The sweet affliction


  • Health
  • Sunday, 12 Jan 2003

There are presently 177 million diabetics in the world and this will hit 300 million in 2025. Now that's a lot of sweetness that we can do without, writes Dr P.K. YAP. 

A COMMON scenario – let’s peek in at Mr Tan’s “annual” medical examination (actually his first in the last five years!) 

“So, Mr Tan, you’re 45 years old now; do you have any serious past illnesses?” 

“No, I am in good health.” 

“Do you have any allergies, asthma, operations, diabetes, hypertension?” 

“Yes, I have diabetes for the past two years.” 

“But you said you had no serious illnesses?” 

“But doc, surely diabetes isn’t serious. So many friends and colleagues of my age have it and they are in good health. Many of our cabinet ministers have it too! I feel great – I don’t need any medication!”  

“Diabetes is a silent killer. How do you know that they don’t have any complications? Let me examine you now, then I’ll tell you more about diabetes ?” 

After the examination 

“Well you don’t seem to have any of the complications of diabetes, but I’ll have to run some tests on you and send you to an ophthalmologist for a more detailed examination of your eyes. We’ll also talk more about management after the tests. 

“Now, about diabetes ?” 

“Never mind, doc, I’ve got an encyclopaedia of medicine and Internet access. I’ll read up on it and discuss diabetes with you next week. I’ve got a meeting in the next half hour so I have to go. Thanks for your time doc.” 

The next week, Mr Tan bounces into the consultation room armed with a bundle of notes... 

“Mr Tan, you results are ready. Your diabetic control is poor. Your fasting blood sugar is 8.0 mmol/l. The normal is 6.1 mmol/l, but acceptable control should be less than 7.0 mmol/l. The more important result is the Glycosylated Haemogoblin, or Haemogoblin A1c, or HbA1c for short.  

“To put it in a simple manner, we are checking the ‘sugar in your red blood cells’ and since the cells circulate in your blood for two to three months, this reading will tell me your average sugar control for that period. It’s 8.0%, which is high. The target should be 7.0%. 

“Your cholesterol level is also elevated. I’m especially worried about the LDL cholesterol, which is 4.5 mmol/l. The normal is 3.4 mmol/l, but diabetics should aim for 2.6 mmol/l. I’ll explain why later. 

“Now, let’s check your blood pressure again. Last week it was 150/90 mmHg, which is high, but I thought you might have been a little tensed up. Ooops, it’s still 150/90. The target for a diabetic is 130/80 mmHg. If it’s still raised a third time, you’ll have to go on treatment.” 

The diabetes epidemic in Asia 

“OK doc, now let me tell you what I’ve learnt about diabetes from the Internet. First, there are two major types of diabetes. Type 1 is due to failure of the pancreas to secrete insulin and these patients will require insulin injections. Type 2 is the common type and is due to either a lack of insulin or ineffectiveness of the insulin secreted because of insulin resistance. I think I’ve got this type.  

It’s Type 2 diabetes that is developing more rapidly in Asia than in other parts of the world. This is probably due to the Thrifty Gene Hypothesis (ref Star 22 Dec, 2002) which explains why the Asian population is growing fatter and why this is driving the epidemic of diabetes. In fact, Asians may be more prone to diabetes than their Western counterparts. In Malaysia, the 1997 survey showed that over 8% of the population had diabetes – it may be 10% by now.” 

“You really have done a lot of homework, Mr Tan. Yes, Type 2 diabetes is the problem. Traditionally, Type 1 diabetes affects mainly children, and this type of diabetes is relatively uncommon in Asia compared with the West. But now more and more young children, some as young as 10 years old, are getting diabetes. But it’s not Type 1 – it’s Type 2 diabetes, the form which affects adults predominantly.  

In fact, when I was a medical student, Type 2 diabetes was called Adult-onset Diabetes, but now everything is topsy-turvy! It has been estimated that within 20 years, there may be as many Type 2 diabetic children as there are Type 1. This is because kids are getting fatter as you mentioned. Have you heard of coca-colonisation and nintendozisation? These are very apt phrases coined by an Australian doctor!” 

Microvascular complications 

“Now, doc, let me tell you about the complications of diabetes. They are called microvascular complications, and classically they affect the eyes and kidneys, as well as the nerves.  

“The eye and kidney complications (retinopathy and nephropathy) may be silent for years, till blindness and kidney failure occurs – and these are the most dreaded complications of diabetes. Sometimes the nerves and blood vessels of the leg can also be damaged and the result is gangrene and amputation, another terrible result of diabetes. 

“The only way to pick up this silent eye complication, or diabetic retinopathy because it affects the retina mainly, is to visit an eye specialist regularly.  

“For the kidney complication, called diabetic nephropathy, I should check my urine for protein regularly. There was also mention of microalbuminuria. It is the earliest sign of kidney disease. There is a special test to detect these minute amounts of albumin or protein in the urine. The normal test is not sensitive enough.” 

Macrovascular complications 

“You’re right and wrong at the same time, Mr Tan. Blindness, kidney failure, gangrene and also peripheral neuropathy, where the nerves are damaged, are all the classical complications of diabetes. But the fact is that up to 80% of diabetics are going to die of a heart attack or possibly a stroke! This is something that has emerged the last few years.” 

“You’re not serious, are you, doc? You mean that diabetics are more likely to die of a heart attack or stroke before they go blind or get kidney failure?” 

“That’s right, Mr Tan. The microvascular complications are important – but so are the macrovascular complications. Macrovascular refers to the “big blood vessels”, and the blood vessels of the heart and brain and leg come into this category. The blood vessels of the retina and kidneys are small, hence it is called microvascular.” 

“Why should diabetics be so prone to heart attacks and strokes?” 

“At the moment we are not sure. The Common Soil Hypothesis tries to explain this. It suggests that both atherosclerosis (the hardening and blockage of the blood vessels), and Type 2 diabetes both share a common origin, and coexist independently of each other; though each may eventually exacerbate the other.  

“A genetic predisposition is important, and this, together with environmental influences, including the intrauterine environment (while we were developing in our mother’s womb), will determine if we get both Type 2 diabetes and atherosclerosis. 

“It’s because diabetics are so prone to cardiovascular disease that the targets for your blood pressure and cholesterol are so strict. The targets are the same as for patients who have already suffered, and survived a heart attack.  

“Studies have shown that diabetics have the same chance of dying from a first heart attack as non-diabetic patients who have already suffered a first or second heart attack. Just being a diabetic puts you in the high-risk category.” 

Management 

“OK, Mr Tan, enough of the theory. Have you thought of how you are going to remain healthy?”  

“Yes, doc. I’ve read about all the new drugs available, including the ones that can reduce insulin resistance and the ones that prevent my blood sugars from peaking after meals. I want those!” 

“You are not going to get those! There’s too much emphasis on medication, and too much unwarranted expectations based on drug firm advertisements. It’s back to basics for you first.  

There is no substitute for diet and exercise, and medication is only added on if your blood sugar still cannot be controlled. Medication without any change in your lifestyle is not going to work, it’s an utter waste of money. 

“First, it’s diet management. A lot of the information I am going to give you is common sense. I stress, I am NOT going to ban you from cakes or chocolates for the rest of your life – but they should only be taken in small quantities, on special occasions.  

“Secondly, exercise. I suggest you start with walking three to five kilometres a day. It doesn’t have to be at one go. It can be cumulative. It’s called “Lifestyle Exercise” because you can incorporate this into you daily routine, eg climbing the stairs instead of using the lift, walking to the shop instead of driving and so on. 

“When you are fitter you can extend the range and variety of your exercises. I warn you, regular exercise can be addictive! 

“See me in about a month and if your control is still poor we’ll consider starting you on a drug.” 

The next month will prove crucial to Mr Tan’s health outlook. If he can manage his diet, and maintain a consistent exercise programme, it bodes well for his health. It’s in his hands. 

NOTE: This article is a contribution of The Star Health & Ageing Panel, a group of panellists who are not just opinion leaders in their respective fields, but have wide experience in medical education for the public. 

This group of specialist doctors and members of the academia are committed to public education, and the weeks ahead will see numerous articles that promote healthy ageing and the prevention of disability in men and women.  

The members of the panel include: Datuk Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; A/Prof Sarinah Low, psychologist; Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Guna Sittampalam, consultant obstetrician and gynaecologist; Dr Ting Hoon Chin, consultant dermatologist; Dr Ng Wai Keong, consultant neurologist. 

  • The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. 

    The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article. 

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