What you need to know about diabetes

If you don’t know what diabetes is, or if you have an idea and would like to learn more about it; then let’s start with this section.

Diabetes is a chronic condition associated with abnormally high levels of sugar (glucose) in your blood. Normally, your blood sugar is well-managed by your body thanks to a hormone called insulin; which is produced by your pancreas. Insulin will lower the sugar in your blood and keep it from going above a dangerous level.

Diabetes develops when the following conditions occur:

• Insufficient production or absence of insulin
• Your body is unable to use insulin properly (insulin resistance)

With a low amount of insulin or inability to use it properly, your blood sugar will rise. If it rises and remains at a high level for a long period of time, you will develop life-threatening complications and diseases.

There three main types of diabetes, type 1 diabetes, type 2 diabetes and gestational diabetes. Understanding the main types of diabetes is simple.

Type 1 diabetes means your body does not produce insulin. As a result of your body attacking itself (known as an autoimmune reaction or autoimmune disease), the cells that create insulin in your pancreas are destroyed and will produce little to no insulin. Type 1 diabetes often develops in children or teenagers, but can appear at any age. Type 1 diabetes cannot be prevented.

If you have type 2 diabetes; you still have insulin in your body, but the body either doesn’t produce enough or use it well enough. It can also develop if your body becomes resistant to insulin and its effects. Type 2 diabetes is often first discovered in middle-aged and older individuals, although like Type 1 it can develop at any age. Type 2 diabetes can be prevented or managed with healthy lifestyle choices.

*The majority of patients in Malaysia have type 2 diabetes (79%).

Gestational diabetes is a type of diabetes that develops in women when they are pregnant, which will usually go away after the baby is born. Doctors will test their patients for gestational diabetes during their pregnancy, followed by treatment and helping their patient to manage the condition. If you have had gestational diabetes, you have a higher chance of developing type 2 diabetes after your pregnancy. Your child may also have a higher risk of obesity and developing type 2 diabetes if your gestational diabetes is not managed well.

Apart from the three main types of diabetes, there is also a condition known as Prediabetes, which is diagnosed when your blood sugar is higher than normal but not high enough to be considered type 2 diabetes. People who have type 2 diabetes usually develop prediabetes first, and of course; people with prediabetes are at a high risk of developing type 2 diabetes.

We can reduce the rate of progression (before prediabetes becomes full-blown diabetes) through an active lifestyle and prescribing medication.

Risk factors of Type 1 diabetes

There is no known cause of what triggers that response in the first place because the body could be attacking itself for years before type 1 diabetes is diagnosed. Some of the risk factors of type 1 diabetes are:

• Age – Type 1 diabetes can manifest at any age, but is known to start before the age of 40. It is often diagnosed in children between 4 to 7 years old and between 10 to 14 years old.
• Family History – Having an immediate family member with type 1 diabetes puts you at a slightly higher risk of also developing type 1 diabetes or developing it at an earlier age.

The risk factors for type 1 diabetes are not as well-defined compared to the known risk factors for type 2 diabetes and prediabetes. Weight, however, is not believed to be a factor for type 1 diabetes.

Risk factors of Type 2 diabetes

On the contrary, being overweight is strongly linked to the development of prediabetes and type 2 diabetes. As with type 1 diabetes, nobody knows what exactly causes the cells to become resistant, although a few factors are known to increase a person’s risk developing type 2 diabetes:

• Age – Most cases of type 2 diabetes are diagnosed in people at the age of 45 and above. It is recommended to get screened for diabetes every year for patients aged 45 and above.
• Genetics – As with type 1 diabetes, a strong family history of diabetes increases a person’s risk of type 2 diabetes
• Environmental factors – A sedentary lifestyle means the body does not burn enough sugar for energy, making your cells less sensitive to insulin
• Being overweight – Excess weight and fatty tissue will raise the insulin resistance of your cells

It is important to note that not all people who have type 2 diabetes are overweight; it can still develop in individuals who have their weight under control. Type 2 diabetes prevention is also not just for the old, as the incidence rates in children and young adults continue to rise.

Risk factors for gestational diabetes

During pregnancy, the placenta produces more hormones to sustain a woman’s pregnancy, but these hormones increase the cells' insulin resistance. The pancreas will produce additional insulin to counter this effect, but there are cases where the pancreas cannot keep up with the surge of hormones. Thus, gestational diabetes occurs. Similar to type 2 diabetes, the risk factors for gestational diabetes are:

Family history – A family history of diabetes increases your risk of developing gestational diabetes during pregnancy and type 2 diabetes after pregnancy

Being overweight – Being overweight before pregnancy may affect your body’s insulin sensitivity; this may also carry over into your pregnancy.

How would I know if I have diabetes?

Pre-diabetes and diabetes rates are very high amongst Malaysians. It makes sense to be screened for diabetes, particular if you are in a high risk group (as outlined in the sections above). Screening includes a blood test (glucose tolerance test), HbA1C level test, a fasting or random (non-fasting) blood glucose level test. Your doctor will guide you throughout your screening.

Screening should be carried out if you have symptoms of diabetes:

• Tiredness
• Unexplained weight loss
• Passing more urine than usual either during the daytime or night time
• Excessive thirst
• Blurred vision
• Frequent infections in the genitalia or frequent itching

If you have no symptoms, then screening should be carried out if you are overweight or obese (BMI greater than 23 kg/m2) or have a waist circumference greater than 80cm (for women) or 90cm (for men) AND have one or more of the following risk factors:

• First degree relative with diabetes mellitus
• History of heart disease
• Hypertension (blood pressure greater than 140/90) or currently receiving treatment for hypertension
• Previously pre-diabetes
• Low HDL (lower than 0.9) or increase Triglyceride (greater than 2.8 mg/dL)
• History of previous gestational diabetes or baby weighing more than 4kg
• Polycystic ovarian syndrome (for women)
• Being physically inactive

(Reference: Malaysian Consensus guidelines on Diabetes 2015 (5^th edition))

When you look at the statistics of leading causes of death, diabetes may not be among the top five causes. However, most death certificates list the primary disease as the cause of death without listing that their primary disease was caused by diabetes. Hence diabetes can be both a direct and indirect cause of death for millions.

Mild episodes of high blood sugar can be treated easily and may also return to normal sometimes. However, when your blood sugar levels are very high and remain high for a long period of time, it can lead to life-threatening complications.

Diabetes is a disease which is associated with many complications. This means that early good control can prevent or delay some of the complications described below:

Diabetic ketoacidosis (DKA) happens when your body starts breaking down fat into a type of acid called ketones. Too much of this acid in your blood causes it to become acidic and can lead to a diabetic coma, making this a life-threatening condition if not managed properly.

Hyperosmolar hyperglycaemic state (HHS) or severe dehydration is caused when your body is trying to get rid of excess sugar through your urine. The increased frequency of urination causes thirst, headaches and drowsiness as dehydration sets in.

Diabetic peripheral neuropathy (nerve damage) is caused by high blood sugar damaging the nerves close to the surface of the skin. It usually affects the lower half of the body (legs and feet) before affecting the arms. Nerve damage will cause you to:

• feel numbness or become unaware of certain injuries
• increase your sensitivity to the point you feel pain even while remaining still
• worst-case, the nerve damage will reach a point of requiring amputation of the affected limb to relieve the pain or symptoms

High blood sugar can also cause damage to the blood vessels, triggering a response that will cause plaque build-up and hardening of the arteries (known as atherosclerosis). By damaging the blood vessels, a number of other complications can develop:

• Diabetic Kidney disease (Chronic Kidney Disease) – High blood sugar damages the blood vessels in your kidneys. This may cause end-stage renal failure and may even lead to other health complications.
• Hypertension (high blood pressure) – A damaged blood vessel will not be able to stretch well, increasing a person’s blood pressure. High blood pressure can lead to cardiovascular disease and also kidney disease; with the reverse being true. A person whose kidneys are affected by diabetes may also end up developing high blood pressure.
• Cardiovascular disease (CVD) – High blood sugar will damage your blood vessels over time, increasing your risk of CVD. People with diabetes tend to develop CVD at a younger age compared to those without, and CVD is one of the most common causes of death among adults with diabetes.
• Stroke – A person with diabetes has a 1.5 times higher chance of having a stroke, which can be traced back to how high blood sugar levels damages the nerves and blood vessels.
• Damage to the eyes – Diabetes can cause swelling in the macula, the part of our eye that we use to read, drive and see people. The swelling and damage caused by high blood sugar will eventually lead to loss of vision and even blindness if not treated early.
• Glaucoma is a disease that damages the nerves connecting our eyes to our brain, and diabetes doubles the chance of someone having glaucoma.

Other complications include diabetic coma, depression and amputations due to the infection of an injury to the feet.

There is currently no cure for diabetes as it is a chronic disease. While type 1 diabetes cannot be prevented, prediabetes, type 2 diabetes and gestational diabetes can be prevented by avoiding a sedentary lifestyle.

1) Exercise for about 30 minutes a day, go for a walk, cycle around on a bike or do some swimming. With adequate exercise and physical activity, your body will:

• Require more energy; which it gets from breaking down sugar.
• Reduce your blood sugar as it breaks down sugar for energy
• Increase your cells’ sensitivity to insulin as sugar breaks down and enters your cells

30 minutes of moderate physical activity does not have to be in one go; you can split it into smaller sessions throughout the day.

2) Lose excess fat and weight, as the risk of diabetes increases with your weight and waist circumference. Ideally, your BMI should be within 18.5 – 23; any value higher than 23 is considered as being overweight. Aim for a 5 – 10% weight loss. This will improve your diabetes or reduce the risk of progression to diabetes by 50%.

If you are pregnant, then it is recommended for you to speak with your doctor first on how much weight is healthy for you to put on during pregnancy, rather than think about losing it.

3) Diet – A healthy diet is important in diabetes management, especially one high in nutrition, fiber, whole grains and protein. Cutting down on fats, calories, refined carbohydrates and sweets also helps to keep your blood sugar under control. Of course, there is no specific diet for all diabetic patients, the recommended amount of food depends on each person; thus it is best to create a meal plan for yourself by discussing with your doctor and dietitian.

Apart from lifestyle changes to manage your blood sugar, most diabetics require more than just lifestyle changes. A diabetes treatment plan often includes one if not all of the following:

• Insulin therapy is often used to keep a person’s blood sugar levels within a healthy range. There are many types of insulin (fast-acting, short-acting, long-acting) and which is best depends on the person. Because your blood sugar changes throughout the day, it is best to discuss with your doctor to determine which works best for you.
• There are newer agents called GLP 1-RA that are suitable for some type 2 diabetics
• Diabetes medications are often prescribed depending on the patient’s needs and symptoms. Some medications will stimulate your pancreas to produce more insulin, some help your body break down sugar, some help to reduce your blood sugar.
• Bariatric surgery (weight-loss surgery) is not considered as diabetes-specific treatment, but obese individuals with type 2 diabetes experience significant improvements to their blood sugar levels. In most cases of patients, the surgery sends type 2 diabetes into remission due to weight loss and improved insulin sensitivity. The body’s blood sugar can often be controlled without the need of medication.
  Not everyone is eligible for bariatric surgery, however. To read more about bariatric surgery, read our blog on bariatric surgery here: https://www.islandhospital.com/medical-info/en/bariatricsurgery

• Your doctor will discuss your options for treatment and screening for co-morbid illnesses like kidney disease, heart disease or nerve damage.

Coping with diabetes can be a challenge as there are significant changes to one’s lifestyle, finance. Complications can be depressing, which is why understanding the disease is the first step to coping. Guidance is important.

Patients are empowered to look after themselves with help from the doctor, nurses and dietitian to guide them along the way.