S Shanmugam MBBS 1976 MD (Gen. Med) 1985
(Tirunelveli Medical College, Tirunelveli)
Director, Physician and Diabetologist Gomathi Sankar Diabetes and Hypertension Research Center Tirunelveli, Tamil Nadu, India
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Diabetes Mellitus
© 2006, S Shanmugam
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 2006
9788180618697
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd, Sector 60, Noida
Thiru CS ankara Kumaru Pillai
and
Thirumathi S Gomathi
5PREFACE
In India, there is a big issue or rather near total confusion related to Diabetes Mellitus and its prevalence in the recent decades due to inflow of Western statistics of migrant Indians or Asians from United Kingdom, Fiji Islands, etc and also city based statistics of India, which are trying to project India as the World Capital of Diabetes Mellitus. But, unfortunately this question of whether India is to be or not to be the World Capital of Diabetes Mellitus is yet to be properly answered in spite of there is a big army of Diabetologists and Physicians in India. There are limited contributions to the original or basic research and ideas in Indian context. If such types of work are done, that has got an important role to play for the guidance and management of Diabetes Mellitus at grass root level in Indian context. It will be really a welcome change and most rewarding exercise in academic circle. As an example, we can quote that usage of Metformin, a drug used as an oral antidiabetic is known to Indian Diabetologists for more than twenty-five years but we have very less research papers on the same. In USA, Diabetologists started using this drug for a decade and they have got quite a lot of papers in this area and are the ones now mostly quoted and also widely reported in world literatures.
India is a vast country with people of various linguistic, religious and cultural backgrounds. So, the people are in different physical and mental mould regarding the eating habits, work culture, exercise planning and approach to a chronic disease like Diabetes Mellitus. So, the natural history of Diabetes Mellitus behaves differently in different types of these ethnic variations within the country. A thorough study is needed on various types of these ethnic subgroups. To project the knowledge available from Western textbooks and literatures to Indian population is unjustifiable and impractical and that is what is done mostly at the moment in clinical practice.
Apart from the above differences, India is having five types of economic divisions among the people. They are
- Below poverty line (BPL).
- Basic amenities affordable.
- Modern facilities affordable.
- Rich.
- Highly rich.
Each type has got a different behavioral pattern of understanding the disease itself and also regarding the long term follow up. So, the incidence of complications of Diabetes Mellitus, a disease of complications is high in majority of Indian patients.
A genuine attempt was made by me when I joined Postgraduate course in Medicine in 1980 regarding the status of research in India in the field of Diabetology. Research in medicine may be basic or applied. In Diabetology, Indian population is not thoroughly studied regarding the various issues in Diabetology or for that matter about basic questions. Mostly we come across applied research, that too, to support the factors already discussed in Western countries or to disprove them in Indian context. Will that sort of research improve our image in other countries regarding the knowledge base of Diabetology in spite of ours is considered as the World Capital of Diabetes Mellitus? Definitely not.
We need to put forth new ideas, which were not thought of previously by any researcher in the world. In the process of this exercise, we might be able to find solutions for Diabetes Mellitus including a possible cure, which is at the moment a distant dream.
The thinking has created lot of new avenues for research in Diabetology, years after years and the new ideas were the rule than exception while presenting papers or writing articles in conferences or journals. That has created a floodgate of ideas for me to share with my fellow Diabetologists and Physicians.
This textbook on Diabetes Mellitus is more of a research oriented discussion about the Diabetes Mellitus in an order like a textbook pattern so that the new information are blended with old ones to get new ways of thinking for the younger generation to evolve better strategies for future research and management of Diabetes Mellitus. Apart from this, the textbook will be a guide for the academicians to get themselves involved in what is called basic research in Clinical Medicine especially Diabetology. This will create a ripple of knowledge to be useful for better management of Diabetes Mellitus and also better recognition for the works of Indian Diabetologists at the International arena.
With these few words, I hope the task of new presentation of Diabetes Mellitus having research orientation in Indian context is a big challenge than writing a regular textbook and I hope, I have fulfilled the task to the maximum extent possible.
Dr S Shanmugam
Tirunelveli
7ACKNOWLEDGEMENTS
This book is possible because of the intensive desire to do new information. The records and the observations from the patients whom I treated for the past quarter century are the base for the work of this nature. Inspite of, I cannot acknowledge every body individually, I hope the confidence reposed by them in my treatment, which are times may be new methods which are not described in standard textbooks, have helped to make new ways of presentation in Diabetology.
The credit for the chance given to me for writing this book of a different kind goes to the following personnel of Jaypee brothers. They are
Mr JP Vij, Managing Director of the publications.
Mr Tarun Duneja, General Manager (Publishing).
Mr R Jayanandan, Author Co-ordinator whose untiring encouragement is responsible for the work to be completed in time and published.
The untiring efforts of my work for this book is possible but for the cooperation of my wife Dr Rajathi Shanmugam and my children Miss S Gomati and Master S Sankar Krishnan who helped me to do this work, in spite of the hardships experienced by them due to my preoccupation with this work, I should acknowledge their help. Master S Sankar Krishnan helped me in the manuscript and the computer related works and special thanks to him for the efforts put forth by him.
The Scientific committees of different conferences, which selected my new ideas for presentations for the past years from 1985 to till date, need a special thanks in spite of individually it is difficult to acknowledge them.
8INTRODUCTION
Diabetes Mellitus is a disease of antiquity and universality. Diabetes Mellitus in short, DM can be considered as today's disease of pandemic. There is an alarm bell ringing throughout the world regarding the DM scenario. Is it right or wrong? -A debate is also going on. There is an important element of Indian views, experiences, research, treatment modalities and education for the diabetic population of India with its vast diversity of people, customs, food habits and mental approach to a chronic disease which is at the moment could not be cured but only can be controlled. Apart from that, a vast array of therapeutic modalities like Ayurveda, Siddha, Unani, Acupuncture and the likes are available for the common man to choose from and there are claims of cure by a group of people which always tempt any body with this sort of human suffering to try and indulge in. With this short back ground in mind, an Indian perspective of Diabetology without simply following the already available data from Western literature is programmed to be presented in the following pages.
Diabetes Mellitus is a metabolic cum vascular disorder with various presentations and subgroups. The disease is very much researched, worked out and worried about, written and talked about universally because of the nature of complications, one may get out of this syndrome. There was a dictum in Medicine in 19th century. If one knew well about Syphilis, the person knew about Internal Medicine fully. In the 20th century, if one knew well about Diabetes Mellitus, he/she knew about Internal Medicine totally was the dictum, which can explain about the way in which the complications present themselves and the resultant increase in the morbidity and mortality of the diabetic population. The increase in the prevalence of the Diabetes Mellitus and the awakening and awareness about the disease among the general population, makes it a disease of masses now. During the past twenty-five years, while analyzing the Indian scenario in Diabetes, I have important contributions, though not well studied but presented in various academic conferences are giving a real impact towards the Indian contribution to Diabetology for the betterment of the patients of Diabetes Mellitus as well as for the prevention of Diabetes Mellitus if not for the cure of the Diabetes Mellitus.9
The research areas were ranging from basic principles of metabolism like Theory of Metabolic Dominance to pathogenesis of the IDDM type of DM in the form of nitrosamines and the NIDDM –Type-II namely the relative obesity and coffee as a cofactor and in MRDM, the possible role of beedi smoking. The chapter on diet gives different but practical tips for better management of diabetic patients by the doctors including a new formula of diabetic drink. The problem of acute complications especially Diabetic Ketoacidosis is presented in a research oriented way for better management by Intensive care Specialist and even with less laboratory support in medium settings of medical service.
The important complications of Diabetes Mellitus namely Macrovascular diseases, which consist of Stroke, Acute Myocardial Infarction, and Peripheral Vascular Disease are dealt with applying Indian experience. Diabetic microvascular complications from the Physician's point of view are Diabetic nephropathy and neuropathy and new therapy on the nephropathy including a novel method of end stage renal failure is dealt with for management of them economically since people in developing countries like India are in need of such a therapy.
Management of Hypertension in Diabetes is a topic of great clinical importance and is dealt with separately.
The recently much talked about Autonomic dysfunctions of Diabetes Mellitus, regarding which I have done original research work as a Post Graduate in 1980–1982 for the dissertation for M.D (Gen. Med) –This is a treatise, which at that period was considered as an impossible task in our Medical college even by well experienced Professors and is widely dealt to clear doubts about Indian contribution on this important subject in the form of cardiovascular manifestations. Postural hypertension which is a new slogan in medicine and also a hard nut to crack in Diabetology namely Diabetic Impotence for which a therapy was made out by me in 1995 are dealt with separately.
The diabetic patients are poor risk surgical patients compared to general population is a well known fact. The specific and peculiar surgical problems of Diabetes, the anesthetic risks of the patients of long duration, the pre, per and post operative care of them for better outcome are discussed in detail in the Indian context.
Women and Diabetes is a topic, which is dealt in such a way that this can be an introduction for another textbook on this subject for Obstetricians and Gynecologists, Physicians and Diabetologists. The 10important outcome oriented discussion, which you cannot find in any textbook, will attract even Western Practitioners to look for details.
New information like vascular syndrome and long term follow up of DM and so many topics, which are dealt with, are food for thought for people dealing with food related disease. Community oriented Diabetology is the need of the hour in India and detailed planning is made on this area and this only will make the care of diabetic patients in India a possible reality with scientific out look and with economy. This will make the Science of Diabetology affordable even to the poorer of the poor.
Diabetic prevention is an area in which role of natural antioxidants and also the role of antioxidants in PVD and diabetic nephropathy are dealt in appropriate chapters.
No references have been given, since this book is a collection of twenty five years of Romance with the sweet disease of universe and the resultant offsprings. The vision of this work is to have a technology, which is culturally and socially acceptable, scientifically viable and financially affordable to all the people suffering from the chronic disease of this universe and millennium.
With this brief introduction let us deal in detail about a kaleidoscopic view of Diabetology in the eyes of an Indian Diabetologist.