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Sugar diabetes

Sugar diabetes (synonym: sugar diabetes, sugar disease) is a disease characterized by a violation of all types of metabolism as a result of insulin deficiency in the body and manifested by hyperglycemia and glycosuria.


Etiology . Heredity plays a significant role. The disease can occur under the influence of neuropsychiatric injury, prolonged overstrain of the nervous system, infection (flu, sore throat ), excessive consumption of carbohydrates , traumatic brain injury , etc.

Pathological anatomy. The main changes are found in the insular apparatus of the pancreas (see), which synthesizes the hormone insulin ; they are expressed by a decrease in the number of islets and the number of β-cells in them. In the pancreas are hyalinosis and fibrosis of the islets. In diabetes mellitus, common lesions of the capillaries (kidneys, retina, etc.) are also found.

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Pathogenesis . There are relative and absolute lack of insulin (see). The first may occur with normal insulin activity of the blood and the preservation of the islet of the pancreas. These cases of diabetes are associated with impaired tissue metabolism, for which compensation requires an amount of insulin in excess of the physiological norm. The absolute lack of insulin is associated with a deficiency of β-cells of the islets, the origin of which plays the role of pancreatitis , pancreatic tumors and other diseases. In the pathogenesis of diabetes mellitus, overeating is important, causing an overstrain of function (5-cells of the islets and contributing to revealing their hidden deficiency. In diabetes, the carbohydrate, protein, fat, water-salt metabolism and vitamin balance are disturbed.

The course and symptoms . The main symptoms of diabetes are thirst ( polydipsia ), excretion of large amounts of urine ( polyuria ), constant feeling of hunger, itching , hyperglycemia (see) and glycosuria (see). Patients drink a lot (up to 6–10 l of fluid per day). Often, especially in young patients, you can see a kind of blush on the face. The back surface of the palms and feet has a yellowish color. The skin is dry, rough, flaky; covered with scratches caused by itching. On examination of the skin, it is often possible to detect boils , eczema . Tongue dry. The liver is often enlarged. According to the severity of the clinical course, three forms of diabetes are distinguished: mild, moderate and severe. When compensating for the process, the patient maintains working ability and constant weight. The development of diabetes mellitus may be preceded by a state where clinical symptoms of the disease and glycosuria are absent, only the diabetoid type of the sugar curve is observed, i.e. after the load with carbohydrates (glucose, galactose , etc.), the rise of the curves is much higher and stays at high numbers longer than in healthy. Timely detection of this condition is important for the prevention of diabetes.

Diabetes mellitus is a chronic disease with a tendency to an increase in insulin deficiency and, consequently, to a transition to a more severe form. Contribute to the exacerbation of the disease: errors in nutrition, improper treatment, acute and chronic infections, intoxication , liver disease. Exacerbation of diabetes can lead to a serious complication - coma (see). Usually a few days before a coma, precursors appear: an increase in polyuria and thirst, severe weakness, drowsiness. At this time, you can smell the acetone from the patient's mouth. Urine and blood usually have a high content of sugar and ketone bodies (see Acetonemia). The sugar content in the blood usually exceeds 300 mg% (precomatose state).

Diabetes mellitus is relatively rare in childhood and adolescence. Over the years, its frequency increases and reaches a maximum of 40 - 60 years. Men and women are equally affected.

Complications : coma, glomerulosclerosis (bilateral diffuse kidney damage, manifested by proteinuria , hypertension , edema), pyelonephritis (see), retinopathy (changes in the retina of a non-inflammatory nature), cataract (see), furunculosis (see), septic processes, polyneuritis (see), amenorrhea (see below. Pregnancy and sexual function in women), a decrease in potency in men (see below. Sexual function in men).

The diagnosis is based on the patient's complaints (thirst, polyuria, weakness, decreased performance, pruritus) and data from laboratory tests of blood and urine. Differentiate should be with renal diabetes, which is characterized by normal blood sugar and normal sugar curve. From bronze diabetes (hemochromatosis) diabetes mellitus differs mainly in the absence of pigmentation of the skin.

Forecast . With proper systematic treatment is favorable. It worsens in the presence of the above complications and in neglected, poorly treated cases.

Treatment . The main therapeutic agents are: diet, insulin, antidiabetic hypoglycemic drugs .

A patient with newly diagnosed diabetes is hospitalized. Treatment with one diet can only be applied in patients with mild diabetes. Assign a normal physiological diet based on age, height, weight of the patient and the nature of his work. The daily diet includes 60% carbohydrates, 24% fat and 16% protein. In moderate and severe diabetes mellitus, insulin or its prolonged-acting preparations are prescribed: protamine-zinc-insulin, zinc-insulin suspension (ICS), amorphous zinc-insulin suspension, crystalline zinc insulin suspension. In some cases, in the absence of contraindications, insulin is prescribed in combination with oral hypoglycemic agents.

The insulin dose is calculated on the basis of the daily glycosuria (1 U of insulin contributes to the absorption of an average of 4 g of sugar). The greatest effect with the introduction of insulin occurs in 2-4 hours; duration of 6-8 hours. When insulin therapy is necessary to determine the sugar content in daily urine and blood. When treating with insulin, the following complications are possible: allergic reactions, insulin edema (sodium chloride should be limited and calcium chloride should be prescribed), lipodystrophy.

In case of insulin overdose or abnormal diet during insulin therapy, hypoglycemia can occur (see), the initial signs of which are hunger, weakness, trembling , sweating. If measures are not taken in time (the patient must eat a few teaspoons of granulated sugar, sugar or several candies), hypoglycemic coma may develop (see).

For the treatment of diabetes mellitus, sulfa drugs (bukarban, butamide, oranil, etc.) and biguanides (adebit, dipotin, silubin) are used. Contraindications to the appointment of sulfa drugs are: diabetes mellitus for children and adolescents, liver and kidney damage with a significant violation of their function, blood diseases, pregnancy , acidosis, precomatose and comatose states.

In case of non-urgent surgical interventions, preparatory treatment of the patient with diabetes mellitus with insulin and diet is necessary (combination of insulin with sulfonamides or biguanides is possible). In case of urgent surgical interventions, the patient with diabetes needs to enter another dose of insulin before the operation. A further dosage of insulin is determined by the level of glycemia and glycosuria.

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Sanatorium-resort treatment is indicated in cases of diabetes mellitus of mild and moderate severity in a state of stable compensation without tendency to acidosis ( Essentuki , Borjomi , Pyatigorsk , Jermuk , Java, Isti-Su, Truskavets , Berezovsky Mineralnye Vody, etc.). Patients with severe diabetes are referred to local sanatoria .

Therapeutic and physical culture prescribed for diabetes mellitus of mild and moderate severity. Begin with simple exercises lying and sitting. Increase the load gradually. If there are no contraindications from the internal organs, allow walking, easy dosed sports . If there are complications, select the appropriate therapeutic exercises.

Prevention . Limiting carbohydrate intake in families with aggravated diabetic heredity. Detection of the condition when the only manifestation of the disease is the diabetic type of the sugar curve. Prevention of exacerbations and the prevention of complications is reduced to a systematic, proper treatment of diabetes.

Pregnancy and sexual function in women . In diabetes mellitus, sexual function in women (amenorrhea, premature menopause , etc.) suffers. Rational therapy evens out violations. During pregnancy, diabetes mellitus is uneven - it worsens in the second half of pregnancy. Insulin treatment should be strictly individualized. Pregnancy in diabetes can result in miscarriage or premature birth . Due to the large fetus often observed in pregnant women suffering from diabetes, the labor act is delayed and the percentage of postpartum complications increases. Women with diabetes should from the very beginning of pregnancy be under the systematic observation of an obstetrician and an endocrinologist, who determine the terms of hospitalization in the department of pathology of pregnancy, indications for premature delivery.

Indications for termination of pregnancy: severe diabetes mellitus, the presence of nephro- and retinopathy, diabetes mellitus in both spouses.

Sexual function in men. Violation of sexual function (reduction of sexual desire and weakening of erection ability) is sometimes the first manifestation of diabetes. The degree of decrease in sexual ability is not related to the level of glycosuria. With the systematic treatment of sexual function is restored. In addition to treating the underlying disease, testosterone propionate, vitamins C, E, and B are indicated.

Sugar diabetes (synonym sugar diabetes, sugar disease) - a chronic disease of the body with a violation of all types of metabolism. In France, there are 25, and in the United States — 20 patients per thousand population. All over the world, according to incomplete data, there are up to 30 million patients with diabetes. Persons of both sexes, of all ages, are ill, but more often at the age of 40-60 years. The disease occurs everywhere, most often develops gradually.

Etiology and pathogenesis. There is no single cause of the disease. For the occurrence of diabetes mellitus, a hidden functional inferiority of the islet apparatus of the pancreas is necessary, which can translate into mental trauma, physical trauma of the skull or pancreas, infections, intoxication, excessive consumption of carbohydrate foods, intravenous glucose infusions. Obesity and hereditary predisposition to the disease can also contribute to more frequent incidence of diabetes, as well as inflammation and sclerosis of the pancreatic vessels, liver cirrhosis, inflammatory processes in other organs, pituitary disease (acromegaly, Cushing's disease), adrenal glands (pheochromocytoma), thyroid gland (thyrotoxicosis), etc.

When the disease develop enhanced neoglycogenesis in the liver, hyperglycemia, glycosuria, polyuria, polydipsia, and often weight loss. Due to absolute or more often relative insufficiency in the body of insulin and the development of neoglycogenesis, glycogen decomposition in the liver increases, some sugar in the renal tubules is not reabsorbed and excreted from the body with urine. Thirst and dry mouth appear due to dehydration. Increased appetite develops due to increased formation of lactic acid in the muscles, kidneys, lungs, spleen and increased energy expenditure of the body. Cachexia may appear as a result of the breakdown of existing reserves of proteins, fats and carbohydrates.

The easy occurrence of infections in diabetes mellitus is explained by the fact that during neoglycogenesis the blood γ-globulins are split, from which antibodies are usually formed. The liver loses glycogen, but is enriched with fats and proteins. The functions of the liver weaken, ketogenesis processes are enhanced. Ketone bodies accumulate in the blood, which are partially neutralized by ammonia or plasma bicarbonates. As a result, the alkalinity of the body decreases and acidosis develops. The body loses sodium, phosphorus and potassium. Potassium deficiency leads to paralysis of the respiratory muscles.

Clinical manifestations: hyperglycemia, sugar is detected in urine, in severe cases - acetone, acetoacetic acid and β-hydroxybutyric acid. From 3 to 8 liters of urine are excreted per day.

The severe complications of the disease include diabetic or hyperglycemic coma and hypoglycemic reaction. Patients noted skin itching, itching of the vulva. The skin is dry, scaly, hair is dull, nails are thick, on the palmar surfaces there may be yellowish deposits like xanthomatosis. On the skin can be found traces of scratching and boils. In young patients, blush of the cheeks is noted as a result of general capillary toxicosis. Abrasions and cuts do not heal for a long time. Gingivitis, alveolar pyorrhea, tooth loss develop. The liver often increases, and in children it is noted in 80-85% of cases. Liver function decreased. With diabetes mellitus, pneumonia and pulmonary tuberculosis often develop. In the blood, the level of cholesterol rises, which along with the fluctuations of sugar and adrenaline in the blood contributes to the development of early atherosclerosis. Therefore, in diabetes mellitus, thrombosis of cerebral vessels and coronary arteries of the heart can be observed. Increased vascular permeability, there is a general capillary toxicosis, as a result of which hemorrhages may occur. Often diabetes is combined with hypertension. Patients develop polyneuritis, often knee and abdominal reflexes. Muscle weakness, arthropathies develop, some muscle groups atrophy. Patients complain of pain in the legs and feet, often along the nerve trunks. Possible retinopathy, cataracts.

Severe complications of diabetes are glomerulosclerosis (see KIMMELSTILA-WILSON SYNDROME) and diarrhea. Reduced sexual desire, men have sexual weakness, in women - amenorrhea or menorrhagia, during pregnancy - spontaneous miscarriage, stillbirth. In women with diabetes, pregnancy in the first half of it has no particular effect on the course of the disease, although there is sometimes an increased need for insulin. However, in the second half of pregnancy, glycosuria may increase, apparently, due to an increase in kidney throughput for sugar during this period, which is associated with the action of progesterone. In the second half of pregnancy, the production of adrenocorticotropic hormone of the pituitary gland is also enhanced, which increases the release of cortisone and neoglikogenesis. It is believed that due to the effect of insulin produced by the fetus, sometimes in the second half of pregnancy, the carbohydrate metabolism of the mother improves. During childbirth, adrenaline adrenaline production increases and the amount of sugar in the blood increases. After childbirth, the sugar level of the puerperal decreases, as a result of which the doses of insulin to be administered should be reduced.

To prevent the development of acidosis during pregnancy should follow the correct diet regimen and insulin therapy. The use of sulfonamides instead of insulin during this period is contraindicated.

The peculiarities of diabetes in children include its rapid development, weight loss, blush on the cheeks; The disease in children is often genetically caused and triggered by infections, mental and physical trauma, and may be the result of an unhealthy diet.

In children, as in adults, in the pre-comatose state, sharp abdominal pain, peritoneal phenomena, and hematemesis may appear. In most children, the liver increases, changes in the cardiovascular system, including atherosclerosis and even myocardial infarction, retinopathy, and even cataracts, develop early. Growth and sexual development may be delayed. Only children develop MORIAC SYNDROME (see). There is a lighter tendency to acidosis than in adults.

Treatment. The main place in the treatment of the disease is a physiological diet with an individual account of the patient’s energy expenditures. To calculate the physiological diet, one recognizes the theoretical weight of the patient, subtracting one hundred from the number of his height using Brock's formula. With a home-style lifestyle, up to 30 calories per kg of weight is consumed, with light, intense, hard and very hard work, 40, 50, 60 and 65 calories per kg of weight are required, respectively. For example, for a person engaged in hard work, with a growth of 170 cm, the diet should be 70X50 = 3500 cal. 15–20% of daily calories should be replaced by proteins, 25–40% by fats, 60–40% by carbohydrates. The daily ration should be distributed so that the 1st and 2nd breakfasts take 45-50% of the ration, 40-45% for lunch and 10% for the dinner for dinner.

S. G. Genes and E. Ya. Reznitskaya proposed three types of diets for diabetes: sparing, intermediate and physiological tables (or tables I, II and III):

Diet Squirrels Fat Carbohydrates Calories
I
II
III
87
108
129
69
84
100
202
330
495
1827
2577
3488

In the case of oversupply in a patient, the total calorie is reduced by 15–20%, and with exhaustion increases by 10–15%.

M.M. Bubnova and M.I. Martynov recommend the following exemplary diets for children:

Age in years Content, g Calories
proteins fat carbohydrate
2-3
3-4
5-7
7—9
10 and older
53.0
60.2
64.3
90.0
106.5
32.0
38.6
49.4
55.2
62,8
182.0
217.0
280.0
284.0
354.0
1273
1513
1860
2095
2500

Calculation of the physiological diet for children is convenient to produce as follows: 1000 calories for the 1st year of a child’s life and another 100 calories for each subsequent year of life. For example, a child of 10 years should receive 1900 (1000 + 100-9) feces per day.

In the mild form of diabetes, a single physiological diet is sufficient. In moderate and severe forms of the disease, insulin is added to the diet to increase the ability of tissues to oxidize glucose, improve tissue permeability for glucose, retain neoglycogenesis, and glycogen deposition in the liver. The dose of insulin is distributed throughout the day, depending on the level of glycemia and glycosuria. At the same time, for every 5 g of the extracted sugar, 1 IU of insulin is prescribed. This is done to prevent hypoglycemic reactions, since the sugar equivalent of insulin (i.e., the amount of sugar corresponding to an insulin unit) is not constant even in the same patient. When it is increased, the amount of insulin assigned at the rate of 1: 5 may be redundant if it is first calculated for all the daily amount of sugar produced without a reserve balance.

In order to avoid hypoglycemia with the use of insulin, food with a sufficient carbohydrate content is administered 15 minutes and even 2.0-2.5 hours after the administration of insulin (the period of its greatest sugar-lowering action).

When indications for the use of large quantities of insulin it is administered in several stages. This makes it possible to more evenly distribute the daily rate of nutrition and use a smaller amount of insulin on the same diet, since its sugar equivalent increases as the single dose decreases. At the same time, the last dose should be administered 3-4 hours before sleep in order to avoid night hypoglycemia. It should provide a high-calorie diet and a sufficient amount of insulin in patients with diabetes mellitus and tuberculosis, as well as patients with diabetes mellitus during pregnancy.

To prevent postoperative acidosis in patients with diabetes mellitus, it is necessary to normalize metabolic disturbances with the help of fractional insulin and a full-fledged diet before any operation, and reduce the amount of fat in the postoperative period and add hydrocarbons.

For disorders of the coronary and cerebral circulation, hypertension, atherosclerotic myocardiosclerosis, insulin should be administered in fractional doses and, accordingly, distribute carbohydrates in the diet in order to prevent hypoglycemic states.

In order to lengthen the term of action of insulin, ordinary insulin is often replaced by insulin preparations with a prolonged hypoglycemic effect, which is slowly absorbed after subcutaneous administration. So, protamine-zinc-insulin reduces sugar within 24-26 hours with a maximum effect 8-10 hours after administration. Corresponding figures: for insulin-zinc amorphous suspensions — 10–12 and 1.5 hours; for insulin-zinc crystalline suspension - 24 and 10-12 hours; for insulin-zinc suspension mixed - 24 and 8-10 hours; for globin-zinc-insulin, 14 and 3-5 hours.

In the presence of endogenous or administration of exogenous insulin, it is possible to use glucose-lowering sulfonamide preparations (BZ-55, D-860, etc.). Сульфонамиды стимулируют выделение инсулина Р-клетками островков Лангерганса, тормозят действие расщепляющего инсулин фермента печени инсулиназы и способствуют отщеплению инсулина, связанного липопротеинами крови, в связи с чем сульфаниламиды наиболее эффективны v пожилых лиц с наклонностью к тучности, получающих 20—30 ЕД инсулина в сутки.

Сульфонамиды назначают, если состояние больных не коррегируется одной физиологической диетой.

Рекомендуется вводить от 0,5 до 1,5 сульфонамидов в сутки после еды. Противопоказания к применению препаратов: тяжелая ацидотическая форма заболевания, юношеские и детские формы его, наличие сопутствующих осложнений со стороны печени, почек, периферических нервов, глаз и т. д.