58. Alternative therapies in management of Diabetes

Diabetes mellitus is a metabolic disorder in the endocrine system. This dreadful disease is found in all parts of the world and becoming a serious threat of mankind health. There are lots of chemical agents available to control and to treat diabetic patients, but total recovery from diabetes has not been reported up to this date. In addition to adverse effects, drug treatments are not always satisfactory in maintaining euglycemia and avoiding late stage diabetic complications. Alternative to these synthetic agents, plants provided a potential source of hypoglycemic drugs and are widely used in several traditional systems of medicine to prevent diabetes. Several medicinal plants have been investigated for their beneficial effect in different type of diabetes. Other alternative therapies such as dietary supplements, acupuncture, hydrotherapy, and yoga therapies less likely to have the side effects of conventional approaches for diabetes.
Diabetes mellitus is a metabolic disorder characterized by hyperglycemia, abnormal lipid, and protein metabolism along with specific long-term complication affecting the retina, kidney, and nervous system. Diabetes mellitus has a significant impact on the health, quality of life and life expectancy of patients as well as on the health care system.

Diabetes mellitus has been recognized as a growing worldwide epidemic by many health’s advocacy group including WHO. The WHO has estimated that diabetes will be one of the world leading cause of death and disability with next quarter century. The statistics are alarming; 30 million people were diagnosed with diabetes worldwide in 1985, by 1995 the number had risen to 135 million, and at the current rate there will be some 300 million by the year 2025 as predicted by the WHO.Currently, there are more than 17 million type 2 diabetic patients in the United States (or ~5.9% of the population), 11 million in Europe, and 6 million in Japan; which represents a potential primary therapeutic market of over $6 billion. In the United States in 1997, the American Diabetes Association (ADA) reports that the total economic cost of diabetes was estimated to be $98 billion which includes $44 billion in direct medical and treatment costs, and $54 billion in indirect costs related to disability and mortality. The prevalence of all forms of diabetes is estimated to be 2%-3% of the world’s population, with the number of diabetics increasing by 4%-5% per annum.
Pathophysiology and Complication
Diabetes is known to have a strong genetic component with contributing environmental determinants. Although the disease is heterogynous, there appear to be a fairly consistent phenotype once the disease is fully manifested. Whatever the pathogenic cause the early stage of diabetes is characterized by resistance insulin, targeting tissue mainly in liver, skeletal muscle, and adipocytes. Insulin resistance in the tissue is associated with excessive glucose production by the liver and impaired glucose utilization by peripheral tissue, especially muscle.

Most of the food we eat is broken down into simply sugar called glucose. The glucose is the main source of fuel to get energy for the body. After digestion, the glucose reaches our blood stream, where it is available for body cells to utilize for energy, but insulin is needed for glucose to get into cells. Insulin is a hormone secreted by the pancreas to transport glucose from blood into different cells of the body. If the pancreas does not produce enough insulin or the produced insulin does not work properly, the glucose cannot enter the body cells. So glucose stay in blood cells which makes the blood sugar level high.

Thus the body losses the main source of fuel for the energy even though the blood contain high amount of glucose. Since glucose is not metabolized, high amount of glucose circulate in blood, kidney remove extra sugar from blood and excrete it in the urine.Since body does not utilize glucose, the body is under constant impression of hunger that’s why in diabetes appetite increases and patient eat more frequently.

With increased insulin secretion to compensate for insulin resistance, base line blood glucose level can be maintained with in the normal range, but the patient may demonstrate impaired response to prandial carbohydrate loading and to oral glucose tolerance test. The chronic over stimulation of insulin secretion gradually diminishes and eventually exhausts the islets beta cells reserve.

The quality of life of diabetic patient with chronic and severe hyperglycemia is adversely affected. Characteristic symptoms of tiredness and lethargy can become severe and lead to a decrease in work performance in adults and an increase of falls in the elderly.

The most common acute complications are metabolic problems (hyperosmolar hyperglycemic non ketonic syndrome or HHNS) and infections. The long-term complications are macrovascular complication, microvascular complications, and diabetic foot.
Conventional Therapy
The general consensus on treatment of type 2 diabetes is that life style management at the forefront of therapy options. In addition to exercise, weight control and medical nutrition therapy, oral glucose lowering drugs, and injections of insulin are the conventional therapies.

Pharmacological treatment is indicated when fasting glucose level exceeds 140 mg/dl the postprandial glucose level exceeds 160 mg/dl or HbAlc exceeds 8 %.[12]
Pharmacological Treatment and Limitations
Oral glucose lowering drugs: Five classes of oral agents are approved for the treatment of diabetes. Oral therapy is indicated in any patients in whom diet and exercise fail to achieve acceptable glycemic control. Although initial response may be good, oral hypoglycemic drugs may lose their effectiveness in a significant percentage of patients. The drug category includes sulfonylurea, biguanide, alpha-glucosidase inhibitor, thiazolidinedione, and meglitinide. These drugs have various side effects such as sulfonylurea causes weight gain due to hyperinsulenemia[13,14] biguanide cause weakness, fatigue, lactic acidosis, alpha glucosidase inhibitor may cause diarrhea while thiazolidinediones may increase LDL-cholesterol level.

Insulin is usually added to an oral agent when glycemic control is suboptimal at maximal dose of oral medication. Weight gain and hypoglycemia are common side effect of insulin.Vigorous insulin treatment may also carry an increase in atherogenesis.

Need and Scope of Alternative Medicine
Regardless of the type of diabetes, patients are required to control their blood glucose with medication and/or by adhering to an exercise program and a dietary plan. Due to modernization of lifestyle type 2 diabetes mellitus is becoming a major health problem in developing countries. Patient with type 2 diabetes mellitus are usually placed on a restricted diet and are instructed to exercise the purpose of which primarily is weight control. If diet and exercise fail to control blood glucose at a desired level, pharmacological treatment is prescribed. These treatments have their own drawbacks ranging from development of resistance and adverse effects to lack of responsiveness in a large segment of patient population. Moreover, none of the glucose lowering agents adequately control the hyperlipidemia that frequently met with the disease.

The limitation of currently available oral antidiabetic agents either in terms of efficacy/safety coupled with the emergence of the disease into global epidemic have encouraged alternative therapy that can manage diabetes more efficiently and safely.
Alternative Approach
Complementary and alternative therapy is treatments that are neither widely taught in medical schools nor widely practiced in hospitals. The use of CAM in the worldwide is increasing. In 1997, 42% Americans had used an alternative medical therapy. Total visit to complementary practitioners (629 million) exceed total visit to US primary care physicians (386 million). In Canada, a recent survey found that 75% people with diabetes used nonprescribed supplements (herbal, vitamin, mineral, or others) and alternative medications. Overall research indicates that most people who use CAM therapies do so in addition to, rather than in place of conventional medical treatment although some do not receive any concurrent conventional medical care. CAM for diabetes have become increasingly popular the last several years. Alternative therapies with antidiabetic activity have been researched relatively, extensively, particularly in India. Ideal therapies should have a similar degree of efficacy without troublesome.
Adapted from :Alternative therapies useful in the management of diabetes: A systematic review
Awanish Pandey et al; J Pharm Bioallied Sci. 2011 Oct-Dec; 3(4): 504–512.

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