Dr Smita Brahmachari
Abstract :- The present article focuses to provide practical information on the management of Diabetes Mellitus with respect to the current concepts and management strategies practiced by health care professionals in the care of individuals with diabetes. Homoeopathic remedies are found to be safe and effective alternative in treatment of patient suffering from this chronic disease.
Keywords :- Diabetes mellitus, Homoeopathy, Management, Miasmatic T/t.l
Introduction :- Today on the eve of the twenty first century, we see that the world health situation is no longer that clear cut and simple. Many developing countries have made great progress in combating infectious diseases and malnutrition, thereby improving the length and quality of life of their people. But rapid urbanization and industrialization in those same countries, together with the adoption of modern lifestyle that adversely effect have brought new problems in the form of chronic non-communicable diseases. In many developing countries these new problems are arriving before the old one’s are resolved leading to a double burden of the disease. The incidence of diabetes has risen from almost nothing a century ago to a level of major concern today. Diabetes is a very old disease since the inception of human civilization [500 A.D.]. It is described in Indian Ayurvedic literature as ‘Madhumeha’ or honey in the urine / sweet urine.
Definition:- According to the International Expert Committeee working under the sponsorship of American Diabetes Association [ADA] 1997, Diabetes mellitus is a group of metabolic disease characterized by hyperglycaemia [high blood glucose] resulting from the defects in the insulin secretion / action or both. Chronic hyperglycaemia of diabetes is associated with long term damage, dysfunction of various organs especially the eyes, kidneys, nerves, heart and blood vessels. For easy understanding Diabetes is a state of high blood glucose [blood sugar] due to absolute / relative lack of hormone insulin. Scientifically speaking, it is more correct to use ‘Blood glucose’ instead of blood sugar, since there are many types of sugar of which glucose is just one [the simplest].
Diagnosis:-The primary diagnostic criterion for DM is elevation of blood glucose levels during fasting or at 2 hours following a meal. Normal plasma glucose values for adults in the fasting state are 80 – 120 milligrams per decilitre [mg/dl]. Definition of unequivocal DM requires a fasting blood sugar level greater than 126 mg/dl or a 2-hour post ingestion plasma glucose level equal to or greater than 200 mg/dl for the appearance of classical symptoms of Diabetes. These symptoms, which include excessive urination, urine containing sugar, hunger, thirst, fatigue and weight loss, are common to all types of DM.
Classification:-Despite the use of a plethora of different terms in the past, diabetes is now generally classified as type I DM [insulin dependent diabetes mellitus] and type II DM [non-insulin dependent diabetes]. Other variants of DM include maturity-onset diabetes of youth, tropical diabetes, which shows characteristics of both insulin dependence and non-dependence, and gestational diabetes, which occurs during the latter part of pregnancy. Approximately 90-95% of all diabetics may be classified as type II, and about 5% as type I. Some 2% of diabetics have DM as a secondary result of other disease or injury.
Epidemiology :- According to the study by WHO, between 1995 and 2025, the number of people with Diabetes in India is projected to rise from 19 to 57 million, i.e., an increase of 95% indicating global burden of diabetes. By 2025, in developing countries 76% of all persons will be suffering diabetes as compared with 62% in 1995. Worldwide, 122% rise is projected from the total of 135 to 300 million. That is more than 2 fold global increase will occur because of population gain and growth as well as from obesity, unhealthy diets and sedentary lifestyle. These later factors are closely associated with urbanization and industrialization. The top three countries with Diabetes in prevalence rate by 2025 will be India [57 million], followed by China [38 million] and USA [22 million]. In India there are presently 4 crore diabetics. The rising prevalence of diabetes in our country, both among the urban and rural population, has established the fact that majority of Indians are vulnerable to this fatal disease.
Management:-Diabetes is all about sugar – the sugar in our bodies known as blood sugar or blood glucose. Every cell in our bodies must have a constant source of glucose in order to fuel metabolism. Our cells use glucose to power processes such as growth and repair. When we eat a meal the digestive system converts much of our food into glucose which is released into the bloodstream. The hormone insulin, which is secreted by the pancreas gland, moves glucose from the blood and funnels it into the cells so it can be used as fuel. If the cells are unable to get adequate amounts of glucose they can literally starve to death. As they do, tissues and organs begin to degenerate. This is what happens in diabetes. It also brings with it the burden of nephropathy, retinopathy, hypertension, stroke and coronary artery disease. [So management of this disease may include medications and lifestyle modifications such as achieving and maintaining proper weight, diet, exercise and foot care combined with regular ongoing blood glucose level monitoring. Currently, one goal for diabetics is to avoid or minimize chronic diabetic complications, as well as to avoid acute problems of hyperglycemia or hypoglycemia. Adequate control of diabetes leads to lower risk of complications associated with unmonitored diabetes including kidney failure (requiring dialysis or transplant), blindness, heart disease and limb amputation.
1. Diet :- It is not easy being a diabetic. Oral drugs or insulin are of absolutely no use if the person concerned is not willing to change the life style and the eating habits. Diet then is an important part of the daily routine of a diabetic. For most Type 1 diabetics there will always be a need for insulin injections throughout their life. However, both Type 1 and Type 2 diabetics can see dramatic normalization of their blood sugars through controlling their diet. As diabetes can lead to many other complications it is critical to maintain blood sugars as close to normal as possible and diet is the leading factor in this level of control.
I. The goal of diet therapy is to obtain an ideal body weight by consuming the desired amount of calories.
II. Ideal body weight [IBW] and Body Mass Index [BMI]:- IBW (in kg) = (Height in cms – 100) × 0.9, BMI = Weight in kg / (height in mts)2.
III. BMI:- Normal = 17 – 27 (in males); 17 – 25 (in females), lean (underweight) < 17, Overweight > 27 – 32; Obesity > 32.
IV. Encourage :- Whole food high in fibre, low animal fat intake, no added salt and avoidance of sweet.
V. Distribution of nutrients in the diet :- Carbohydrate = 60 – 65%, Protein = 15 – 20% and Fats = 15 – 25%.
VI. Balanced diet :- Diet should not be monotonous. It should be a balanced diet prepared by proportionate quantity of different food groups depending upon desire and aversion, age, sex, weight, height, occupation of the patient, type of Diabetes and its complications.
VII. Constituents of the diet :- Allowance – 60 – 65% of total calories. Sources are cereals and its products (mainly whole grain cereals), pulses, beans, fresh fruits and vegetables. A diabetic patient can take rice in right amount preferably mixed with dal or rajmah with green vegetables in consultation with the physician.
VIII. South Indian dishes like Idlis and Dosa which have low fat content are good for them. Indian roti is best as it raises the blood sugar levels slowly.
IX. Proteins :- Allowance 15 -20% of total caloric consumption/day and adult needs 0.8 kg in wt. of protein per day. The sources are i.] First class proteins (animal proteins) :- Non–veg – egg, chicken, mutton, fish and in veg – milk, curd and paneer. ii.] Second class proteins – Soyabeans, grams, dals, peas, beans, nuts (dry fruits). iii.] Third class proteins – cereals, oats, barley, ragi, wheat and rice. Meat has got high fat content while dal has got high protein content. Protein intake should be reduced in renal failure while increased during pregnancy stage.
X. Seasonal Green leafy vegetables are good source of vitamin B complex and minerals along with supplying antioxidants anf fibers. They are low in caloric value. Sprouts are very nutritive and good as snacks.
XI. Fruits :- Banana, mango, jackfruit and grapes are to be avoided. One fruit of one variety is the recommended amount at a time. Indian Blackberry (jamun) prevents conversion of starch into sugar, thus effective in controlling diabetes.
XII. Fat allowance is 15 – 25% of total calories, 3 – 4 tsf per day. Visible oils for cooking purposes.
XIII. Micronutrients :- Vit.E is supplemented for antioxidants benefits preventing free radical damage which leads to complications. Sodium content(salt) : dietary intake of 1000 mg / 1000 kcal should not exceed 3000 mg /day.
XIV. All diabetic recipes must avoid Sugar as far as possible. Artificial sweeteners can be resorted to, but remember products high in fat and cholesterol, which have been artificially sweetened by aspartame, or saccharin should not be consumed in the name of a being a diabetic diet. Their high calorific content makes them unsuitable for diabetics.
XV. Spices and Condiments :- Fenugreek seeds provides soluble fibre, omega 3 fatty acid, triglyceride and cholestrol, Long clove and tumeric (haldi) – antioxidant activity controlling free oxygen radical damage, Garlic :- 1- 3 gms /day, has fibrinolytic activity, replaces potassium lost in urine; Onion – 20 – 30 gms/day, decrease platelet aggregation and helps in decreasing Blood sugar and lipid.
XVI. Alcohol should be avoided as it provides additional source of calories (each ml providing 7 calories); ppts hypoglycaemia and exacerbates neuropathy, dyslipidaemia, obesity and makes diabetes control difficult.
XVII. Fasting is not advisable for diabetic patients specially the non – obese, avoid overcooking, reheating and deep freezing of food, certain food like papad and bhujia and fried things to be avoided.
XVIII. Avoid Smoking and tobacco.
XIX. Special food for diabetics :- Bitter gourd (karela) – this vegetable contains high quantity of ‘plant insulin’ and thus lowers blood sugar effectively; Flax seed – richest source of omega 3 fatty acids, controls diabetes by maintaining the sensitivity of the cell membrane, facilitates insulin and uptake of glucose by the cells. Water extracts of Cinnamon has found to promote glucose metabolism and control cholestrol.
2. Exercise:- About 2500 years ago, ancient Indian physician Susruta stressed upon the importance of exercise in the treatment of Diabetes. Shortly after the discovery of insulin in 1922, it was shown that exercise potentiates the effect of insulin. Benefits of exercise are innumerable – Helps in long term glycaemic control, reducing body weight, the requirement of oral hypoglycaemic agents or insulin, improvement in insulin, lipid profile, cardiovascular function, increases body fitness and stamina, sense of well-being, improves the quality of life, prevents atherosclerosis and ageing. Response to exercise depends upon diabetic status of the patient, blood glucose level, availability of insulin and state of hydration. Ideal time for exercise is early morning. The patient should have small snacks before exercise to prevent hypoglycaemia. But there are certain risks associated with exercise – Hyperglycaemia (in poorly contolled diabetic pt.s), Ketoacidosis, Hypoglycaemia (in tightly controlled diabetes), heart attack (sudden Myocardial infarction in pt. with silent Myocardial ischaemia) and sudden blindness (in diabetics with proliferative Diabetic retinopathy due to vitreous haemorrhage). The patient may resort to yoga, meditation and perform regular pranayama to avoid stress which ppts. Diabetes.
3.Medications:- In Allopathy The most prevalent form of medication is hypoglycemic treatment through either oral hypoglycemics and/or insulin therapy. Insulin and five classes of oral therapy (sulphonylureas, meglitinides, biguanides [metformin], glitazones and [alpha]-glucosidase inhibitors) are currently available to treat diabetes. Patients with type 1 diabetes mellitus require direct injection of insulin as their bodies cannot produce enough insulin. Injection can be done by insulin pump, by jet injector, or any of several forms of hypodermic needle. For type 2 diabetics, diabetic management consists of a combination of diet, exercise, and weight loss, in any achievable combination depending on the patient. Obesity is very common in type 2 diabetes and contributes greatly to insulin resistance. Weight reduction and exercise improve tissue sensitivity to insulin and allow its proper use by target tissue. Patients who have poor diabetic control after lifestyle modifications are typically placed on oral hypoglycemics.
4. Clinical evaluation:- In addition, a strong partnership between the patient and the physician is an essential tool in the successful management of diabetes. The patient should have regular appointments with the physician. Upon the diagnosis of diabetes, a detailed medical examination is highly essential to obviate complications at a early stage.
- Height and weight measurements
- Blood pressure measurements
- Thyroid profile [T3, T4, TSH]
- Examination of hands, fingers, feet, and toes for circulatory abnormalities
- Blood tests for fasting and postprandial blood sugar estimation, HbA1c, and lipid profile.
- Family history of diabetes, cardiovascular disease, and CVA to be enquired
- Prior infections and medical conditions
- A list of current medications, including: Prescription medications, Vitamin, mineral or herbal supplements to be enquired.
- Smoking history, including encouragement to stop smoking (if applicable)
- Signs of complications with pregnancy.
- Eating and exercise habits
- Vision abnormalities, to check for eye health issues
- Routine and microscopic urine examination to exclude kidney abnormalities.
Diabetes can be very complicated, and the physician needs to have as much information as possible to help the patient establish an effective management plan. The physician can also make referrals to a wide variety of professionals for additional health care support.
Personal (home) glucose monitoring :- Control and outcomes of both types 1 and 2 diabetes may be improved by patients using home Glucose Meters to regularly measure their glucose levels. The effort and expense may be worthwhile for patients when they use the values to sensibly adjust food, exercise, and oral medications or insulin. These adjustments are generally made by the patients themselves following training by a clinician. Regular blood testing, especially in type 1 diabetics, is helpful to keep adequate control of glucose levels and to reduce the chance of long term complications of the disease. There are many (at least 20+) different types of Blood Monitoring Devices available on the market today; not every meter suits all patients and it is a specific matter of choice for the patient, in consultation with a physician or other experienced professional, to find a meter that they personally find comfortable to use. Self-testing is clearly important in type I diabetes where the use of insulin therapy risks episodes of hypoglycaemia and home-testing allows for adjustment of dosage on each administration.
5.homoeopathic approach of treatment of diabetes mellitus :- According to Homoeopathic guidelines, the patient is to be treated not his organs or parts or systems or tissues. So also in Diabetes mellitus our objective of treatment is patient himself not the pancreas nor the B-cells. So the constitutional treatment is the only way for radical cure of DM along with proper diet control and regular exercise. Our aim is not merely to bring down the blood sugar level but to have improvement in both subjective and objective sphere of the patient.
Miasmatic background:- In the pathogenesis of Type I DM [I.D.D.M.], where destruction of the β cells is the soul cause of this disease, syphilitic miasm should be present in this disease process. In the other hand from the pathogenesis of Type II DM [N.I.D.D.M.], insulin resistance [inability of the peripheral tissues to respond to insulin], and abnormality of glucose receptors and β cells of pancreas are the primary causes rather than inadequacy of insulin. So incoordination is the soul factor in the disease process. Therefore Sycotic miasm should be present here. And where secondary causes [especially the psychological stress] are the main responsible factor causing functional disturbances in the disease pathogenesis of Type II DM [N.I.D.D.M.], psora is the dominanting factor behind the disease process.
Samuel Hahnemann, stated in his ‘Chronic Disease’ that Diabetes is a Psoric manifestations. As per the above knowledge of different pathogenesis we can consider this statement as a prime true and on the field of basic Psora other miasms [Sycosis and Syphilis] can build up their own manifestations accordingly. According to many Stalwarts, Diabetes belongs to a mixed miasmatic state of Psora and Syphilis.
Chronic miasmatic states Psora, Sycosis, Syphilis and the resultant combination of these miasm play the important role in the development of Diabetes mellitus. Syphilis by its destructive process cause a diminution of the effective mass of islets of langerhans, which leads to absolute lack of insulin resulting I.D.D.M., Psora leads to functional disturbances resulting diminished effectiveness of insulin and developing N.I.D.D.M., on the other hand Sycosis by its incoordination results in endocrinal disharmony and dysfunctional feed back mechanism, thereby insulin antagonist increases in circulation leading to relative decrease in biological effectiveness of insulin. Now the basic pathology behind all Complications is angiopathy [both micro and macro] which comes under the domain of syphilitic miasm.
So the above discussed miasmatic cleavage should be taken into consideration during the selection of similimum. Homoeopathic medicines are found to be safe and effective in the treatment of case of Diabetes. A few medicines are discussed below with their proper indications:-
- Acetic Acid :- Diabetes with anaemia, burning thirst and debility.
- Alloxanum :- Diabetes with Osteoporosis, muscular weakness, glycosuria without hyperglycaemia.
- Apis :- Diabetes with pain in tendoachilles.
- Carbo veg, Kreosotum, Sec cor :- Humid gangrene of diabetics, collapse, persistent epistaxis
- Chionanthus :- Diabetes with hepatic troubles, enlarged liver and spleen.
- Chimaphila :- Diabetes with prostatic enlargement, unable to urinate unless feet are wide apart, burning scanty urine with mucopurulent sediment.
- Flouric acid and Aur met :- Diabetes associated with acquired or hereditary syphilis.
- Helonias :- Diabetes becoming rapidly grave, melancholic pt., thirst, restless. Emaciated.
- Ignatia and Nat phos :- Diabetes of nervous origin, pt. has silent grief.
- Kreosotum:- General action in diabetic gangrene, ulcer with offensive discharge.
- Lycopus :- Diabetes with heart troubles.
- Lactic acid and Elaps :- Diabetes with strong elimination of uric acid in urine, HTN, gouty modalities.
- Plumbum met :- Diabetes with paralytic tendency.
- Phos acid :- Diabetes of nervous origin with impotency.
- Thyroidinum :- Diabetes with h/o of allergic manifestations, stressful life.
- Uranium nit:- Diabetes with assimilative disorders and great emaciation.
Conclusion :- Constitutional antimiasmatic treatment along with due stress on preventive measures plays significant role in radical cure of patients suffering from diabetes and also preventing long term complications.
- Boericke W., “Pocket Manual of Homeopathic Materia Medica with Repertory and Indian Drugs”, Reprinted edition, New Delhi, B. Jain Publishers Pvt. Ltd., 2004.
- Hahnemann, Samuel.: “The Chronic Diseases, Their Peculiar Nature and Their Homoeopathic Cure.”, B. Jain Publishers Pvt. Ltd. Reprint Edition: 2005.
- Park, K.: “Text book of Preventive and social medicine”, M/s Banarsidas Bhanot publishers, Nineteenth edition, February 2007
- Hahnemann, S; “Organon of Medicine”, Indian Book & Periodical Publishers. Reprinted 5th & 6th edition, Reprint edition. April 2004.
- Stephens J. McPhee, Maxine A. Papadakis, Eds Ralph Gonzales, Roni Zeiger; “Current Medical Diagnosis and Treatment”, 2009.
Dr. Smita Brahmachari – She has done her M.D. (Hons.), Dept. of Repertory, from National Institute of Homoeopathy, under the West Bengal University of Health Sciences. She is presently working as Medical Officer in Delhi Govt. Dispensary, under Dept. of ISM&Homoeopathy, Govt. of NCT Delhi. The readers are requested to give their feedbacks in the author e-mail id : firstname.lastname@example.org.