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Sunday November 18, 2012 MYT 12:00:00 AM
Monday July 15, 2013 MYT 12:19:00 PM
There are fundamental changes you have to make when you discover you have diabetes, but there is no reason why you can’t live life to
AN ancient Egyptian princess, daughter of Pharoah Seqenenre Tao II, who was the last of the original line of Egyptian Pharaohs, might have been able to postpone her mummification if she had learnt to manage her diabetes better, medical experts say.
Fast forward 3,500 years later, the incidence diabetes has steadfastly climbed to such an extent that the World Health Organization (WHO) has granted diabetes epidemic status.
Approximately 95% of diabetics have type 2 diabetes mellitus (T2DM). An estimated 230 million people over the world have T2DM, and this is projected to rise to 440 million people by 2030.
In Malaysia, the figures are equally disturbing. One in five Malaysians are diabetic, but what is even more worrying is the alarming fact that for every one person diagnosed with diabetes, there is at least one other who remains undiagnosed. This would mean that the actual number of Malaysians with diabetes could actually be 5.2 million, or more!
Given the number of people with this disease and the progressive nature of its course, aggressive and continuous management is paramount to improve the morbidity and mortality associated with this disease.
Yet, despite the constant barrage of facts and awareness campaigns and a wide array of agents to treat T2DM, tight glycaemic control continues to be achieved in less than half of patients.
Living with diabetes
Talking about her diagnosis, Erina Lee’s first description of diabetes is that “it was disorienting – I was very much feeling like a deer in the headlights”.
It was three years ago that Lee went for a sleepover with her college friends and they ordered pizza. But that night, Lee could not stop drinking – complaining of a really horrible thirst.
Lee thought she had a caught a bug and that it would pass. But at work that week, she was in a persistent foul mood, agitated, and she noticed that she had lost a noticeable amount of weight in a short span of time.
“I had this intense thirst, I was bad tempered and didn’t feel like myself at all. I was drinking anything I could to quench the thirst – juice, cola, you name it,” she recalls.
“I passed out in the middle of a board meeting... and the doctor came back to me and said, ‘Did you know you were type 2 diabetic?’ and I said, ‘I had no idea,’” states Lee, who has a family history of diabetes.
“I think you do have to become your own doctor to an extent. I let it become a part of my life and did not fight it, or deny it. In a way, getting the diagnosis was a relief – I really thought I was dying and I never want to experience that thirst again.”
People with type 2 diabetes frequently have no symptoms, or the symptoms appear subtle. Similar to Lee’s case, when symptoms do appear, one of the first may be an increase in thirst. This is often accompanied by additional problems, including dry mouth, increased appetite, frequent urination – sometimes as often as every hour – and unusual weight loss or gain.
Even the famous can get it
In another part of the world, American Idol judge and MTV America’s Best Dance Crew executive producer Randy Jackson was diagnosed with T2DM in 2003.
At the time, Randy was not just at the peak of his career, he was also at the peak of his weight. “Growing up in Louisiana meant that I was used to eating rich Southern fried foods, and I didn’t have any sort of exercise routines.
“It took me between six to eight months before I got over the shock of my diagnosis. I chalk up the fact that I got diabetes to my body saying, “Dude, you have been doing wrong for way too long!” he was quoted as saying.
Talk show host Larry King also has type 2 diabetes. “It’s definitely controllable,” King has said on his show.
This sentiment is echoed by consultant endocrinologist Dr Alex Tan Tong Boon, who also stressed that diabetes patients must take charge of the disease in order to manage it effectively. “There are no bad numbers. They’re all good because they tell you what to do next,” says Dr Alex flatly.
Management of T2DM has to be tailored to the individual needs and circumstances of each patient, e.g. the benefits of tight glucose control must be weighed against any potential complications such as recurrent hypoglycaemia.
According to Dr Tan, the number of diabetes patients is not only increasing, they are getting it at a younger age. Many patients are in their 20s, and the disturbing thing is that even children are not spared.
Previously, childhood diabetes could be attributed to type 1 (which typically arises when the body’s own immune system destroys the insulin-producing cells of the pancreas). But as obesity creeps up on young people, T2DM has also become a disease of childhood. Now it’s occurring with alarming frequency.
The Malaysian Clinical Practice Guidelines (CPG) on diabetes recommends testing for diabetes for high risk children (people with impaired glucose tolerance or the metabolic syndrome) from ages as young as 10 years. For normal adults, testing should begin at 30 years of age.
Consultant physician and endocrinologist Dr Malik Mumtaz emphasises that for individuals who are predisposed to diabetes, lifestyle intervention is strongly indicated and often more effective than the use of pharmacological treatment.
“For almost all newly diagnosed patients, the recommendation is to induce serious behaviour and lifestyle modifications by way of a reduced calorie diet (20-25 kcal/kg body weight) and increased physical activity (at least 150 mins/week). The patients are then closely monitored for a period of up to three months.”
Indeed, the figures are behind him all the way: from the Diabetes Prevention Programme (DPP) to the Finnish Prevention Study, such research demonstrates that lifestyle intervention alone can reduce the incidence of diabetes in high risk patients by up to 50%.
Apart from physical activity, the CPG advocates medical nutrition therapy (MNT) as an important feature in preventing diabetes, managing existing diabetes, and delaying complications. It states that proper diet is crucial at any stage of management of diabetes.
The goals of MNT (together with medication) are to attain and maintain blood glucose, blood pressure and lipid profile as close to normal as safely as possible. These goals can be achieved through healthy food choices.
Both Dr Malik and Dr Tan are helping to educate people with T2DM about the importance of early and effective management of the ABCs of diabetes – A1C, or blood sugar, Blood pressure, and Cholesterol – as part of their treatment plan, which can help reduce the risk of serious complications, including heart disease, a leading cause of death among people with T2DM.
In fact, adults with T2DM are two to four times more likely to die from heart disease than adults without the illness, whilst the risk of a stroke in a diabetic patient is at a staggering 400%.
We could perhaps draw a quick anecdote from a scene from the US TV series, 30 Rock. Tracy Jordan was speaking to Dr Leo on the seriousness of diabetes. “(Diabetes is) quite serious. If left untreated you could lose a foot.” Asked Tracy, “Could I replace it (the foot) with a wheel, like Rosie from the Jetsons?”, to which Dr Leo conceded, “I suppose. But then you’d have to register as a motor vehicle.”
Intensive management of diabetes in patients, which according to various major clinical studies such as the United Kingdom Prospective Diabetes Study (UKPDS), can reduce cardiovascular and microvascular complications. The UKPDS also suggests that the benefit of tight glycaemic control in patients with T2DM extends beyond a finite period of intensive management, a phenomenon coined as the “legacy effect”. Dr Malik explains that intensively treated patients also might have maintained beneficial health practices other than glycaemic control after the UKPDS trial ended.
“Sometimes, lifestyle treatment alone is not sufficient. Very often, it is an arduous challenge to get patients to adhere to diet regimes and exercise routines. I think, to a certain extent, we have to be realistic and practical,” adds Dr Malik.
“Therefore, making the next step in treatment is mandatory to achieve ideal glycaemic control.”
As humans, we might need a little push at times, and this comes in the form of oral treatment.
Metformin is the most widely prescribed first-line agent for the management of T2DM and is standard first-line pharmacotherapy, along with diet and exercise. Mechanistically, metformin suppresses glucose production by the liver and improves insulin sensitivity; however, metformin alone is frequently insufficient to maintain glycaemic goals in the face of progressive beta-cell failure and increasing insulin resistance.
“Treatment today has to be individualised for each patient. We need to use a choice of any compound that is deemed to be appropriate for the patient, therefore making it as patient-centred as possible. There is no case of a one-drug-fits-all. We cannot say that just because metformin is cheap and widely available, prescribing metformin is a sure-fire way to treat T2DM,” explains Dr Malik.
A second medication may be necessary if a patient does not achieve the defined targets. The choice of treatment has to again be tailored for the individual patient. Some patients may even require insulin because of exceedingly high sugars.
Individualising treatment, as advocated by Dr Malik, depends on various factors, such as the likelihood of hypoglycaemia, weight gain and also, financial standpoints. Patients must understand that diabetes is a chronic disease and as such, treatment is long term. Different classes of medications are used to maximise the effectiveness of the treatment.
“Different classes of diabetic drugs work differently. For instance, DPP-4 inhibitors slow down the breakdown of incretin hormones and the risk of hypoglycaemia is low,” concurs Dr Tan. This is especially so in the elderly in whom a low blood sugar can have disastrous consequences.
The effects of new drugs such as gliptins, which is a DPP-4 inhibitor, are aplenty. The main focus is to reduce the problems of hyperglycaemia, but we are seeing other positive effects such as a better tolerability profile, lower risk of hypoglycaemia and no weight gain. This newer class of drugs do not increase the risk of cardiovascular disease and currently large clinical trials are underway to provide a clearer picture if they reduce this risk, adds Dr Tan.
This is of course all good news for the diabetic patient as we can then use these drugs in patients with underlying cardiovascular disease in whom drug choices may have been previously limited. Unlike older classes of oral anti-diabetic medications, patients on these newer drugs have minimal side effects.
Dr Malik adds, “Adherence to treatment is important. Stopping medications once the sugar is normal is common. Misconceptions about diabetes drugs damaging the kidneys are also very common. There are many myths that surround the treatment of diabetes and it is important to discuss any doubts you have with your doctor.”
There are no easy methods that can be used to accurately identify which individuals are more prone to develop diabetes based on their lifestyle and genetic makeup; getting tested is the only sure-fire method.
A simple blood test can diagnose diabetes. The A1C test gives a snapshot of your average blood glucose level over the past two to three months. Testing your blood glucose level will let you know how controlled your blood sugars are and if you need to take action to change your treatment plan.
How often and when you test will be based on how controlled your diabetes is, the type of therapy used to control your diabetes, and whether you are experiencing symptoms of fluctuating sugars.
Talk with your doctor to find out how often you should use a glucose meter to check your blood sugar. Some common testing times may be when waking up, before and after meals and exercise, and at bedtime.
“Diabetes is a disease that can lead to many other complications, from the top of your head to the tips of your toes,” Dr Tan notes.
He adds: “If diabetes is detected early, and the patient chooses to make the necessary changes to their lifestyle and stick to it, they can actually stop diabetes from developing further. In fact, there are cases where patients who lose substantial weight can actually become diabetes-free.”
That said, there are no magic solutions to prevent diabetes, and the best thing that you can do for yourself is to take responsibility for your own health. Be aware that what you eat, your physical activity, and how you live your life will have a direct bearing on whether you develop diabetes in the future.
The same concept applies regardless of whether or not you have diabetes. In fact, if you do get tested for it and find out that you have diabetes, you may want to keep the following ABCs in mind:
Dr Tan advises all diabetes patients and their caregivers to better empower themselves with the necessary skills to deal with diabetes by learning all they can about it, and the basics of diabetes management. This knowledge will be a big help in preventing problems and minimising the need for medical care.
These skills include learning how to:
“If you have recently found out that you or a loved one has diabetes, start educating yourself. The more you know about it, the easier you can deal with the problem. Help yourself by taking ownership of the problem and commit to making the necessary changes,” advises Dr Tan.
“The diabetes patient and their caregivers must be responsible for their own choices in order to manage this disease properly. Medications should be taken as prescribed by their doctor, recommended diets should be followed, and if an exercise regimen has been included as well, then they should try to stick with it.”
Dr Tan is quick to stress that living with, and managing diabetes, is a tough journey. “There are several milestones, with the most critical one being your readiness (and willingness) to commit to these changes.
“Follow up by making plans, preferably with medical advice from your doctor and dietician. Carry out this plan in stages if you need time to acclimatise yourself to your new lifestyle.
“Lastly, get the right kind of support from your family and friends,” advises Dr Tan. “They’ll be there for the times when you need moral support to successfully manage and deal with the disease.”
Life goes on
Both Dr Tan and Dr Malik are confident that diabetes patients will find that living with diabetes is entirely possible; they can even do so while enjoying a good quality of life.
Inevitably, sacrifices will have to be made, but diabetes patients will find that with proper planning, they can still live a long and productive life. The key is to embrace these changes with a positive outlook.
Lee cannot agree more. “I do still indulge – you can’t live in Malaysia and not have your teh tarik or curry mee occasionally – but I have learned to eat in moderation. There are fundamental changes you have to make when you discover you have diabetes, but there is no reason why you can’t achieve your dreams. I made the decision that diabetes was going to live with me; I wasn’t going to live with diabetes.”
This article is courtesy of AstraZeneca (M).
Insulin in diabetes
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