• Diabetes Mellitus is a group of metabolic disorders leading to defects in Insulin Secretion and/or Insulin action leading to high blood sugar levels and other Systemic and Metabolic changes(Including Proteins and Fat metabolism).
• Almost 370 million people worldwide have Diabetes Mellitus in various stages.
• In India, there are approximately 65 million Diabetic patients (second only to China).
• Almost every living being is at risk of contracting Diabetes Mellitus.
• Family history of Diabetes (First degree relative) :

  1. No Diabetic parent : Risk is 14%

  2. One Diabetic Parent : Risk is 29.2%.

  3. Father having Diabetes : 20 times more risk than the General population.

  4. Mother having Diabetes : 7 times more risk than the General population.

  5. If both parents are Diabetic then the risk of acquiring Diabetes is about 40%.

• Indian Ethnicity.
• Urban more than rural.
• Early exposure to cow's milk protein (Absence of Breast feeding in infancy).
• Children kept away from socialization and mixing with other people.
• Patients of Polycystic Ovarian Syndrome.
• Low Birth weight babies.
• Obesity.
• Sedentary life style people.
• Increased waist circumference.
• Females on long term Oral Contraceptive Therapy.
• Smokers
• Alcoholics

If you have one or more of the following symptoms then you should investigate yourself for Diabetes Mellitus :

• Involuntary weight loss.
• Loss of Muscle mass.
• Excessive thirst (Polydypsia)
• Excessive Hunger (Polyphagia)
• Excessive urination (Polyuria)
• Unexplained weight gain (Diabetes Mellitus type 2 ; Insulin Resistance Syndrome)
• Sexual Dysfunction (Low Libido, Erectile Dysfunction , Anorgasmia)
• Unexplained Infertility
• Abortion, Miscarriage, Stillbirth
• Polyhydramnios during pregnancy
• Repeated Vaginal and Penile infections (Candida)
• Repeated Urinary Infections
• Skin Changes (Hyperpigmentation, Skin thickening/Thinning, Premature Greying of hairs, Dermatitis, Eczema, Repetitive fungal infections etc.)
• Non Healing wounds/Ulcers
• Unexplained Fatigue, Weakness, Lethargy
• Unexplained Mood Changes
• Unexplained Irritability
• Unexplained Bowel Complains (Constipation/Diarrhoea)
• Unexplained Abnormal Sweating pattern
• Unexplained Giddiness while changing posture
• High Blood Pressure OR Low Blood Pressure
• Changes in Vision (Refractory Errors, Cataract , Glaucoma , Retinal Changes etc.)
• Abnormal sensations like Tingling, Numbness, paresthesia, loss of sensations.
• Repeated Dental and Gum infections

• Hyperlipidemia (High Cholesterol, Triglycerides, LDL)
• High Random Blood Sugar levels
• Incidental finding of Abnormal ECG and Stress Test.
• Abnormal findings in Fundoscopy and other ophthalmic examination
• Abnormal findings in Audiometry
• Abnormal Nerve Conduction studies and Electromyography
• Abnormal Kidney function test (Including Creatinine)
• Abnormal Urinary analysis (Sugar/Ketones/Proteins/Bacteria/Pus Cells in Urine)

• Environmental
• Genetic
• Hereditary
• Autoimmune
• Pancreatitis
• Obesity
• Sedentary Life style/Lack of Physical Exercise
• High Carbohydrate / Fat intake in diet
• Refined Sugar Intake
• Oxidative Damage
• Inflammation
• Infections like Rubella, CMV, Coxsachie Virus etc.
• Other Endocrine diseases likePCOD, Cushing's disease,Acromegaly,Hyperthyroidism etc.
• Stress
• Medicines Induced like Niacin,Glucocorticoids, OCP, Growth hormone, Thiazides, Thyroid hormones, Phenytoin etc.
• Addictions/Substance Abuse like Alcohol, Smoking, Neuroexciting drugs etc.
• Tumours
• Toxins

• Diabetes Mellitus Type 1
• Diabetes Mellitus Type 2
• Insulin Resistance Syndrome
• Gestational Diabetes
• Others (Genetic, Drug induced , Infections, Endocrinopathies etc)

"Once you are diagnosed to have Diabetes Mellitus, your risk of getting Cardio Vascular (Heart) complications are equal to any patient who has already had a heart attack"

Almost all the systems of the body can be affected adversely by Diabetes Mellitus :

• Atherosclerosis
• Hypertension
• Obesity (DM Type II)
• Cachexia (DM Type I)
• Ischemic Heart Disease
• Cardiomyopathy
• Pericarditis
• Pericardial Effusion
• Neuropathy
• Myopathy
• Non healing ulcers/ Diabetic Foot
• Autonomic Dysfunction (Postural hypotension, Erectile Dysfunction, Premature Ejaculation, Bladder and Bowel disturbances, Abnormal sweating, Giddiness, Dizziness, Fainting, Syncope etc.)
• Mood and Memory Disturbances
• Hypoglycemia leading to convulsion/Coma.
• Diabetes Keto acidosis
• Hyper osmolar Coma
• Electrolyte imbalances leading to Seizures, Convulsions, Unconsciousness.
• Nephropathy leading to Kidney Failure/End Stage Renal Disease.
• Ophthalmic Complications (Cataract, Glaucoma, Retinopathy)
• Erectile Dysfunction , Impotence, Infertility
• Abortion, Miscarriage, Stillbirth
• Polycystic Ovarian Syndrome
• Macrosomia and other birth defects in newborn
• Premature Ovarian Failure
• Dermatological Complications (Acantosis Nigricans, Hirsutism , Dermatitis, Eczema, Ulcers, Alopecia etc)
• Repeated Infections
• Low Immunity
• Fatty Liver, Gall Stones
• Bronchiectasis, Emphysema
• Pancreatitis
• Sleep Apnea
• Multiple Endocrine disturbances
• Others

Diabetes Mellitus is associated bi-temporally with other Endocrine (Hormone) Disturbances and diseases including :

• Hypothyroidism
• Hyperthyroidism
• Obesity
• Acromegaly
• Cushing's syndrome
• Pheochromocytome
• Polycystic Ovarian Syndrome (PCOS)
• Hirsutism
• Low Testosterone in Men
• High Testosterone in women
• High Estrogen in Men
• Abnormally low/high Estrogen and Progesterone in women
• Low Dopamine
• High Prolactin
• High counter-regulatory hormones like Growth Hormone , Glucagon , Glucocorticoids
• Abnormal IGF-1
• High Aldosterone
• Low DHEA
• Low Vit D
• Inappropriate Incretins effects
• Abnormal Adipokines (Leptin, Adiponectin) effects.
• Others

Diabetes Mellitus management should therefore not be limited to Insulin management. The associated Endocrine and Systemic imbalances need to be corrected simultaneously.

• Grave's Disease
• Hashimoto's Disease
• Pernicious Anaemia
• Addison's Disease
• Vitiligo
• Cystic Fibrosis
• Celiac Disease
• Polyglandular diseases
• Others

• Down's Syndrome
• Turner's Syndrome
• Kleinfelter Syndrome
• Prader Willi Syndrome
• Myotonic Dystrophy
• Others

What is Gestational diabetes?

• There occurs some physiological alteration in the carbohydrate metabolism in pregnancy.
• Human pregnancy is characterized by Increased Insulin Resistance which helps to ensure a steady glucose supply to the fetus.
• The hormones like human placental lactogen, Estrogen and progesterone contribute to this state.
• If these alterations are exaggerated then there is abnormal glucose tolerance leading to "Gestational Diabetes".
• Alternatively pregnancy may unmask an underlying pre-diabetic state.
• GDM can be diagnosed by Glucose Tolerance Test.This can be done during the first visit and then repeated on 24 weeks and then 32-34 weeks.
• 2 hrs GTT of more than 140mg/dl or above indicates GDM.
• Obesity, Over weight, Family history of Diabetes are risk factors of developing GDM.
• High occurrence in Asians.

How does it affect the mother and the baby?

• Excessive Fetal growth (big baby)
• Obstructed labour.
• Increased chances of developing Gestational Hypertension.
• Increased mortality rate of mother and fetus.
• Increased chances of developing overt Diabetes in mother (almost 50%).
• Chances of Respiratory distress Syndrome in baby.
• Increased risk of abortions.

Is there any way to avoid it?

• Weight Control.
• Maintaining the calorie intake.
• Small frequent meals during pregnancy (Balanced diet).
• Avoid Obesity/Over weight before conception.
• Stay active through out pregnancy.
• Pre-conception screening and counselling.

How is it treated?

• Calorie Control 30-35 Calories/Kg of present weight.
• 50-55% Carbohydrate, 20-25% Proteins and rest in form of fat.
• Split the daily meals in 5-6 portions.
• Insulin Therapy, whenever needed.
• Normal physical activity plus graduated daily exercise like walking.
• Monitor Body weight, Blood Pressure, Haemoglobin, Glycosylated Haemoglobin, Blood Sugar and other parameters.
• Fetal development assessment by Ultrasonography.
• Educate the patient and the family about GDM.
• It needs to be a team approach comprising of Gynecologist, Diabetologist, Neonatologist, Trained nurse and Educator.

Is it a common occurrence?

• In developed countries the rate is almost 7%.
• In developing countries Including India the prevalence is almost 16-17%.
• It seems to happen almost equally in rural and urban areas in India.

• Investigations in Diabetes Mellitus do not simply end in monitoring the Blood Sugar levels (Fasting Blood Sugar , Post Prandial Sugar, Glucose Tolerance Test , Glycosylated Hb etc.).
• Being a multisystem , metabolic and Endocrine disease influenced by Genetics and Life Style , the cause and complications should be investigated/monitored simultaneously.
• The whole series of Clinical Systemic examination , Biochemical laboratory evaluation and Imaging parameters (Diagnostics and Screening) are key for successful management of Diabetes Mellitus.
• The Occupational , Psychological , Social evaluation is equally important.
• Diabetes Mellitus being a multisystem disease calls for the evaluation of all the systems of the body.
• Diabetes Mellitus being a Metabolic disease calls for evaluation of the Metabolic profile.
• Diabetes Mellitus being an Endocrine Disease calls for evaluation of all the related hormones.

Who should do Genetic Testing ?

• Family history of Diabetes Mellitus.
• Vague symptoms of Diabetes Mellitus but Laboratory reports normal.
• High risk ethnicity with unhealthy life style.
• Obesity with no signs of Diabetes Mellitus.
• Low birth weight babies.
• Down's Syndrome.
• Turner's syndrome.
• Klinefelter's syndrome.
• Other Genetic disorders.
• Pre Marriage Counselling.
• Pre natal Counselling and risk assessment.
• Risk assessment in an individual with genetic testing.

• BLOOD SUGAR CONTROL

1. Life style management

2. Weight management

3. Dietary management

4. Medical Management (Including Insulin and Incretins)

• Identification of Risk Factors.
• Management of Metabolic factors including Hyperlipidemia and hypoproteinemia
• Prevention of Complications
• Balancing other Hormonal and Systemic disturbances
• Diabetic Foot Management
• Management of Cardiac Complications
• Management of Neuropathy, Nephropathy, Retinopathy, Myopathy
• Psychological management
• Occupational and Social management
• Management of Sexual Dysfunction including Erectile Dysfunction
• Surgical management

1. Metabolic/Bariatric Surgery