In diabetes, the doctor empowers you to help yourself. Without your help, the battle against diabetes is lost, writes Dr PK YAP.
DIABETES is a killer with an appetite for more. An estimated 140 million people are affected by diabetes worldwide, of which eight million are in the ASEAN region. The WHO estimates that, in the next 25 years, there will be 300 million diabetics.
In Malaysia, in 1982, there were 310,800 diabetics and, today, one million of the adult population are diabetics. This figure shows that 8.7 out of every 100 Malaysians aged above 35 suffer from diabetes.
The prevalence of type 2 diabetes in Asia will increase by 91% between now and 2025 (compared to the worldwide increase of 72%). It will affect the predominantly younger, and most productive segment of the population.
On a personal level, the person afflicted with diabetes will have to make the necessary lifestyle changes (in addition to other treatments) to prevent complications of the disease. On the societal level, the cost of treating the complications of diabetes, especially in developing countries, will be astronomical (Figure 1). This puts a strain on resources that are already at best stretched to its limits.
Hence, a greater awareness of the problem, and instituting the necessary preventive measures, are vital.
Complications can be acute or chronic. As chronic complications are by far the more common and important, this article will concentrate on this aspect of diabetes. A few case histories (based on actual patients whom the author has seen, but with their names changed, of course) to illustrate these points will be discussed. By and large, diabetes is a silent disease and at diagnosis, many patients already have some complications.
Another way of classifying complications is by whether the large (macro-) or small (micro-) vessels are implicated. So MACROVASCULAR disease will refer to the involvement of the heart (angina and heart attacks), brain (strokes) and blood vessels of the foot (peripheral arterial disease). MICROVASCULAR disease refers to the classical complications of diabetes where the high blood sugar acts like a poison and damages the eyes, kidneys and probably the nerves.
Although the various forms of microvascular disease are the classical complications of diabetes, recent statistics suggest that up to 80% of diabetics, unless aggressively treated, will suffer from a heart attack or stroke. In other words, a diabetic is more likely to die of a heart attack before he/she dies from kidney failure or goes blind!
Diabetes is a multi-system disease. Besides affecting all the organ systems, it also lowers body immunity so that patients present with infections, ranging from mild to serious. Thus women may present with severe fungal infections of their private parts and in fact this may be the first symptom of diabetes.
Diabetics are also more susceptible to serious infections like tuberculosis. On the other hand a urinary tract infection, common in women, may spread to the bloodstream, and hence to the rest of the body so that a life-threatening septicaemia is the result.
Some examples of infections include: mild infections such as fungal infections of the genitals of both males and females and delayed healing of wounds; moderate infections such as urinary tract infections and pneumonias; and severe infections such as septicaemia complicating the above infections and various forms of tuberculosis which may remain silent for months.
Let's take a look at two common scenarios: Audrey, a precocious 16-year-old girl, developed an itchy rash around her private parts. This quickly progressed to superficial ulceration, accompanied by a creamy vaginal discharge. Her doctor said that this was the result of having sex with her boyfriend, something which she strenuously denied. It was only when her blood sugar was noted to be high that a diagnosis of diabetes was made.
Karine, a matronly 50-year-old diabetic, developed symptoms of a urinary tract infection. She consulted a sinseh who recommended “cooling fluids” and an herbal remedy. Two days later she developed high fever with chills and shivering and a severe backache, then suddenly collapsed. She was rushed to hospital where her blood pressure was noted to be low and a diagnosis of septicaemic shock was made. The bacteria had spread from her urinary tract to the blood stream and to the rest of her body. The herbal remedy was later found to contain steroids which further lowered her immunity and contributed to the septicaemia. After a week of intensive treatment in hospital, she pulled through.
Peripheral and autonomic neuropathy
The peripheral nervous system refers to the system which we are “conscious” of, and have a certain amount of control over. For example, it mediates pain sensation and movements. On the other hand the autonomic nervous system mediates the “automatic” functions of our body and runs in the background, so to speak. Examples would be control of the entire bowel system from the stomach to the rectum, the beating of the heart, maintenance of blood pressure, the urinary system, and even sexual function.
Numbness and tingling of the feet occur when the peripheral nerves are affected. This may be so bad that the patient cannot sleep at night. Muscle wasting may also occur in some instances. The common sites affected are the small muscles of the hand and feet, and the thigh muscles.
When the autonomic nervous system is affected, the patient may complain of postural hypotension, that is, the blood pressure drops when he or she stands up suddenly. Silent heart attacks are also more common in diabetics. Distension of the stomach due to delayed emptying of the stomach is a problem, and constipation or the opposite, “diabetic diarrhoea”, may occur.
In males, erectile dysfunction (the old term was “impotence”) may also be the result; and females may complain of decreased vaginal lubrication.
A common scenario is as follows: Ganga was only 43 years old but he had been a diabetic for almost 15 years. He had developed erectile dysfunction for the last four years, but the arrival of Viagra enabled him to satisfy both his wife and his mistress.
One day, after a passionate evening at his mistress’s flat, he suddenly felt faint. A GP was called to the flat, but by then Ganga had recovered. “I’m fine, doc – I have no chest pain or breathlessness. Maybe we were just a bit too adventurous this time!” he said grinning at his mistress.
The doctor noted that his blood pressure was low and insisted that he go to hospital immediately. A silent heart attack was diagnosed. Because his autonomic nervous system was affected, the “signals” of a heart attack – pain, sweating, etc, were not present. Ganga was lucky to survive. He was told that after cardiac rehabilitation he could safely continue using Viagra – but to have sex only with his wife so as to reduce the extra “stress”!
Diabetic nephropathy or kidney disease
Much has been written about this recently. To summarise, high blood sugar acts like a poison to the kidneys, slowly damaging it. The first sign of kidney damage would be trace amounts of protein in the urine, referred to as “microalbuminuria”. A special test is required to pick this up.
It is important to note the relationship between hypertension and diabetes. Up to 70% of diabetics will eventually develop hypertension. This could be a consequence of ageing or it could be related to subtle renal involvement. What is clear is that hypertension will further damage the kidneys, and the damaged kidneys will in turn accelerate the progress of hypertension; and thus a deadly, vicious cycle is set up.
The high blood sugar also acts like a poison to the retina (the back of the eye) and slowly damages it, giving rise to a “retinopathy”. The early stages are entirely silent and the only way of detecting it would be to get an eye specialist to examine the retina after dilating the pupils.
The first sign of a retinopathy is tiny spots of bleeding over the retina (microaneurysms) and this could eventually progress to overt bleeding and scarring of the retina, giving rise to blindness. There is NO cure. Laser therapy is used only to prevent further bleeding and this is not universally effective.
Diabetics with eye involvement (retinopathy) commonly have renal involvement (nephropathy) and vice-versa.
Here are two common scenarios. Christopher had long-standing diabetes for many years but had refused to see an ophthalmologist for assessment. “Doc, I can see an ant on the opposite wall 20 feet away and in my hunting group I’m the best marksman.” He was finally persuaded to see the ophthalmologist and discovered to have fairly advanced retinopathy.
Jo, a highly motivated diabetic, had a different story to tell. “That first eye specialist missed the diagnosis completely. He said my eye was normal but luckily I decided to seek a second opinion and discovered I had early eye disease. The first specialist didn’t bother to dilate my pupils first – I think he was in a hurry to go for lunch.”
NOTE: an experienced eye specialist once told the author that the only difference between his examination and the author’s examination of a diabetic patient’s eye was that he insisted on dilating the pupils first. “I can see 100% more than you can after dilating the pupils.”
Diabetic foot disease
Diabetic foot disease results from two basic problems. The first is the decreased sensation of the foot due to nerve damage associated with diabetes so that the patient may traumatise the foot without realising it.
In extreme instances, the patient may even step on a nail without feeling any pain. Pain is the body’s way of warning us not to walk in a certain way, or to avoid trauma. But basically it is the day-to-day “pounding” of the foot without any pain feedback that damages the foot and causes ulcers, and bone and joint damage.
Secondly, the poor circulation of the foot means that the damaged areas will not be able to receive sufficient oxygen and nutrients for repair or to fight the resultant infection so that gangrene may eventually develop.
Here's a common occurrence. Stephen was the CEO of a big company. He was also a long-standing diabetic. While entertaining at his home one Saturday evening, he walked barefooted and stepped on a bottle cap with sharp edges and the cap became embedded in his sole (he weighed 110 kg!). Because he had diabetic peripheral neuropathy, he did not feel any pain. On Monday morning, he smelt something unpleasant, and on examining his sole, he discovered the bottle cap embedded there, and pus oozing from the wound. Only quick action by his doctors prevented gangrene from setting in. Diabetics with poor or no feeling in their feet should inspect their soles EVERY DAY, preferably with a mirror.
Treatment of diabetic complications
The whole aim of treatment is to delay or prevent the onset of the chronic complications of diabetes because management of established complications is so expensive. Pharmaceutical companies are racing to come up with novel products with this sole aim in mind, but very few have been tested in humans, and none have been marketed successively so far. The chart below summarises the treatment modalities available currently.
Diabetes is a silent disease in the early stages. Therefore a lot of motivation and discipline is required on the part of the patient to adhere to a diet and to exercise regularly. Medication, even the use of insulin, without dieting and exercise, is not going to work. The primary reason for treating a disease with no pain or other symptoms (in the early stages at least) is to prevent the long-term complications – for which there is NO cure.
If you have diabetes, DO NOT try to treat yourself. Consult a doctor, but of course, it is important to be well-informed about the disease yourself. In no other disease is the cooperation between the doctor and the patient so important.
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.
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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