I was at the Divali Nagar some nights ago when I was browsing the Halvaiya’s (Indian Sweet Seller’s) booth. The vendor at the booth shouted out to an old Indian woman passing by, ‘Tanty, come and get your mithāī (sweets) here for Divali’. She replied, ‘No thanks bet, I done sweet too bad aready with meh sugar’. In Trinidad and Tobago (T&T) we all know the common term ‘sugar’ for the medical condition Diabetes Mellitus (DM), and being a doctor; I was a bit taken aback by the response of the old woman. In the medical fraternity, we all know that the season of the Divali is one in which our patients indulge themselves, a little more than they should, in foods rich in complex and simple sugars. Research into DM in T&T, has shown that this period results in a higher frequency of patients presenting with uncontrolled blood sugars. Bearing this fact in mind, I decided to write this article in an effort to prevent this and other medical issues that might arise from DM by sharing my knowledge.
According to the Centre for Disease Control and Prevention (CDC), DM is a chronic (long-lasting) disease that affects how your body turns food into energy. Most of the food you eat is broken down in your digestive tract into their simpler elements such as sugars, fats and proteins, the essential fuels your body requires to function. DM involves the mechanism of the prevailing hormone ratios and how they affect your body’s utilization of the fuel you need to burn to produce energy to survive. Put simply, it is a disease involving hormones, especially the one called insulin, and how it controls and regulates the utilization of fuels we yield from food, especially sugars. Bear in mind, that the disease of DM involves an element of your hormonal regulation. This would mean that, it is one of a spectrum of disease involving the hormones e.g. impaired glucose tolerance (IGT), DM, pregnancy induced DM (Gestational DM), and Polycystic Ovarian Syndrome (PCOS). Also, we may tend to think of it as a disease that only involves the utilization of the fuel of sugar because its discovery was related to uncontrolled blood sugars. However, as mentioned above, it is a disease of utilization of all fuels; sugars, fats and proteins. Hence, we notice that individuals with uncontrolled blood sugars have associated with it, weight loss due to the breakdown of protein in muscle tissues and elevated cholesterol and fats due to mobilization of these as a fuel source in blood.
Because most of the research on DM is based on the hormone insulin and how it controls blood sugars, our understanding about the disease is based on these parameters. After you have a meal and it is broken down into fuel elements which are absorbed in blood and your blood sugar level rises. For normal functioning though, your body requires a blood sugar level of 60-100 milligrams of glucose per deciliter of blood (mg/dl). To maintain blood sugar at the level so your body can optimally function, your pancreas, in response to the elevated blood sugar, begins to secrete the hormone insulin in your blood. Insulin acts like a key to let sugar into the cells of your body for use as energy, resulting in a fall in blood sugar back to the normal range mentioned above. If you have diabetes, your body either does not make enough insulin (Type 1 DM) or cannot use the insulin it makes as well as it should (Type 2 DM). When there isn’t enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream after a meal, which over time can cause serious and possibly life-threatening health problems. Type 1 DM is usually a disease from childhood as the patient is born with the defect of not being able to produce insulin. Type 2 DM is usually a disease that one may be genetically predisposed to and their risk of developing it, usually in adulthood, is due to a unhealthy lifestyle of a diet rich in carbohydrate/sugar combined with a sedentary habits.
There is no cure yet for diabetes, but healthy lifestyle habits, taking medicine as needed, getting diabetes self-management education, and keeping appointments with your health care team can greatly reduce its impact on your life.
Today, we will focus on type 2 DM, due to its high prevalence and incidence despite the knowledge available to prevent it. In T&T, there is a certain genetic predisposition to this type of DM as one with a parent or sibling with type 2 DM is at risk of developing the condition. Also, due to the ethnic makeup of our nation, our population has a greater potential to develop type 2 DM. Research has shown, that those of Asian (East Indian and Chinese) as well as Mesoamerican (Amerindian) lineage are more genetically predisposed to developing type 2 DM than those of other ethnicities. These are termed non-modifiable risk factors as we cannot change them. However, other modifiable characteristics that do not discriminate based on ethnicity such as age of 45 or older, being overweight and being physically active less than 3 times a week, puts all at risk. The latter two are quite prevalent in an age of technology and the present world of work. One must also bear in mind our crime situation that deters us from accessing public spaces for exercise and its impact on our ability to achieve the required amount of activity to prevent type 2 DM. As mentioned above, pregnancy also puts one at risk of developing DM. Thus pregnancy is termed as a diabetogenic state. Also, someone who developed DM during pregnancy has a greater risk of developing DM in their later years.
Based on the above risk profile that can be determined by what was described in the last paragraph, one can determine when one can start screening for DM. Because our population is at risk and not much data is available, we may start as early as age 40 to screen for DM or even earlier if patients present with the symptom triad of Ps; polydipsia (increased thirst), polyphagia (increased hunger) and/or polyuria (increased urination), or even a strong family history of type 2 DM. The earlier DM is diagnosed the better long-term outcome for the patient. This is because life-threatening complications e.g. coma due to high or low blood sugars in the short term and long-term complications like; stroke, heart attack, amputation of limbs due to blood circulation compromise, kidney failure, blindness and nerve damage, can all be prevented. As a matter of fact, the onset of these latter complications do not start when these patients develop DM, but when their blood sugars were relatively high during a period of IGT or Prediabetes. At the stage of IGT the blood sugars are not elevated enough to make a diagnosis of DM, but the organ damage begins as the patient has a higher risk of developing DM. IGT is reversible once the correct medication and lifestyle changes are instituted. However, once the diagnosis of DM is made, this is not reversible. However, if one is diagnosed with DM, this is not a death sentence and one can live a fulfilling long life once medication and life-style changes are instituted just as with prediabetes.
To get screened for type 2 DM there are certain blood tests that can be done at your public or private health facility. This is important if you are at risk, as often, those with undiagnosed DM may have no symptoms and live unknowingly with the disease, only to find out that they have it when they present with a life threatening complication. These tests include an Oral Glucose Tolerance Test (OGTT) where the individual is made to fast after having dinner by 8pm on the previous day and on the day of the test a fasting blood sugar blood sample is taken, after which the patient is given 75g of glucose to drink dissolved in water within five minutes. Another sample is drawn two hours after he consumes the last drop (two hours post prandial).
Another test that is now being used is the percentage of glycocylated heamoglobin (HbA1c) in one’s blood. The advantage of this test is you do not have to fast and it gives an indication as to how well your blood sugar was controlled over the past six to eight weeks.
After the diagnosis of DM is made the HbA1c percentage is used as the gold standard marker of blood sugar control. Random or fasting values only give a snapshot in time of blood sugar control and HbA1c give an indication of a period of control over six to eight weeks, which is of more value when we speak of diabetes control. For diabetics, a value of 6.5 to seven percent is the target and if it is greater than seven treatment modalities of lifestyle and medication is altered to achieve control. For controlled DM, an HBA1c every six months is recommended and for uncontrolled, every three months.
If someone is diagnosed with IGT or DM the following treatments may be instituted:
Initiate treatment with medication like oral hypoglycemic. For IGT Metformin is recommended. And for DM, a range of oral hypoglycemic and insulin preparations may be considered depending on control. It is better to initiate insulin therapy early as it delays the onset of long-term complications.
A dietitian referral to advise on meal portions where carbohydrates (sugars) are concerned as well as fats and cholesterol.
The patient is advised to become physically active at least three to four times a week for 30-40 minutes per day. In that time they should try to achieve 80 percent their target heart rate which is calculated using the formula 0.8(220-age)
Regular visits to see a doctor every three months for review and monitoring for early signs of complications via blood tests, ECG, examination of the pulses, eye exam and foot exam. At these visits medications may need to be adjusted if necessary.
Group support among fellow Diabetics as motivation is essential in proper management. Organizations such as Diabetes Association of T&T are great resources in this regard.
In a modern age where man is no longer required to hunt or gather food to survive, he is no longer physically active, a condition for which his body is not evolved. Thus, lack of exercise and consumption of large amounts of sugars in processed foods, has led to obesity and inability of his body cells to respond to insulin and the development of type 2 DM. There is much we can do to prevent this, based on the correct lifestyle choices that involve healthy behavior. Unfortunately, elements like the media which give primetime advertising to companies that encourage bad health behavior like; fast-food, alcohol, etc. makes it difficult for the individual. If one is unfortunate to have a diagnosis of DM, remember, this is not a death sentence and if you seek the advice of the relevant healthcare professionals and follow it, you can live a long and fulfilling life.