Dr Sunil Mishra, Endocrinologist, Medanta Hospital
Managing diabetes is always a challenge, here I present three case scenario with diabetes mellitus, to highlight some important unnoticed aspects of management
Diabetes Mellitus Scenario I: Person with prediabets:
35 years old gentleman found to have fasting glucose 116 mg/dl and HbA1C of 6.2%. His lipids shows total cholesterol- 225 mg/dl; and triglyceride- 256 mg/dl. He is taking antihypertensive treatment for 7 years. His BMI is 29, and family history is positive for diabetes. Can he prevent diabetes? YES… there is evidence that diabete can be prevented especially in people with at risk for diabetes (pre-diabetes). Scientific studies aiming at 5% weight loss have shown to delay diabetes over 15 years follow up. Further weight loss also helps in decreasing blood pressure; lipids and helpful for heart disease prevention. People who loose more weight and maintain ideal body weight can reverse most of the metabolic disorders as well. For prevention of diabetes, healthy diet- food cooked at home from raw ingredients, adequate intake of fibers (vegetables; fruits and salad) and protein; limiting carbohydrate; avoiding processed food, avoiding canned juices. Regular exercise depending on physical status of person should be adopted.
Scenario II : Person with diabetes mellitus for 5 years
45 years old lady, bank executive, is known case of diabetes mellitus for 5 years. She is currently having gliptin and metformin combination. Her HbA1C is 6.3%. She is concerned about raised HbA1C. In current situation, she is having good sugar control with HbA1C below 6.5%. Further she is on oral medication combination, which will not cause low sugar (hypoglycaemia). Therefore she should be encouraged to maintain above good sugar control and additionally should be evaluated for associated disorders like hypertension; lipid disorders; weight and its related issues. She need to check annual kidney status (KFT and urine albumin leakage); diabetes eye disease; foot examination; and heart and vascular health.
Scenario III : Person with diabetes mellitus for 20 years
In next case scenario, 65 years old gentleman; known to diabetes for more than 20 years; heart disease – for which angioplasty been done. For last one year he is having deranged kidney function. He is currently on oral medications for diabetes and that is resulting into recurrent episodes of hypoglycaemia, including hospitalisation for same. He was told to maintain very tight sugar control to avoid further complications. After recent discharge from hospital, insulin was suggested as his kidney function does not allow oral medications. In current scenario- optimal glucose control is desirable rather than tight glucose control. He is at very high risk of hypoglycaemia. Glucose values ranging between 90-140 mg/dl in pre-meal and below 200 mg/dl post meal should be considered in target. HbA1C should be maintained between 7.5-8%. Insulin is better option if safe oral medications are failing to maintain above targets as some of the oral medications may cause very low sugar in elderly with kidney derangement. Further he should be evaluated for diabetes eye disease, which usually occurs with kidney disease.
In summary above three case scenario highlight preventive opportunities at different stages of diabetes. In first case we aim for preventing diabetes, in second we aim to prevent development of complications and in final case the aim is to limit further worsening of complications. Diabetes is a disease of opportunities, you can be benefited if you are well aware and do discuss with your doctor for better long term management.
About Dr Sunil Mishra
Dr. Sunil Mishra is a MD (Internal Medicine) and a DM (Endocrinology & Metabolism) from AIIMS, New Delhi. Dr. Sunil Mishra is currently with Medanta Hospital Gurugram as consultant Endocrinologist. Before joining Medanta Dr Mishra was working as an Associate Professor at HIHT University Dehradun