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Jan 9, 2008

Know this sweet enemy

Diabetes – to fight it, you must first know all about it!

THE shocking truth today is that almost everyone knows someone with diabetes. Be it a friend, relative or loved one, diabetes changes people’s lives.

In 2006, the global prevalence of diabetes hit 4% of the world’s population (246 million people); it hit an alarming 8% of our population (2.1 million people) in Malaysia.

Uncontrolled hyperglycaemia (excess sugar) affects almost every organ in the body through both large (macrovascular) and small (microvascular) blood vessel damage.
Despite improvements in healthcare facilities, better treatment and extensive awareness campaigns, it seems difficult to overcome the void that surrounds the disease. The first step to being in control of this disease is to know all about it.

What is diabetes?

The heart of the problem lies in the pancreas, a leaf shaped organ situated adjacent to the stomach in the human body.

Apart from compliance to medication, patients succeed far better in achieving glycaemic goals by realising the importance of lifestyle modification, especially towards diet and physical exercise.
Among other functions, the pancreas is responsible for the secretion of insulin, the principal hormone that regulates the uptake of glucose into muscle, fat and most other cells of the body.

Secreted from the beta cells of the pancreas, the deficiency or insensitivity of insulin plays a cardinal role in diabetes, leading to a state of high blood sugar levels, termed hyperglycaemia.

Types of diabetes

The World Health Organization recognises three main types of diabetes: type 1, type 2 and gestational diabetes. Although all types share the common dysfunction, the causes are different.

In type 1 diabetes, the lack of insulin is due to an autoimmune destruction of the pancreatic beta cells resulting in insulin deficiency.

Type 2 diabetes is characterised by insulin resistance, the inability to utilise insulin at the target organs. Exceptionally high amounts of insulin are required to maintain glycaemic levels and diabetes develops when the pancreas is unable to keep up with the demand.

Similarly, insulin resistance may be triggered by the hormones of pregnancy, leading to gestational diabetes.

Signs and symptoms

The classical triad in diabetes is frequent urination (polyuria), excessive thirst (polydypsia) and increased appetite (polyphagia).

In addition, type 1 diabetes patients experience weight loss despite normal or excessive eating habits. Symptoms manifest earlier and more rapidly in type 1 than in type 2 diabetes patients whose symptoms may be subtle or even absent.

Many type 2 patients are often diagnosed incidentally during health screenings or present with complications of diabetes such as reduced vision, poor healing of wounds or even a stroke.

Consequences of uncontrolled diabetes

Uncontrolled hyperglycemia affects almost every organ in the body through both large (macrovascular) and small (microvascular) blood vessel damage.

While macrovascular damage begins almost simultaneous to the diagnosis of diabetes, microvascular damage begins as early as the onset of the disease.

In most patients the onset of the disease process may precede a good 10 years with insulin insufficiency before the disease may be diagnosed clinically.

Microvascular complications predominantly affect the eyes (diabetic retinopathy), nerves (diabetic neuropathy) and the kidneys (diabetic nephropathy).

It is dreadful that Malaysia has the highest population of patients on dialysis due to diabetes in the world today!

While microvascular complications may be devastating to live with, macrovascular complications may lead to more fatal outcomes such as stroke and heart attacks.

Screening for diabetes

Screening practices differ across healthcare providers and availability of facilities. Some recommend universal screening for adults above 40 years of age and periodically thereafter.

Earlier screening is recommended for those with high risk factors such as obesity, family history of diabetes and other concomitant chronic conditions such as hypertension and lipid abnormalities.

Confirming the diagnosis

Diagnosing diabetes is done by demonstration of recurrent or persistent hyperglycaemia through one of the following ways:

1. A fasting plasma glucose (FPG) level of above 7.0 mmol/L

2. A random plasma glucose (RPG) level above 11.0 mmol/L

3. A 2-hour post prandial glucose (PPG) level above 11.0 mmol/L

When symptoms are absent, a positive diagnosis should be made pending confirmation by another one of the above methods on a different day. Most physicians consider FPG > 7.0 mmol/L on two consecutive days to be diagnostic of diabetes.

Patients who have FPG between 6.1-7.0 mmol/L are termed impaired fasting glycaemia and those with PPG = 7.8 mmol/L are termed impaired glucose tolerance.

These two pre-diabetic groups should not be ignored as they are at a major risk of developing both full-blown diabetes and cardiovascular diseases in the future.

Although a poor diagnostic indicator, an elevated level of glucose irreversibly bound to haemoglobin, known as glycosylated haemoglobin levels (HbA1c), is a good treatment tracking tool as it reflects the average glucose levels over approximately the last three months. Measured in percentage, HbA1c >6.0% is considered abnormal by m ost labs.

How can diabetes be controlled?

The paramount aim of treatment is to achieve and more importantly maintain good glycaemic control through which the complications can be managed or even avoided.

Doctors should adopt a holistic approach towards the patient with the provision of patient education, dietary support and timely screening of complications in addition to pharmacological therapy.

Apart from compliance to medication, patients succeed far better in achieving glycaemic goals by realising the importance of lifestyle modification, especially towards diet and physical exercise.

Historically, since 1921, when insulin was discovered and used in the treatment of diabetes, the number of diabetes related amputations and deaths reduced tremendously compared to the years before.

Today, there still remains no substitute for insulin in the treatment of diabetes despite the advances in the oral anti-diabetic range of drugs.

A frequent myth about insulin is that it is perceived as a last resort rather than the physiological substitute to the original deficiency of the disease.

The goals!

Recent recommendations by the American Diabetes Association and the European Association of Diabetes for “good glycaemic control” in patients with diabetes is HbA1c <>

They add that early initiation of insulin may be the answer to achieving goals rapidly. Evidence has shown that people who achieve and maintain good glycaemic control have a significantly lower incidence of diabetes related complications.

Every 1.0% reduction in HbA1c has been associated with a 37% reduction in microvascular complications and 14% reduction in diabetes related heart attacks.

Diabetes is life long disease and is progressive in nature. The key to sustaining good quality of life is by staying a step ahead of the disease.

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