 Diabetes mellitus is as a result of autoimmune conditions and hence the association with vitiligo, a skin condition where the dark melanin producing cells normally present in the skin of black people are attacked and destroyed by cells of patient’s own immune system, the condition appears as white patches all mover the body and has no known cure.
On the other hand, very dark spots may appear in the skin of the armpit, back of elbow and hands and , they are called ancathosis nigricans and their appearance is not a good sign for diabetic patients on insulin. They are different from the milder diabetic pretebial spots,
Growth factors summoned to rectify damage caused by age are believed to be partly responsible . these include epidermal growth factor, insulin-like growth factor I, growth hormone, etc
RCCOMMENDATIONS
Know the medical history of your family so you PLAN how to tailor your life style with regards to food drinks , travel and stress management. You must avoid sugar and excess carbohydrates, wheat in whatever forms should be taken only in moderation.
Stick with a Doctor, seek opinion from other Doctors as you deem reasonable but remain connected with one you can see at any time , no matter the number of sophisticated gadgets you have, they are no substitutes for your Doctor
Single lab tests do not diagnose Diabetes mellitus, clinical symptoms and signs together with blood and urine tests are considered and confirmation established before diagnosis is made
Diabetes mellitus can cause damage to important organs like the Heart, Kidneys , Brain and the eyes, long before the patient becomes aware, any unusual observations in these areas should be brought to the attention of your Doctor
If you are diabetic and already have complications such as ulcers in the limbs, the situation has gone beyond seeking solution from alternative medicine practitioners. Surgery to save life with insulin carefully calculated to control blood sugar will serve you better when combined in the province of a well established center
Avoid performance enhancing drugs ; they can kill your heart . wait until your condition is stable, plan your exercise to go with your diet program and exercise with common sense; using mild hands and legs exercise with short walking either alone or in combination, you can to test your physical strength and your ability to have successful coitus without endangering your health. The supervision of your physician or dietician must never be ignored
Skin complications of insulin injection site can also occur; they may be unsightly but pose no danger . unusual thickening or loss of pigment should be made known to the care giver
Attention to other risk factors for vascular disease (smoking, dyslipidemia, hypertension) and improved glycemic control are also important.
