Prepared by Dr. Lim Shueh Lin
Gleneagles Hospital Penang
Diabetes Mellitus is a chronic disease whereby the blood sugar in the body is high due to inability of the body to utilize sugar as the main source of energy, causing the blood sugar to rise above normal range. The high blood sugar in the long run will cause damage to the big blood vessels (macrovascular diseases) resulting in stroke; blockage of the coronary vessels (coronary heart disease) resulting in heart attack; and blockage of the blood vessels of the legs causing non-healing diabetic ulcer, at times resulting in the amputation of limbs. If not well controlled, diabetes will also cause damage to the small blood vessels (microvascular complications) in the eyes, kidneys and limbs resulting in blindness, kidney failure, as well as limb nerve damage. Once the damage is done, it is unfortunately permanent.
How common is diabetes? Very much so in Malaysia. According to the 2015 National Health and Morbidity Survey, 17.5% of Malaysians aged 18 years old and above have diabetes. In other words, almost one in five adult Malaysians has diabetes. What is even more alarming is at least 50% of these people do not know they have the condition. There was a general increasing trend in prevalence with age, from 5.5% in the 18-19 years age group, reaching a peak of 39.1% among the 70-74 years age group. We are now seeing more of our young people and adolescents living with diabetes.
The problem is diabetes is a silent disease. Many people who have it do not exhibit any symptoms or signs. For these people, diagnosis of diabetes can only be made through a blood test. It is recommended that people who are at risk of diabetes should do a regular blood test either annually or twice yearly to measure their blood sugar level. Remember that a majority of people with diabetes do not have any warning signs until the diabetes is very severe. So if you fit any of the risk factors for diabetes, you need to be proactive and check your blood glucose regularly.
The risk factors for diabetes are:
1. First-degree relative with diabetes. Once you have a first-degree relative with diabetes, your risk of getting diabetes is 50%.
2. Women with a history of diabetes in pregnancy (GDM)
3. Overweight or obese (BMI > 23)
4. People with heart disease
5. People with hypertension
6. People with high triglyceride but low HDL cholesterol
7. People who are physically inactive
8. People who have abnormal sugar test previously (pre-diabetes range)
9. People above the age of 30 years old
10. People who have symptoms suggestive of high sugar (this is not very common)
Symptoms of high blood sugar:
2. Feeling of excessive thirst
3. Passing excessive urine
4. Weight loss
5. Blurred vision
6. Multiple skin infections
7. Itchy private areas (vulvovaginitis, balanitis)
8. Non-healing ulcers
There are many ways you can screen for diabetes. The easiest will be to go to your doctor and do a finger prick glucose test. A clearly normal finger prick glucose test would indicate that you do not diabetes. However, if the result is borderline or clearly abnormal, then you need a proper laboratory blood glucose test. Tests that can be done are fasting blood glucose, random blood glucose, oral glucose tolerance test or glycosylated haemoglobin A1C. The latter the average blood glucose in the body for the last three months. If in doubt, it is best to discuss with your doctor what type of glucose test is best for you.
If both your parents have diabetes, you can still delay the onset of diabetes by leading a healthy lifestyle. You cannot change your family history but you can take charge of your life. You can delay the onset of diabetes by keeping your weight in check, consuming a healthy diet, and working out regularly. The ideal amount of exercise is at least 150 minutes per week; i.e. an average of half an hour five times weekly. Studies have shown that such practices have helped people with diabetes or even pre-diabetes to revert to normal blood sugar level.
Types of Diabetes
There are two types of diabetes, namely Type 1 Diabetes and Type 2 Diabetes.
95 percent of diabetes is due to type 2 diabetes whereby the problem lies in either one of more of the following:
1. Ineffective body insulin
2. Low production of insulin by the pancreas
3. Excessive production of glucagon by the pancreas
4. Excessive production of sugar by the liver when blood sugar is already high
5. Overactive re-absorption by the kidney of the sugar from urine back to the blood
In contrast, type 1 diabetes affects less than five percent of the diabetes population. It is an autoimmune disease whereby the body’s immune system attacks the beta cells of the pancreas that produces insulin.
Treatment Options for Diabetes
Diet and exercise play a very crucial role in the management of diabetes. The main principle is to control the quantity of carbohydrates. Take complex carbohydrates rather than refined carbohydrates, and if possible, ensure that food and drink are free of any sugar at all. If the patient has a sweet tooth, then it is best to consume zero calorie sweeteners such as Stevia, Equal, etc. Exercise will reduce blood sugar so it is recommended that diabetes patients engage in at least 150 minutes of physical activity a week.
For type 1 diabetes, the main treatment is insulin therapy. There are three main groups of insulin; namely meal insulin, background insulin (also known as basal insulin), and premixed insulin (a mixture of meal insulin and basal insulin). In general, people with type 1 diabetes need to inject insulin between two and four times a day depending on the type of insulin they are on.
Patients of type 2 diabetes have even more treatment options. There are multiple types of oral medication. Some stimulate the pancreas to produce more insulin, some work by improving the function of the insulin, some reduce the sugar production of the liver, and others work by getting rid of the excess sugar in the urine. Quite often the patients may need a combination of medications. There are also injectable medications such as insulin and GLP hormone that can be used for type 2 diabetes.
The main aim is to achieve good sugar control whether it is by using oral medications with or without injection therapy. Ultimately, the goal is to prevent diabetes-related complications. To do that, we need to bring the sugar level down to what is ideal, which is usually a fasting sugar of 4-6mmol/l, two-hour post-meal sugar of 4-8mmol/l, as well as a HbA1C (average sugar in the last three months) of <7%.
There are a few myths surrounding diabetes treatment that I would like to clarify here:
1. Too many medications will harm the kidneys. Diabetes medications or insulin is meant to be consumed long term and are safe to be used for many decades. Kidney problems due to diabetes is the end-result of long term high sugar level in the blood.
2. Anyone who needs insulin therapy are at the end of the road. Insulin is a type of hormone that our body produces. Some diabetic patients require insulin injection in order to control their sugar. This does not mean they are worse off than those on tablets. The ultimate aim is to get the sugar level to the targets without spells of low sugar with whatever means necessary.
3. Take small but multiple meals. It is not recommended for diabetics to do that. It is better to take three main meals and minimum snacks in between, especially for those on insulin therapy.
Diabetes is life-changing but it does not have to be debilitating. For those with a family history of diabetes, they may delay the onset of the condition by leading healthy lifestyles and maintaining ideal body weight. Combined with the plentiful treatment options available, patients can sustainably keep the chronic disease under control.