The triad in the treatment of diabetes mellitus is dietary life style, exercise and antidiabetic medications. Exercise and diet modifications have a major role in control of blood sugar levels. Initially managed by increasing exercise and dietary life style modification, medications are typically needed as the disease progresses.

 

Dietary management

• More of carbohydrate must be given as complex starches rather than simple sugars as they breakdown more slowly to release glucose in blood.
• The presence of fiber in complex carbohydrate like grains, vegetables and other starches slows the glucose absorption.
• One should emphasize more on the high fiber food instead of high fiber supplements.
• Foods to avoid- Glucose, sugar, honey, all sweets, chocolates and candies
• Foods to be restricted- alcoholic beverages, fried food, deep fried food, dry fruits, potatoes, sweet potatoes
• Foods to be taken- Green, leafy vegetables, tomatoes, cucumber. Fruits like guava, amla, papaya, and others
• It is important to control the amount and time of food intake. Meals should not be missed.
• Try to substitute the craving for sweet by taking some fruit

Exercise

• Exercises in diabetics help to control their bodies, gain strength, courage and confidence.
• Exercises improves circulation mainly arms and legs preventing diabetic complications like neuropathy, diabetic foot.
• It also reduces the risk of heart diseases, stroke found in diabetics.

Aerobic exercises like walking, jogging, aerobic dance or bicycling. If there are problems in feet or legs, you may consider exercises like swimming, bicycling, rowing or chair exercises.

The best among aerobic exercise is brisk walking, but need to regularly for 4-5 days in a week for at least 25- 30 min.

Aerobic tap backs: Start with the feet together. Tap the right foot to the back and return to center, tap the left foot back and return to the center. Alternate tapping the right and left foot back as you press the both arms to the front.

Antidiabetic medications

Antidiabetic drug	examples	Advantages	Adverse effects
Insulin secretogouges- Sulfonylureas	Glipizide, Gliclazide, Glibenclamide, Glibornuride and Glimepiride	Stimulates insulin secretion by beta cells of the pancreas	Hypoglycemia, nausea, vomiting, antabuse effects, hyponatremia and others
Insulin secretogouges- Meglitinides	Repaglinide, Nateglinide	Stimulates insulin release from pancreatic beta cells.	Hypoglycemia is faster and shorter compared to sulfonylureas
Insulin enhancers- Thiozolidinediones	Pioglitozone, Rosiglitazone	Decrease of hyperglycemia, glycosylated hemoglobin, plasma free fatty acids.	Weight gain, fluid retention, heart failure, and liver distrurbances
Alpha-glucosidase inhibitors	Acarbose,Miglitol	Decreases post-prandial hyperglycemia.	Abdominal flatulence, bloating, diarrhea and pain.
Aldose reductase inhibitors	Tolrestat, Imerestat, Vitamin-C 100mg/day	Reduces sorbitol accumulation in RBC’s
Insulin enhancers- Biguanides	Metformin	Decreases hyperglycemia without risk of hypoglycemia. Suppresses appetite- useful in obese individuals	Lactic acidosis, nausea, vomiting and diarrhea.

 

 

Newer class of drugs

Testosterone treatment is very efficient in insulin resistance.

Peptide analogues

• Glucagon like peptide analogues- Exenatide
• Dipeptidyl pepditase-4 inhibitors- Sitagliptin
• Amylin analogue- Pramlintide

Insulin preparations

The primary indication of insulin is in type I diabetes mellitus and gestational diabetes.

If Antidiabetic medications fail, insulin therapy may be necessary – usually in addition to oral medication therapy – to maintain normal or near normal glucose levels.

Types of insulin

Types of insulin	Onset in (hr)	Peak (hr)	Duration (hr)
Aspart, Glulisine, Lispro	0.2 - 0.5	0.5 - 2	3 - 4
Regular	0.5 - 1	2 - 3	6 - 8
NPH	1.5	4 - 10	16 - 24
Lente	1.5 – 3	7 – 15	16 - 24
Ultralente	3 - 4	9 – 15	22 -24
Glargine	----	No peak	24 - 36

 

 

Protocol for insulin therapy

Bed time NPH or Glargine insulin with anti diabetic medications, start 10- 15 units and titrate the fasting glucose to 120 mg/dl.

For twice day insulin start 0.5 U/kg with 2/3 in morning and 2/3 as NPH, to give insulin 20-30 min before meals.

For 2 or more injections daily, add Metformin or glitazone, if total insulin dosage exceeds >1-2 U/kg

Glycemic goals

• Self monitoring of glucose
• Laboratory monitoring of glucose

Test	Blood glucose (FBS, PPBS)	HbAIc	Lipid profile
DM with insulin treatment	Depends on blood glucose level	Every 3 months	yearly
DM without insulin treatment	Every 3 months	Every 3-6 months	yearly

 

 

• A good control on diet
• Regular aerobic exercises
• Antidiabetic medication on regular use