COMPLICATIONS OF DIABETES MELLITUS (DM) (Microvascular)

DIABETIC RETINOPATHY

Diabetic retinopathy is damage to the photosensitive part of the eye (retina) common in long standing diabetes mellitus for at least 10 years. It is the leading cause of blindness amongst people under the age of 65 years. High blood sugars puts small blood vessels at throes of being destroyed especially those of the eye. The damaged blood vessels are weak and leak fluid and lipids.[1]

These small blood vessel leaks may cause some of the blood vessel to be occluded leading to ischemia (lack of blood supply) and as a way of body's adaptation to these changes, new blood vessel grow to provide alternative blood supply to areas in the eye which lack blood. These new blood vessels lack connective tissue and are fragile with high likelihood to bleed into the eye segments. [2]

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To take you through a crush course of anatomy, the eye has got two segments i.e anterior and posterior segment. Anterior segment is filled with aqueous fluid secreted by the cilliary gland. The posterior segment is filled with the vitreous body. [3]

Bleeding into these segments causes visual loss which may be reversible but when left untreated results into profound and irreversible loss of vision, traction of the retina leading to retinal detachment. [2]

DIABETIC NEPHROPATHY.

Diabetic nephropathy is when there is an increase in albumin excretion through the urine. According to American Diabetes Association, about 40% of people with type 1 and 2 DM are suffer from diabetic nephropathy. [4]

Diabetic nephropathy is characterized by thickening of the glomerular basement membrane and enlargement of the mesangium. Thickened glomerular basement membrane is defective in its function and allows proteins in blood to permeate. This causes proteins to appear in urine which is unusual occurrence in absence of kidney pathology. [2]

According to the level of albuminuria, Diabetic Nephropathy is categorized into two:-

1. Microalbuminuria- the urine albumin excretion is >20µg/min and less than or equal to 199µg/min.
2. Macroalbuminuria- urine albumin excretion of more than 200µg/min [4]

Mesangium enlargement leads to defects in glomerular filtration with resultant diminished function if the kidney filtration. This leads to accumulation of water and waste products in the body (renal failure). [2]

Care:-

1. In type 1 DM, annual screening for microalbuminuria.
2. In type 2 DM, screen for microalbuminuria at the point of diagnosis then done annually thereafter.
3. Treating lipid problems with cholesterol lowering tablets.
4. Treating and monitoring of high blood pressure.
5. Achieving better glycaemic control. [4]
   
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DIABETIC NEUROPATHY.

This is damage to the nerves that occurs in people with diabetes mellitus. It is more prevalent in people with poorly controlled blood glucose level. High blood sugar is toxic to the nerves in the body and is implicated with damage to nerves and blood vessels. [5]

Peripheral neuropathy- this involves damage to the nerves of the feet and occasionally hands. Individual with peripheral neuropathy may present with:-

• Loss of sensation of feet and/or hands.
• Not able to elicit a 10-g mono-filament device.
• Reduced ankle and knee reflexes.
• Loss of balance
• Hypersensitivity of feet and legs which worsen at night with patient not able to tolerate weight of beddings on the lower limbs.
• Burning sensation. [2]

Autonomic neuropathy- different systems like the cardiovascular system, gasto-intestinal system, genito-urinary system and the skin.

• Heart- increased heart rate at rest, postural hypotension.
• Gastro-intestinal system- abdominal bloating, feeling of satiety, delayed stomach emptying, nausea, vomiting, altered bowel habits with evidence of diarrhea and stool incontinence.
• Skin- excess facial sweating with eating.
• Urinary system- urine incontinence, urine retention/incomplete emptying of bladder, increased risks to urinary tract infections.[6]
  
  
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References.
1. Wikipedia, the free encyclopedia. Diabetic Retinopathy. Viewed at http://www.en.m.wikipedia.org/wiki/diabetic_retinopathy. Viewed on 20/05/2015, last edited 2days ago by Spokbot (from the date of view)

2. Medicine, Second Edition 2004. By John Axford and Chris O'callaghan.  Diabetic Mellitus, Lipoprotein Disorders and other metabolic diseases- complicstions of diabetes mellitus. Viewed on 20/05/2015

3. Ross and Wilson textbook of Anatomy and Physiology, in health and illness, by Anne Waugh and Allison Grant. Tenth edition. The Special Senses, sight and the eye. Viewed on 20/05/2015.

4. America Diabetes Association, Diabetes care. Diabetic nephropathy: diagnosis, prevention and treatment by Jorge L. Gross, MD, Mirela J. De Azevedo, MD, Luis Henrique Canani, MD, and Themis Zelmanovitz, MD. Viewed at: http://www.care.diabetesjournals.org/content/28/1/164.abstract. viewed on 21/05/2015

5. Mayo Clinic, Diseases and Conditions. Duabetic neuropathy by Mayo clinic staff. Revised on Feb 24th, 2015.
Viewed at: http://www.mayoclinic.org/diseases-conditions/diabetic-neuropathy/basics/definition/con-20033336.

6. Wikipedia, the free encyclopedia. Diabetic Neuropathy. Edited 11 days ago (from date of viewing 23/05/2015) by Paine Ellsworth.
Viewed at: http://en.m.wikipedia.org/wiki/Diabetic_neuropathy

WHY ICE CREAM MAY NOT BE GOOD FOR YOU

Facts can't be fathomed.

An ice-cream vendor will not pass-by without appreciating his or her services because of high demand for ice-creams.

But do you know ice-cream have a detrimental health implication to your body?

Ice-cream is an animal product and is loaded with saturated fats which has been associated with high morbidity of heart diseases like heart attack, high blood pressure, stroke e.t.c. These outcomes are as a result of the ability of saturated fats to increase blood cholesterol levels especially the bad cholesterol which accumulates along the inner layer of big arteries causing narrowing and eventually block the blood vessel. Science qua science recommends minimal consumption of saturated fats vis-a-vis unsaturated fats which can be consumed at moderately higher amount beacuse of their proven health benefits. 

References

1. The New York Times, Study Questions Fat and Heart Disease Link NYT.com by Anahad O'conner (on 26/12/2014)
2. Applied Reasearch, Cancer Control and Population Science. Top food sources of saturated fat among US population, 2005-2006 NHANES

SECONDHAND TOBACCO SMOKE (the darkest side to active and passive smokers)

Smoking almost affects every organ in the body. Smoking is the leading cause of preventable death in UK and second most cause of death in U.S after cardiovascular diseases. WHO estimates that tobacco causes 6 million deaths every year with 600, 000 of these deaths occurring among non-smokers due to second hand smoke. 

Secondhand smoke is smoke that comes from a lit end of a cigarette, cigar or pipe. Also exhaled smoke by smokers is also second hand smoke and it poses great health risks to the smoker and non-smokers.

According to American Cancer Society, secondhand smoke is a known to cause cancer. Tobacco smoke contains mixture of different gases and particles. It contains more than 7000 chemicals, 250 of the chemicals thought to be harmful to human health and at least 69 are associated with development of cancer. 

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Smoking causes cancer of nose, mouth, larynx, trachea, esophagus, throat, lungs, liver, stomach, pancreas, kidney, bladder, cervix, bone marrow, blood, colon and rectum. 

OTHER EFFECTS OF TOBACCO SMOKING TO GENERAL HEALTH.

• Smoking compromises the body's defense against infections putting active and passive smokers at risk if severe infections. It is also associated with auto-immune diseases like Crohn's disease and rheumatoid arthritis. 

• Smoke is inhaled and rapidly absorbed into the blood causing rapid heart rate. This an also be associated with the carbon monoxide i smoke which compromises the body's ability to carry oxygen and release it to the body cells.

• Tobacco smoking is associated with increased risk of heart diseases. Its compounds can cause narrowing of blood arteries which later can lead to blockage accounting for heart attack and stroke incidences.

• Tobacco smoke causes increase in total cholesterol values in the blood. This may lead to high blood pressure.

• Smoking increases certain blood clotting factors like fibrinogen and platelets which makes blood thick and risk of clot formation. 

• Male smokers are at risk of developing impotence by 85% as compared to non-smokers.
• Nicotine in tobacco smoke is thought to interfere with body's ability to synthesize estrogen which affects ovulation. Female smokers have 60% more risk of being infertile than non-smokers.

• Exposure of pregnant mothers to tobacco smoke increases risk of abortions, low-birth weight and other pregnancy problems.

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references.

Secondhand smoke- American Cancer Society. Address: http://www.cancer.org/cancer/cancercauses/tobaccocancer/secondhand-smoke

Effects of smoking on your health- U.S Department of Health and Human service. Address: http://betobaccofree.hhs.gov/health-effects/smoking-health/

Health effects of tobacco- Wikipedia. Address: https://en.wikipedia.org/wiki/Health_effects_of_tobacco

Smoking- MedlinePlus. Adress: https://www.nlm.nih.gov/medlineplus/smoking.html

DIETARY FATS (The pros and cons)

SATURATED, UNSATURATED FATTY ACIDS AND TRANS FATS

Just like carbohydrate and protein, fat is an important macro nutrient and form an integral role in nutrition of human body. Fats are hydrophobic, soluble in organic compounds and insoluble in water. Fats function as most dense source of chemical energy to the body with one gram providing 9 kilo calorie.[1]

Fats energy release is more than two folds to what either protein or carbohydrate provides per gram. [2] This translates to what health professional say that consuming more energy dense food (fats) can lead to rapid weight gain with an imminent sequelae of being overweight.[4]

Fats are composed of saturated or unsaturated fatty acids and glycerol.[3]

According to the number and bonding of carbon atoms in fats, fats can be classified in the following categories to include:-

• Saturated fats- they have single bonds between carbon atoms saturated with hydrogen atoms. Mostly found in animal products like milk and milk products, cheese, butter oily fish [3]
• Unsaturated fats- they have one or more double bonds between carbon atoms mostly found in most vegetable oils. [3]

SATURATED FATS

According to American Heart Association, saturated fats increase the 'bad' cholesterol (LDL) in the body increasing the risks to heart diseases and stroke.[4]

Saturated fats increase total blood cholesterol, triglycerides and LDL cholesterol and lowers the 'good' cholesterol -HDL. Saturated fats affects the entire lipid profile increasing risks to heart diseases, stroke and type 2 diabetes mellitus. [5]

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American Heart Association recommends eating little saturated fatty acids to give a total of 5- 6% of the total daily caloric requirement. [6]

TRANS FATS.

Trans fats are produced during industrial process by partial hydrogenation of liquid vegetable oils in the attempt to make them more solid. They give food desirable taste, used for deep frying in fast-food outlets on the grounds that oils with trans fat do last for longer.

According to American Heart Association, trans fats raise the 'bad' cholesterol (LDL) and lower the 'good' cholesterol (HDL) level in blood which is a risk factor for development of heart diseases, stroke and type 2 diabetes.

Trans fats are found in foods like cakes, pizza, biscuits, cookies, pie crusts.

The Michigan F.D.A (Food and Drug Administration) has already given a grace period of 3 years (ending 2018) for the food industry to eliminate trans fats in the food they produce. Trans fat clog arteries increasing risks for heart diseases [8] and type 2 diabetes mellitus. [9]

UNSATURATED FATS.

These fats contain one or more double bound between the carbon atoms. They are divided into two forms:-

Monounsaturated fats- they have one double bond between the carbon atoms. [10] Sources of monounsaturated fats include:-

• Avocado
• Sufflower oil
• Sunflower oil
• Olive oil
• Nuts
• Vegetable oil[11]

Polyunsaturated fats- they contain more than one double bond between the carbon atoms.[10]

Polyunsaturated fats are further divided into:-

• Omega-3 fats
• Omega-6 fats

Omega-3 fats are cardio-protective in that they help in lowering the bad cholesterol in the body, lowers blood triglycerides and lower the systemic blood pressure. Sources are;

• Eggs
• Oily fish like salmon, sardines
• Lean meat.
• Chicken.
• Flaxseed, walnut, soybeans, canola oil.

When omega-6 fats are consumed in place of trans fats and saturated fats, they help to lower risks of heart diseases and stroke. Food sources of Omega-6 fats include;

• Margarine spreads
• Sufflower oil
• Sunflower oil
• Soybeans
• Sesame oil
• Walnuts[12]

The American Heart Association recommends consumption of monounsaturated and polyunsaturated fats in place of trans fats and saturated fats because of their health benefits of lowering the bad cholesterol, lowering triglycerides, lowering the blood pressure and enhancing heart health. [13]

OUR RECOMMENDATIONS IN KENYAN DIET:-

Due to the aggressive nature of industries to make cheaper fats that most of the population can afford, it is our own responsibility as consumers to check food labels and ascertain and appreciate the fact that different fats and oils have different composition of fats. We discredit use of solid fats as they have high levels of saturated fatty acids (SFA) with almost all of them having zero trans fat to use of oils with higher levels of Polyunsaturated fatty acids (PUFA) and Monounsaturated fatty acids (MUFA) and low levels of saturated fatty acids (SFA) as low as 10%.

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References:
1. Fat- Wikipedia, The Free Encyclopedia. Last edited: May 17, 2015. Address: https://en.wikipedia.org/?title=Fat. Viewed on: 17/06/2015.
2. Normal Values, Diet- Ross and Wilson textbook of Anatomy and Physiology in health and illness. 10th Edition, 2006 by Ann Waugh, Allison Grant. Page 464.
3. Introduction to nutrition, fats- Ross and Wilson textbook of Anatomy and Physiology in health and illness. 10th Edition, 2006 by Ann Waugh, Allison Grant. Page 373.
4. Fats 101- American Heart Association. Address: http://www.heart.org/HEARTORG/GettingHealthy/FatsAndOils/Fats-101_UCM_304494_Article.jsp#mainContent. Viewed on: 17/06/2015
5. Saturated fats- Wikipedia, The Free Encyclopedia. Edited on: June 13, 2015 by Jefr. Address: http://en.m.wikipedia.org/wiki/saturated-fat. Viewed on; 17/06/2015.
6. Saturated fat- American Heart Association. Address: http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/Saturated-Fats_UCM_301110_Article.jsp#mainContent. Viewed on:17/06/2015.
7. Saturated fats- Heart Foundation. Viewed at: http://www.heartfoundation.org.au/healthy-eating/fats/pages/saturated-fats.aspx. viewed on: 17/06/2015.
8. F.D.A sets 2018 Deadline to Rid Foods of Trans Fats- NYTimes.com by Sabrina Tavernise. June 16, 2015. Address: http://mobile.nytimes.com/2015/16/17health/fda-gives-food-industry-three-years-eliminate-trans-fats.html?_r=0&reference=. Viewed on 17/06/2015
9. Trans fats- American Heart Association. Address: http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/Trans-Fats_UCM_301120_Article.jsp#mainContent. Viewed on: 18/06/2015.
10. Unsaturated fats- Wikipedia, the free encyclopedia. Edited: 17th April, 2015 by Deli nk. Address: http://www.en.m.wikipedia.org/wiki/unsaturated_fat. Viewed on 18/06/2015.
11. Nutrition for Everyone: Basics: Unsaturated fat|DNPAO|CDC. Address: http://www.cdc.gov/nutrition/everyone/basics/eat/unsaturatedfat.html. Viewed on: 18/06/2015.
12. Unsaturated fats|Dietitians Association of Australia. Address: http://daa.asn.au/for-the-public/smart-eating-for-you/nutrition-a-z/unsaturated-fats/. Viewed on: 18/06/2015.
13. Polyunsaturated fats- American Heart Association. Address: http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/Polyunsaturated-Fats_UCM_301461_Article.jsp#mainContent. Viewed on: 18/06/2015.