THE CONNOTATION OF DIABETES MELLITUS: REVIEW

 Dr. Dilip K. Jani^a, Dr. Tanuja M. Nesari^b, Dr. D. Vijayakumar^c

1. Research Associate, Indian Institute of Chemical Technology, (CSIR), Hyderabad
2. Prof. & HOD, Department of Dravyaguna, Tilak Ayurveda College, Pune
3. Scientist E1, Indian Institute of Chemical Technology, (CSIR), Hyderabad  

Type II diabetes mellitus, also known as non-insulin-dependent diabetes mellitus (NIDDM), is the predominant form of diabetes. In many patients, the initial diagnosis of type II diabetes is delayed perhaps by as much as 10 years because symptoms are often absent or very mild during its early stages. Type II diabetes is particularly common among the elderly and in many minority populations. The risk for type II diabetes increases with obesity, a family history of diabetes, and in women, history of gestational diabetes. It is believed that physical health is associated with theseven favorable habits: sleeping 7–8 h, eatingbreakfast almost every day, avoiding eating between meals, maintaininga desirable weight with respect to height, participating inactive sports, limiting alcohol intake, and avoiding smokingcigarettes¹. To reduce theburden of diabetes among people, it is imperative to increasecurrent efforts in diabetes prevention, quality diabetes care,and patient education. New initiatives may also be required,such as aggressive campaigns to decrease the likelihood of developingdiabetes, especially among youth. The development of culturallysensitive programs to facilitate weight reduction among peoplewith diabetes, using a balanced diet and increased physicalactivity, is also a high public health priority².

Diabetes is clearly a growing public health threat.This update is consistent with earlier prediction of theepidemic nature of diabetes. Specifically for diabetes, muchof the impact of the continuing increase in obesity will bemanifested in future years because of the substantial delay betweenthe onset of obesity and the subsequent development of diabetes. Publichealth strategies to limit this increase and address its impactare urgently needed³.

Many patients with diabetes take complementary therapiesor nutrition supplements and conventional medicines concomitantly.A recent article reported that patients with diabetes are 1.6times more likely than patients without diabetes to use complementaryand alternative medicines⁴. There are wide variations in prevalence rate of diabetes mellitus in various parts of our country. Survey of large number of people from rural as well as urban population of India, reported that prevalence of diabetes and impaired fasting glucose (IFG) is lower in rural population compared to the urban population. The prevalence rate (percent) of diabetes mellitus for persons above the age of 25 years was 3.77%. The prevalence in males was 4.58% and in females it was 2.66%. Impaired fasting glucose was 2.82% in male and 2.78 % in female. The maximum prevalence was observed in the age group of 56 to 65 in both males and females⁵. Education, income, and occupation were associated withincreased diabetes risk in unadjusted models. In baseline modelsadjusted for demographics, respondents with <12 years ofeducation had 50% excess risk compared with those with moreeducation, income and occupation were nolonger significantly associated with increased risk. Furtheradjustment minimized the significance of all associations. Time-dependenteffects were consistently elevated for low education and maleblue-collar occupation, but non-significant after full adjustment. Socioeconomic disadvantage, especially with loweducational attainment, is a significant predictor of incidentType 2 diabetes, although associations were largely eliminatedafter covariate adjustment. Obesity and overweight appear tomediate these associations⁶.The comparison of employment and income of working-age people with and without diabetes was assessed.Diabetic individuals without complicationshad incomes similar to those of non-diabetic individuals⁷.

A striking increase in the prevalence of obesity, as wellas diabetes, was reported between the second and third NationalHeath and Nutrition Examination Surveys. Despite these difficulties, several recent studies have demonstratedthe potential for moderate, sustained weight loss to substantiallyreduce the risk for incidence of type 2 diabetes⁸. Cigarette smoking is an independent and modifiablerisk factor for type 2 diabetes. Smoking cessation is associatedwith weight gain and a subsequent increase in risk of diabetes,but in the long term, the benefits of giving up smoking outweighthe adverse effects of early weight gain⁹. An age-standardized(35–79 years) prevalence of known and newlydetected diabetes was 20% (17–24%) in Europeans, 22% (18–26%)in African-Caribbeans, and 33% (25–41%) in Pakistanis.Marked changes in prevalencerepresent only small shifts in glucose distributions. Regressionmodels showed that greater waist girth, lower height, and olderage were independently related to plasma glucose levels, aswas physical activity. Substituting BMI and waist-to-hip ratiorevealed their powerful contribution¹⁰.

Many patients with diabetes may take complementary therapiesor nutrition supplements and conventional medicines concomitantly.Some of these combinations may lead to potentially harmful interactions¹¹. It is believed that greater attention needs to be paid to the broader systems of environment and culture and their interconnections to understand the use of complimentary and alternative medical therapies¹². A survey done under which the therapies usedfor diabetes included solitary prayer/spiritual practices (28%),herbal remedies (7%), commercial diets (6%) and folk remedies(3%). Excluding solitary prayer, only 20% of respondents usedcomplimentary and alternative medicine to treat diabetes¹³. The diabetic education program also presents an excellent opportunity for all healthcare professionals, who are interested in diabetes care to leadthe way in promoting the control of blood glucose, lipids, andblood pressure to other provider groups and their diabetic patients¹⁴.

The growing utilization of complementary and alternative medicinetherapies represents one of the characteristic phenomenafacing scientific medicine. Studies of the patient’s opinionsand attitudes toward CAM therapies are scarce. Among doctors,it is widely considered that the use of CAM therapies is onlylinked to a particular social or cultural background. A cross-sectional study designed to evaluate the spontaneoususe of CAM therapies. Almost 62% (353) of participants make use of CAM therapies,a higher percentage than that reported in the U.S. (8%) andCanada (37.3%). Mexican patients whouse CAM therapies prefer herbal remedies (94.2%), whilethe remaining 5.8% use other treatments. In Mexico the use ofplants has a long historical tradition, while in the U.S. only20% of diabetic subjects use herbal medicine¹⁵.

Type II diabetes is accompanied by many severe complications, such as blindness, renal failure, lower- limb amputations, cardiovascular disease and stroke. The study was conducted to determine the prevalence of chronic complications and associated factors in type 2 diabetes of 500 diabetic patients having age ≥25 years. Of the 500 diabetic patients examined retinopathy was seen in 43%, neuropathy in 39.6% and foot ulcers in 4%. Nephropathy was found in 20.2%, and was significantly associated with hypertension. The prevalence of micro-vascular complications was higher in the group of patients with HbA1c >8% and was significantly related to duration of diabetes, hypertension and obesity. Hypertension was manifest in 64.6% patients, 61% had raised Body Mass Index and Waist Hip Ratio was more than normal in 88% subjects. Macrovascular complications were encountered in 102 diabetic patients, with angina in 85 (17%), heart attack in 25 (5%) and stroke in 13 (2.6%). The prevalence of diabetic micro-vascular complications was higher in people with poor glycaemic control, longer duration of diabetes and associated hypertension and obesity¹⁶. Time-dependenteffects were consistently elevated for low education and maleblue-collar occupation, but non-significant after full adjustment. Socioeconomic disadvantage, especially with loweducational attainment, is a significant predictor of incidentType 2 diabetes, although associations were largely eliminatedafter covariate adjustment. Obesity and overweight appear tomediate these associations¹⁷.The prevalence of diabetes in Canada is increasing. One of the surveys carried out in Canada illustrates that the proportionof the disease rose from 3.4% in 1994/95 to anestimated 4.5% in 2000/01. The rate for men increased to 4.8%from 3.4%, while the rate for women rose to 4.2% from 3.3%¹⁸. 

In the concern with clinical trials, it is suggested that one should rely only on randomized, clinical trials with clinically meaningful endpoints to determine which agent to be use for the treatment of type 2 diabetes. One could consider HbA_1c levels a surrogate endpoint, since it is obviously not a direct measurement of diabetes-related complications. The oral glucose tolerancetest not be routinely used to identify people with eitherdiabetes or impaired glucose tolerance (IGT) has fueled considerablecontroversy regarding the importance of such testing in eithera clinical or epidemiological context¹⁹.

In one of the study the hypothesis was tested that HbA_1c levels might be more sensitivethan Fasting glucose concentrations in diagnosing diabetes in the 150 subjects. As expected, the proportion with elevated Fasting glucose and HbA_1c valueswas higher. However, the hypothesis was stillnot supported, because 74% had Fasting glucose concentrations 126 mg/dl and only 59% had elevated HbA_1c levels²⁰. It is come to know that there are insufficientdata to determine accurately the relative contribution of theFasting and post-prandial to HbA_1c. It appears that FPG is somewhat betterthan post-prandial in predicting HbA_1c, especially in type 2 diabetes. Absolute Fasting glucose is not a reliable tool for management of type 2diabetes. Published data don’t supportthe conclusion that Fasting glucose is somewhat better than PPG in predictingHbA_1c, especially in type 2 diabetes²¹. In practice, fluctuations occur all the time and one effective way is to monitor the HbA1c, which gives the average blood glucose level of the preceding 2-3 months²². It is come to know that lipoprotein concentrations were directly correlated withLDL cholesterol and negatively correlated with triglyceridelevels in diabetic patients²³.The HbA_1c level was negatively associated withthe polyunsaturated fat–to–saturated fat ratio (P:Sratio) of the diet and positively associated with thetotal level of fat intake adjusted for ageand total energy intake. It provides further support to efforts promoting modificationsin the intake of dietary fat. It is reported that fruit and green leafy vegetableconsumption and vitamin C intake are negatively associated withHbA_1c²⁴.

            The study was conducted on some plants contains appreciable amount of elements like K, Ca, Cr, Mn, Cu and Zn, which are responsible for potentiating insulin action²⁵. In another study the exploration was made on the Anti-diabetic activity of medicinal plants and its relationship with their antioxidant property²⁶.

            Diabetes mellitus strikingly resembles with Madhumeha, which is one of the twenty type of Prameha as described in various Ayurvedic texts. It appears that Prameha is a group of urinary syndromes including Diabetes mellitus and Diabetes Insipidus. The description of Medhumeha is available in ancient treatise of Ayurveda even before modern scientists knew it. As it is a complex disorder having the chain of symptoms and affect many of the systems and organs in the body, it is considered that it requires a complex drug having complex chemical composition. Extensive clinical observation, intuition and insight, and interpretation based on the Tri-Dosha philosophy of Ayurveda will further become the guidelines of research for complex diseases like Diabetes.

ACKNOWLEDGEMENT: We thank Director, IICT and department of AYUSH, Andhra Pradesh for providing all necessary support to conduct study. The authors would also like to thank the NMITLI group for their encouragement and support.

ADDRESS OF CORRESPONDENCE:

Dr. Dilip K. Jani M.D. Ph.D., Assistant Professor, Department of Dravyaguna, G. J. Patel Ayurveda College and Research Centre, New Vallabh Vidyanagar, Anand, Gujarat- 388121, India

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