Regular screening is recommended for those who are at risk of developing diabetes.
There is an arsenal of medications available to help manage diabetes.
WITH Covid-19 raging around the globe, we tend to overlook a disease that has been quietly affecting people worldwide for far longer than this viral infection.
The reason this disease is so surreptitious is because it is noncommunicable, i.e. doesn’t spread from person to person the way the coronavirus does.
But it is just as deadly.
The disease is diabetes and it has been on the rise in Asia – including in Malaysia – more rapidly than the rest of the world.
It also occurs at a younger age in us.
Diabetes affects as many as one in five adult Malaysians, according to the 2019 National Health and Morbidity Survey (NHMS).
Alarmingly, out of that number, almost 6% are those aged below 30 years, i.e. one in every 19 persons being diagnosed with diabetes is in their 20s or younger.
And almost all were unaware they had diabetes until they were tested during the survey.
Multiple complications
According to medical experts like Hospital Putrajaya consultant endocrinologist Datuk Dr Zanariah Hussein, the reasons why Malaysia has a rapidly rising diabetes rate is linked to the population increasingly becoming more overweight, obese and physically inactive, as well as increasingly consuming more highly-dense calories.
“The more frequent of the two main types of diabetes mellitus is type 2, which affects at least 95% of those suffering from the disease, ” she says.
Patients with type 1 diabetes have almost absolute loss of their pancreas’ ability to produce insulin, while those with type 2 diabetes mainly have reduced responsiveness to their own body’s insulin, along with varying degrees of compromise in their insulin production.
Insulin is the hormone that helps drive sugar from the blood into our cells to be used for our body’s energy needs.
Dr Zanariah explains that high blood sugar levels, along with high blood pressure and high blood cholesterol levels, are risk factors for diabetic complications.
Dr Zanariah notes that diabetes is often diagnosed at a later stage when complications may have already set in.
These include small blood vessel damage within the eye, causing leaking or bleeding into the vitreous part of the eye (a vitreous hemorrhage), maculopathy, and even blindness.
Another complication is chronic kidney disease, which, if it progresses to end stage renal disease, will require renal replacement therapy such as dialysis.
There is also the issue of nerve damage, where patients lose sensation in their feet, making them oblivious to injury, infection and gangrene, which could lead to deformity and amputation.
But the most worrying complication is the one that has the most deaths: cardiovascular or heart disease.
Heart disease
The main link between diabetes and cardiovascular disease is that diabetes is one of the recognised risk factors for developing cardiovascular disease, says National Heart Institute (better known by its Bahasa Malaysia acronym IJN) consultant cardiologist and Cardiology Department deputy head Datuk Dr Azmee Mohd Ghazi.
It includes both coronary heart disease and heart failure, he adds.
“When we look at cardiovascular diseases, we consider the five main risk factors: diabetes, hypertension (high blood pressure),
high cholesterol, cigarette smoking and family history, ” he explains.
However, he stresses that even when a person is at the pre-diabetic stage, the risk of developing cardiovascular disease is already increased.
Among the cardiovascular conditions, Dr Azmee notes that diabetes mainly causes coronary heart disease, which is the narrowing of the heart arteries due to a build-up of fatty material.
According to Dr Azmee, managing diabetes well will also help to manage all the other medical conditions it can cause.
The symptoms a diabetic with coronary heart disease will experience are similar to someone who only has heart problems, e.g. shortness of breath or being quick to tire upon exertion or exercise.
“Of course, when you look at other problems like heart failure, people can also get water retention, which causes swelling in the leg and abdomen, but mainly, the early signs or symptoms would still be shortness of breath and tiredness, as well as weight gain due to the water retention, ” he says.
Patients would then need to undergo tests to ascertain the severity of their condition.
These tests can include an electrocardiogram (ECG) and/or an echocardiogram, which uses ultrasound.
In fact, it is recommended that patients undergo an ECG when they are first diagnosed with diabetes, and once every year thereafter.
This is in order to see if the patient already has any underlying heart problems upon diagnosis, as well as to detect any early
structural changes to the heart as time goes by, even if the patient has not yet developed any symptoms of heart disease.
In addition, cardiologists recommend a computerised tomography (CT) coronary angiogram, to see if there are any co-existing coronary arterial diseases.
A cardiac magnetic resonance imaging (MRI) can also be performed to get a better picture of the heart.
Says Dr Azmee: “When somebody with type 2 diabetes has developed problems associated with the heart, we recommend a coronary angiogram to detect significant blockages and to allow us to treat them.”
Sugar control
When one looks at how to control, or even reverse diabetes – which is possible if it is diagnosed early enough and the blood sugar elevation is mild – Dr Zanariah recommends lifestyle adjustments, such as modifying nutrition and diet, and increasing physical activity as a means towards weight reduction.
“More often, however, diabetes is diagnosed at a later stage when blood sugar levels are moderately to severely elevated and complications may have already set in.
“Frequently, doctors will need to use medicines, along with prescribing lifestyle changes, from the onset of diagnosis, ” she explains.
Dr Azmee notes that from a cardiologist’s point of view, it is important that the diabetic medication being given is safe and effective, and can both lower blood sugar levels and reduce the risk of heart disease, as well as death.
He adds that it is also important that patients find the medication easy to take or administer.
There are currently around five or six classes of oral medications that doctors use to treat diabetes, which can also target specific complications that the patient may develop.
But when oral medications are unable to control the sugar levels, the next option is usually insulin.
Insulin is typically given as an injection, with the frequency depending on the level of diabetes the patient has.
This can range from one shot to several a day.
The synthetic insulin works by mimicking the actions of the body’s own natural insulin.
An alternative injection
However, the last 15 years has seen the increasing uptake of medications known as glucagonlike peptide-1 receptor agonists (GLP-1 RAs).
Similar to synthetic insulin, these GLP-1 RAs mimic the action of the natural GLP-1 hormone in the body.
GLP-1 is produced in the small intestines when we eat.
Its function is to signal the pancreas to start insulin production in order to help control blood sugar levels during food intake and digestion.
It also stimulates a feeling of fullness, thus preventing overeating, and helps slow down food absorption in the intestine, thus preventing an after-meal blood sugar spike.
And unlike insulin injections, the use of GLP-1 RA does not run the risk of causing hypoglycaemia (low blood sugar).
It also only needs to be injected once a week.
Early detection is crucial
Dr Zanariah urges all Malaysians to screen for diabetes regularly if they are overweight or obese, have a body mass index (BMI) above 23 or have a relative with diabetes.
Those with heart disease, high blood pressure or pre-diabetes, or are inactive, had pregnancy-related (gestational) diabetes or just delivered a large baby should also be screened.
Dr Azmee advises patients not to think of diabetes in isolation.
Managing diabetes means that you will eventually manage all these other problems as well, as diabetes is the main source of all these complications, he says.
