CHAPTER 2

LITERATURE REVIEW

2.1 YAM

Yam is the common name for some species in the genus Dioscorea (family
Dioscoreaceae). These are perennial herbaceous vines cultivated for the
consumption of their starchy tubers in Africa, Asia, Latin America and Oceania.
There are many cultivars of yam. Yam (Dioscorea spp., Dioscoreaceae) is
classified as monocotyledonous but is considered to be closely related to
dicotyledonous plants as a second cotyledon remains undeveloped in the
embryo (Lawton and Lawton, 1967). The storage organ is probably a swollen
hypocotyl (Lawton and Lawton, 1969), but is often described as a swollen root.
A number of species are grown widely in the humid tropics with D. rotundata
and D. cayenensis being of most importance, followed by D. alata and D.
esculenta (Akoroda, 1993). These are all of African or East Asian origin, with
only the minor species D. trifida being of American origin (Brücher, 1989). The
tubers contain about 1-3Â % protein on a dry weight basis (Coursey, 1995).

Yam is source of carbohydrate; carbohydrates are one of the three major food
groups needed for proper nutrition. Amylase is the digestive enzyme needed to
digest carbohydrates. Carbohydrates in food are an important and immediate
source of energy for the body. Starch refers to carbohydrates found in plants
(grains). Vegetables and fruits are a source of sugar and are broken down to
sugar or glucose. Carbohydrates are present in at least small quantities in most
food, but the chief sources are the sugars are the sugars and the sugars and the
starches (Wright, 1993)

2.2 YAMS NUTRITION FACTS

Yam plant is a perennial vine cultivated for its large, edible, underground tuber,
which can reach up to 120 pounds in weight and 2 meters in length. They are
one of the typical tropical crops requiring hot, humid climates and may cease to
grow when the temperature dips below 68 F.

Yams are similar in appearance to sweet potatoes, however, they are not at all
related to it. Important differences that distinguish them from sweet potatoes;
yams are monocotyledons, larger in size, features thick, rough, dark brown to
pink skin depending up on the cultivar type. Whereas sweet potatoes (Ipomoea
batatas) are dicotyledonous, relatively smaller size and possess very thin peel.
Although the tuber is grown throughout Africa, Nigeria is the world’s largest
producer, and exporter of yams accounting for over 70% of the world total
output.

2.3 HEALTH BENEFITS OF YAMS

 Yam is a good source of energy; 100g provides 118 calories. Its crunchy
edible tuber chiefly composed of complex carbohydrates and soluble
dietary fibre.

 Dietary fibre help reduce constipation, decrease bad (LDL) cholesterol

levels by binding to it in the intestines and lower colon cancer risk by
preventing toxic compounds in the food from adhering to the colon
mucosa. Additionally, being a good source of complex carbohydrate, it
regulates steady rise in blood sugar levels. For the same reason, yam
recommended as low glycaemic index healthy food.

 The tuber is an excellent source of B-complex group of vitamins. It

provides adequate daily requirements of pyridoxine (vitamin B6),
thiamine (vitamin B1), riboflavin, folates, pantothenic acid and niacin.
These vitamins mediate various metabolic functions in the body.

 Fresh root also contains good amounts of anti-oxidant vitamin; vitamin-C

provides about 29% of recommended levels per 100g. Vitamin C plays
some important roles as anti-aging, immune function booster, wound
healing and bone growth.

 Yam contains small amounts of vitamin-A, and beta-carotene levels.

Carotenes convert into vitamin A inside the body. Both these compounds
are strong antioxidants. Vitamin A has many functions like maintaining
healthy mucus membranes and skin, night vision, growth and protection
from lung and oral cavity cancers.

 The tuber indeed is one of the good sources of minerals such as copper,
calcium, potassium, iron, manganese, and phosphorus. 100g provides
about 816mg of Potassium. Potassium is an important component of cell
and body fluids which helps controlling heart rate and blood pressure by
 countering hypertensive effects of sodium. Copper is required in the
production of red blood cells. Manganese is used by the body as a co-
factor for the antioxidant enzyme, superoxide dismutase. Iron is required
for red blood cell formation.

2.4 VARIETIES OF YAM

There are about five varieties of yam to be reviewed. These are D. alata, D.
cayenesis, D. ratundata, D. esculenta and D. elumentorum.

2.4.1. DIOSCOREA ALATA (WATER YAM);

Leaves are broadly ovate and are borne opposite each other on the stem and the
vines are angular. There are no prickles or stipules. The tuber flesh is watery
and creamy white and the tube is unevenly shaped. The skin is thick and there is
a creamy or bright purple epidermal layer immediately below the skin. Maturity
is in about 8 – 10 months. The vines are weak and twin in a counter clock –
inflorescence and produces fruits which are three called capsule containing two
seeds in each cell.

2.4.2. DIOSCOREA CAYENESIS (YELLOW YAM)

This has leaves that are as broad as they are and has cylindrical vines. Prickles
where not joined are long and slender, and cylindrical in cross sect stipules are
generally narrow and constricted towards the base. The tuber skin is thick and
brittle. Vines twin anti-clockwise. This specie has a male inflorescence which
occurs singly or in pairs, but not in groups.

2.4.3. DIOSCOREA ROTUNDATA (WHITE YAM)

D. Rotundata has cylindrical vines with leaves which are long and broad, it is
mostly cultivated in West Africa and the West Indies. The tuber is white and
requires about seven months to mature. Tuber is generally thin skinned and the
vines twin anti-clockwise.

2.4.4. DIOSCOREA ESCULENTA (CHINESE YAM)

Here the vines twin in a clockwise direction and bear alternate, pale green
relatively small cordate leaves. The plant produces a bunch of soft sugary tubers
at the base of the stem. Tubers are small rounded structures. It maturity is about
eleven months. The tubers bruise easily and do not store longer before it start
sprouting within a short time.

2.4.5. DIOSCOREA DUMENTORUM (THREE–LEAF YAM)

D. Dumentorum has cylindrical stems with digitate compound leaves of 3, 5, or

7 leaflets. Twining is clockwise. Tubers are bunched and the flesh colour varies
from white to creamy white or yellow. Tubers may be bitter and sometimes they
are soaked for about three days before being prepared. Some varieties are
poisonous. Tubers reach maturity in about 10 months.

2.5 MEDICINAL USES

Yam tubers used various traditional medicines in China, Korea and Japan. Its
mucilaginous tuber milk contains allantoin, a cell-proliferate that speeds-up the
healing process when applied on ulcers, boils, and abscesses. Its decoction also
used to stimulate appetite and to relieve bronchial irritation, cough, etc.

2.6 COMPOSITION OF YAM

The tuber is the main economically utilizable part of the yam. As with other
crops, there is considerable variation in composition, not only between species,
but also within a single species, or even a single cultivar, according to the
cultural, climatic and eclaphic factors of the environment under which it was
grown, its maturity at harvest and the length of time.

2.7 ALPHA AMYLASE

α-Amylase is a protein enzyme EC [Link] that hydrolyses alpha bonds of large,

alpha-linked polysaccharides, such as starch and glycogen, yielding glucose and
maltose. It is the major form of amylase found in humans and other mammals.
It’s the primary starch-digesting enzyme secreted in the body. To be more
specific, it digests carbohydrates (polysaccharides) into smaller disaccharide
units, eventually converting them into monosaccharides, such as glucose. α-
Amylase is the major form of amylase found in humans and other mammals and
is mainly made in the pancreas and salivary glands, but it’s also produced by the
small intestine mucosa, ovaries, placenta, liver and fallopian tubes.

The amylase secreted by the salivary glands kicks off the enzymatic digestion of
starches in the mouth as food is chewed and mixed with saliva. It might be
surprising, but it’s true that the breakdown of larger, more complex starches into
simpler sugars actually starts in your mouth with simple chewing. This is why
chewing food thoroughly is truly key to good digestion and optimal overall
health.

Amylase is part of a six-step digestive process that begins with chewing in the
mouth and triggers the start of a domino effect in firing off mechanisms and
secretions:

1. Salivary amylase released in the mouth is the first digestive enzyme to

assist in breaking down food into its component molecules, and that
process continues after food enters the stomach.
2. The parietal cells of the stomach are then triggered into releasing acids,
pepsin and other enzymes, including gastric amylase, and the process of
degrading the partially digested food into chyme (a semifluid mass of
partly digested food) begins.
3. The acid also has the effect of neutralizing the salivary amylase, allowing
gastric amylase to take over.
4. After an hour or so, the chyme is propelled into the duodenum (upper
small intestine), where the acidity acquired in the stomach triggers the
release of the hormone secretin.
5. That, in turn, notifies the pancreas to release hormones, bicarbonate, bile
and numerous pancreatic enzymes, of which the most relevant are lipase,
trypsin, amylase and nuclease.
6. The bicarbonate changes the acidity of the chyme from acid to alkaline,
which has the effect of not only allowing the enzymes to degrade food,
but also bacteria not capable of surviving in the acid environment of the
stomach to break it down further.

2.8 AMYLASE HEALTH BENEFITS

Aside from the most key and central function to properly digest carbohydrates,
it also holds a lot of other valuable health benefits.
2.8.1. Improved Digestion

The mouth is the place where both the mechanical and chemical breakdown of
food occurs through the combined use of teeth, jaws and saliva. Amylases are
vital to digestive process because they’re needed to process any starches in
diet, which are a main source from which people derive glucose, the primary
sugar molecule the body uses for energy.

It’s key that you combine your body’s natural amylase-producing ability with
your natural ability to chew. Why is this important? Because if food is not
properly broken down in the mouth, then your body has more work to do in
order to digest and extract nutrients and energy from whatever you eat. By
chewing thoroughly, you give the amylase more time to process any carbs that
you have consumed, and the more time amylase has to work the better and
quicker your overall digestion will be.

In addition, cells in your pancreas make another form of amylase called

pancreatic amylase, which passes through a duct to reach your small intestine.
Pancreatic amylase completes the digestion of carbohydrates.

2.8.2. More Energy

I’m sure you know that food not only provides your body with nutrients, but it
also provides it with the energy it needs to keep you going on a daily basis.
Glucose is the primary sugar molecule that the body uses for energy, and while
you never want to have high glucose levels (think diabetes), you want to obtain
some glucose in your diet from healthy sources.

The amylases in your body break starch down into two sugar units, maltose and
isomaltose, and then other enzymes, called maltase and isomaltase, hydrolyze
these two sugars into the individual monosaccharide glucose. Foods that are
high in starch include breads, grains, cereals, pasta, rice, beans, corn, potatoes
and peas. If it wasn’t for amylase, your body wouldn’t be able to use foods like
these so efficiently to fuel you.

2.8.3. Anti-Diabetes

A 2013 study published in the Journal of Clinical & Diagnostic Research was
designed to determine the serum amylase, blood glucose and the serum lipid
profile in 110 type 2 diabetes patients compared to healthy individuals of the
same age and sex. The research showed that for the diabetic subjects wherever
blood sugar levels were higher, serum amylase activity was found to be
significantly lower. This finding was reflective of pancreas malfunction and
speaks to the importance of a healthy pancreas producing healthy amounts of
amylase.

Another study found that low serum amylase levels are associated with an
increased risk of metabolic abnormalities like diabetes as well as metabolic
syndrome. Together, these studies show the ability of this digestive enzyme to
maintain normal blood sugar levels and help treat or reverse diabetes
symptoms.

2.8.4. Alternative Cancer Treatment

When it comes to fighting cancer, people that choose to fight it holistically

sometimes incorporate digestive enzymes into their natural cancer treatment
plans. The Gonzalez regimen, developed by Dr. Nicholas Gonzalez, is one
holistic approach to cancer that combines prescribed diets, nutritional
supplements, coffee enemas and pancreatic enzymes. The regimen is aimed
at detoxifying the body, correcting nervous system imbalances that might lead
to impaired general health and supporting natural immune processes. The
pancreatic enzymes are believed to be the primary agents within the regimen
thought to have direct anticancer effects.

Enzymes are also a key aspect of the Kelley metabolic protocol to fight cancer,
developed by Dr. William Donald Kelley. Kelley, and famous embryologist
John Beard before him, believed that in order to beat cancer you don’t create a
new method of defense that fails to mimic the human body. Rather, you should
create a method of defense that acts just like the human body, and the human
body uses pancreatic proteolytic enzymes in the natural fight against cancer.

Both of these treatments are controversial, but some conventional and well-
respected cancer treatment centers even agree that patients suffering from
cancer, especially pancreatic cancer, can benefit greatly from pancreatic
enzymes. Having an insufficient amount of pancreatic enzymes is very common
among people with pancreatic cancer, and when the pancreas does not produce
enough enzymes to break down food, pancreatic enzyme products are needed.
Doctors sometimes prescribe digestive enzymes, including pancreatic enzymes,
to patients who have conditions that cause poor absorption. Cancer itself and
conventional cancer treatment are also known to interfere with production and
flow of digestive enzymes and insulin, which is why patients should utilize
natural approaches as well.

2.8.5. Stress Monitoring

Stress is by far one of the worst things in the world for your health, particularly
chronic stress. Research is showing that amylase can be a very helpful and
accurate marker of stress levels.

One study looked at the whether or not the salivary enzyme alpha-amylase
could indicate stress-reactive bodily changes. Researchers repeatedly measured
salivary alpha-amylase and salivary cortisol as well as plasma catecholamines
and cardiovascular activity before, during and after 30 young men underwent
the TSST. Results indicated that salivary alpha-amylase is sensitive to
psychosocial stress and may be a very helpful additional parameter for the
measurement of stress in humans.

Low amylase levels are also something to be concerned about. The

following common health issues could actually be a sign of amylase deficiency:

 Allergies
 Skin rashes
 Gas and constipation
 Mood swings
 Carbohydrate and sugar cravings
 Blood sugar imbalances
 Type 2 diabetes

2.9 GLUCOMETER

Glucometer is a medical device for determining the approximate concentration

of glucose in the blood. It can also be a strip of glucose paper dipped into a
substance and measured to the glucose chart. It is a key element of HBGM by
people with diabetes mellitus or hypoglycemia. A small drop of blood, obtained
by pricking the skin with a lancet, is placed on a disposable test strip that the
meter reads and uses to calculate the blood glucose level. The meter then
displays the level in units of mg/dl or mmol/l.

Since approximately 1980, a primary goal of the management of type I diabetes

and type II DM has been achieving closer-to-normal levels of glucose in the
blood for as much of the time as possible, guided by HBGM several times a
day. The benefits include a reduction in the occurrence rate and severity of
long-term complications from hyperglycemia as well as a reduction in the short-
term, potentially life-threatening complications of hypoglycemia.
Fig 2.1: blood glucometer and test strips

2.10 PRINCIPLE OF GLUCOMETER

Many glucose meters employ the oxidation of glucose to gluconolactone

catalyzed by GOx. Others use a similar reaction catalysed instead by another
enzyme, GDH. This has the advantage of sensitivity over glucose oxidase but is
more susceptible to interfering reactions with other substances.

The first-generation devices relied on the same colorimetric reaction that is still
used nowadays in glucose test strips for urine. Besides glucose oxidase, the test
kit contains a benzidine derivative, which is oxidized to a blue polymer by the
hydrogen peroxide formed in the oxidation reaction. The disadvantage of this
method was that the test strip had to be developed after a precise interval (the
blood had to be washed away), and the meter needed to be calibrated frequently.

Most glucometers today use an electrochemical method. Test strips contain a

capillary that sucks up a reproducible amount of blood. The glucose in the blood
reacts with an enzyme electrode containing glucose oxidase (or dehydrogenase).
The enzyme is reoxidized with an excess of a mediator reagent, such as a
ferricyanide ion, a ferrocene derivative or osmium bipyridyl complex. The
mediator in turn is reoxidized by reaction at the electrode,which generates an
electric current. The total charge passing through the electrode is proportional to
the amount of glucose in the blood that has reacted with the enzyme. The
coulometric method is a technique where the total amount of charge generated
by the glucose oxidation reaction is measured over a period of time. The
amperometric method is used by some meters and measures the electric current
generated at a specific point in time by the glucose reaction. This is analogous
to throwing a ball and using the speed at which it is travelling at a point in time
to estimate how hard it was thrown. The coulometric method can allow for
variable test times, whereas the test time on a meter using the amperometric
method is always fixed. Both methods give an estimation of the concentration
of glucose in the initial blood sample.

The same principle is used in test strips that have been commercialized for the
detection of DKA. These test strips use a beta-hydroxybutyrate-dehydrogenase
enzyme instead of a glucose oxidizing enzyme and have been used to detect and
help treat some of the complications that can result from prolonged
hyperglycemia.

Blood alcohol sensors using the same approach, but with alcohol dehydrogenase
enzymes, have been tried and patented but have not yet been successfully
commercially developed.

2.11 METER USE FOR HYPOGLYCEMIA

Although the apparent value of immediate measurement of blood glucose might

seem to be higher for hypoglycemia than hyperglycemia, meters have been less
useful. The primary problems are precision and ratio of false positive and
negative results. An imprecision of ±15% is less of a problem for high glucose
levels than low. There is little difference in the management of a glucose of
200 mg/dl compared with 260 (i.e., a "true" glucose of 230±15%), but a ±15%
error margin at a low glucose concentration brings greater ambiguity with
regards to glucose management.

The imprecision is compounded by the relative likelihoods of false positives

and negatives in populations with diabetes and those without. People with type
1 diabetes usually have glucose levels above normal, often ranging from 40 to
500 mg/dl (2.2 to 28 mmol/l), and when a meter reading of 50 or 70 (2.8 or
3.9 mmol/l) is accompanied by their usual hypoglycemic symptoms, there is
little uncertainty about the reading representing a "true positive" and little harm
done if it is a "false positive." However, the incidence of hypoglycemia
unawareness, HAAF and faulty counter regulatory response to hypoglycemia
make the need for greater reliability at low levels particularly urgent in patients
with type 1 diabetes mellitus, while this is seldom an issue in the more common
form of the disease, type II DM.

In contrast, people who do not have diabetes may periodically have

hypoglycemic symptoms but may also have a much higher rate of false
positives to true, and a meter is not accurate enough to base a diagnosis of
hypoglycemia upon. A meter can occasionally be useful in the monitoring of
severe types of hypoglycemia (e.g., congenital hyperinsulinism) to ensure that
the average glucose when fasting remains above 70 mg/dl (3.9 mmol/l).

2.12 DIABETES MELLITUS

DM, commonly referred to as diabetes, is a group of metabolic diseases in

which there are high blood sugar levels over a prolonged period. Symptoms of
high blood sugar include frequent urination, increased thirst, and increased
hunger. If left untreated, diabetes can cause many complications. Acute
complications can include DKA, nonketotic hyperosmolar coma, or death.
Serious long-term complications include heart disease, stroke, chronic kidney
failure, foot ulcers, and damage to the eyes.

Diabetes is due to either the pancreas not producing enough insulin or the cells
of the body not responding properly to the insulin produced. There are three
main types of diabetes mellitus:

 Type 1 DM results from the pancreas's failure to produce enough insulin.

This form was previously referred to as IDDM or "juvenile diabetes". The
cause is unknown.
 Type 2 DM begins with insulin resistance, a condition in which cells fail
to respond to insulin properly. As the disease progresses a lack of insulin
may also develop. This form was previously referred to as NIDDM or
"adult-onset diabetes". The primary cause is excessive body weight and
not enough exercise.
 Gestational diabetes is the third main form and occurs when pregnant
women without a previous history of diabetes develop high blood-sugar
levels.

Prevention and treatment involve maintaining a healthy diet, regular physical

exercise, a normal body weight, and avoiding use of tobacco. Control of blood
pressure and maintaining proper foot care are important for people with the
disease. Type I DM must be managed with insulin injections. Type II DM may
be treated with medications with or without insulin. Insulin and some oral
medications can cause low blood sugar. Weight loss surgery in those with
obesity is sometimes an effective measure in those with type II DM. Gestational
diabetes usually resolves after the birth of the baby.

As of 2015, an estimated 415 million people had diabetes worldwide, with type
II DM making up about 90% of the cases. This represents 8.3% of the adult
population, with equal rates in both women and men. As of 2014, trends
suggested the rate would continue to rise. Diabetes at least doubles a person's
risk of early death. From 2012 to 2015, approximately 1.5 to 5.0 million deaths
each year resulted from diabetes.

2.13 SIGNS AND SYMPTOMS

The classic symptoms of untreated diabetes are weight loss, polyuria (increased
urination), polydipsia (increased thirst), and polyphagia (increased hunger).
Symptoms may develop rapidly (weeks or months) in type I DM, while they
usually develop much more slowly and may be subtle or absent in type II DM.

Several other signs and symptoms can mark the onset of diabetes although they
are not specific to the disease. In addition to the known ones above, they include
blurry vision, headache, fatigue, slow healing of cuts, and itchy skin. Prolonged
high blood glucose can cause glucose absorption in the lens of the eye, which
leads to changes in its shape, resulting in vision changes. A number of skin
rashes that can occur in diabetes are collectively known as diabetic
dermadromes.

2.14 DIABETIC EMERGENCIES

Low blood sugar is common in persons with type I and type II DM. Most cases
are mild and are not considered medical emergencies. Effects can range from
feelings of unease, sweating, trembling, and increased appetite in mild cases to
more serious issues such as confusion, changes in behavior such as
aggressiveness, seizures, unconsciousness, and (rarely) permanent brain damage
or death in severe cases. Moderate hypoglycemia may easily be mistaken for
drunkenness; rapid breathing and sweating, cold, pale skin are characteristic of
hypoglycemia but not definitive. Mild to moderate cases are self-treated by
eating or drinking something high in sugar. Severe cases can lead to
unconsciousness and must be treated with intravenous glucose or injections with
glucagon.

People (usually with type I DM) may also experience episodes of diabetic
ketoacidosis, a metabolic disturbance characterized by nausea, vomiting and
abdominal pain, the smell of acetone on the breath, deep breathing known as
Kussmaul breathing, and in severe cases a decreased level of consciousness.

A rare but equally severe possibility is hyperosmolar nonketotic state, which is

more common in type II DM and is mainly the result of dehydration.
2.15 COMPLICATIONS

All forms of diabetes increase the risk of long-term complications. These

typically develop after many years (10–20), but may be the first symptom in
those who have otherwise not received a diagnosis before that time.

The major long-term complications relate to damage to blood vessels. Diabetes

doubles the risk of cardiovascular disease and about 75% of deaths in diabetics
are due to coronary artery disease. Other "macrovascular" diseases are stroke,
and peripheral vascular disease.

The primary complications of diabetes due to damage in small blood vessels

include damage to the eyes, kidneys, and nerves. Damage to the eyes, known as
diabetic retinopathy, is caused by damage to the blood vessels in the retina of
the eye, and can result in gradual vision loss and blindness. Damage to the
kidneys, known as diabetic nephropathy, can lead to tissue scarring, urine
protein loss, and eventually chronic kidney disease, sometimes requiring
dialysis or kidney transplant. Damage to the nerves of the body, known as
diabetic neuropathy, is the most common complication of diabetes The
symptoms can include numbness, tingling, pain, and altered pain sensation,
which can lead to damage to the skin. Diabetes-related foot problems (such as
diabetic foot ulcers) may occur, and can be difficult to treat, occasionally
requiring amputation. Additionally, proximal diabetic neuropathy causes painful
muscle wasting and weakness.

There is a link between cognitive deficit and diabetes. Compared to those

without diabetes, those with the disease have a 1.2 to 1.5-fold greater rate of
decline in cognitive function

2.16 PREVENTION

There is no known preventive measure for type I diabetes. Type II diabetes —

which accounts for 85-90% of all cases — can often be prevented or delayed by
maintaining a normal body weight, engaging in physical exercise, and
consuming a healthful diet. Higher levels of physical activity (more than 90
minutes per day) reduce the risk of diabetes by 28%. Dietary changes known to
be effective in helping to prevent diabetes include maintaining a diet rich in
whole grains and fibre, and choosing good fats, such as the polyunsaturated fats
found in nuts, vegetable oils, and fish. Limiting sugary beverages and eating
less red meat and other sources of saturated fat can also help prevent diabetes.
Tobacco smoking is also associated with an increased risk of diabetes and its
complications, so smoking cessation can be an important preventive measure as
well.

The relationship between type II diabetes and the main modifiable risk factors
(excess weight, unhealthy diet, physical inactivity and tobacco use) is similar in
all regions of the world. There is growing evidence that the underlying
determinants of diabetes are a reflection of the major forces driving social,
economic and cultural change: globalization, urbanization, population ageing,
and the general health policy environment.

2.18 Management

DM is a chronic disease, for which there is no known cure except in very

specific situations. Management concentrates on keeping blood sugar levels as
close to normal, without causing low blood sugar. This can usually be
accomplished with a healthy diet, exercise, weight loss, and use of appropriate
medications (insulin in the case of type I diabetes; oral medications, as well as
possibly insulin, in type II diabetes).

Learning about the disease and actively participating in the treatment is

important, since complications are far less common and less severe in people
who have well-managed blood sugar levels. The goal of treatment is an HbA 1C
level of 6.5%, but should not be lower than that, and may be set higher.
Attention is also paid to other health problems that may accelerate the negative
effects of diabetes. These include smoking, elevated cholesterol levels, obesity,
high blood pressure, and lack of regular exercise. Specialized footwear is
widely used to reduce the risk of ulceration, or re-ulceration, in at-risk diabetic
feet. Evidence for the efficacy of this remains equivocal, however.

2.19 Lifestyle

People with diabetes can benefit from education about the disease and
treatment, good nutrition to achieve a normal body weight, and exercise, with
the goal of keeping both short-term and long-term blood glucose levels within
acceptable bounds. In addition, given the associated higher risks of
cardiovascular disease, lifestyle modifications are recommended to control
blood pressure.
2.20 Medications

Medications used to treat diabetes do so by lowering blood sugar levels. There

are a number of different classes of anti-diabetic medications. Some are
available by mouth, such as metformin, while others are only available by
injection such as GLP-1 agonists. Type I diabetes can only be treated with
insulin, typically with a combination of regular and NPH insulin, or synthetic
insulin analogs.

Metformin is generally recommended as a first line treatment for type II

diabetes, as there is good evidence that it decreases mortality. It works by
decreasing the liver's production of glucose. Several other groups of drugs,
mostly given by mouth, may also decrease blood sugar in type II DM. These
include agents that increase insulin release, agents that decrease absorption of
sugar from the intestines, and agents that make the body more sensitive to
insulin. When insulin is used in type II diabetes, a long-acting formulation is
usually added initially, while continuing oral medications. Doses of insulin are
then increased to effect.

Since cardiovascular disease is a serious complication associated with diabetes,

some have recommended blood pressure levels below 130/80 mmHg. However,
evidence supports less than or equal to somewhere between 140/90 mmHg to
160/100 mmHg; the only additional benefit found for blood pressure targets
beneath this range was an isolated decrease in stroke risk, and this was
accompanied by an increased risk of other serious adverse events. A 2016
review found potential harm to treating lower than 140 mmHg. Among
medications that lower blood pressure, ACEIs improve outcomes in those with
DM while the similar medications ARBs do not. Aspirin is also recommended
for people with cardiovascular problems, however routine use of aspirin has not
been found to improve outcomes in uncomplicated diabetes.