Diabetes unmasked

With the Gulf having the world's highest incidence of diabetes and obesity in the region causing serious concern, Dr Jiju Jacob, diabetes specialist at Al Hilal Hospital, writes on the disease for Gulf Weekly.. Diabetes mellitus is a group of metabolic diseases characterised by high blood sugar (glucose) levels, that result from defects in insulin secretion, or action, or both.

It was first identified as a disease associated with 'sweet urine', and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine.

Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates, for example, after eating food, insulin is released from the pancreas to normalise the glucose level. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.

What is the impact of diabetes?

Over time, diabetes can lead to blindness, kidney failure and nerve damage. These types of damage are the result of damage to small vessels, referred to as microvascular disease. Diabetes is also an important factor in accelerating the hardening and narrowing of the arteries (atherosclerosis), leading to strokes, coronary heart disease and other large blood vessel diseases. This is referred to as macrovascular disease.

In 2007 health ministry officials from across the GCC met in Kuwait to discuss what was termed a 'diabetes pandemic sweeping the region'.

They heard that GCC countries have the worst record in the world for diabetes.

According to The International Diabetes Federation in 2003, the top five countries with the highest percentage of adults with diabetes were: Nauru (South Pacific) (30.2 per cent), United Arab Emirates (20.1 per cent), Qatar (16 per cent), Bahrain (14.9 per cent), and Kuwait (12.8 per cent).

Obesity and inherited predisposition are the major causes of diabetes - both factors appear to be at epidemic proportions in the Middle East.

In Bahrain, 83 per cent of women are obese or overweight according to a 2005 report by the International Obesity Task Force, a London-based think tank that tries to persuade countries to tackle the problem. In the UAE, the figure is 74 per cent and in Lebanon it is 75 per cent.

In the Unites States diabetes affects approximately 17 million people (about eight per cent of the population), in addition, an estimated additional 12 million people have the disease and don't even know it.

Though figures are not currently available for Bahrain, from an economic perspective, the total annual cost of diabetes in 1997 was estimated at $98billion in the United States. The per capita cost resulting from diabetes in 1997 amounted to $10,071; while healthcare costs for people without diabetes incurred a per capita cost of $2,699. During this same year, 13.9 million days of hospital stay were attributed to diabetes, while 30.3 million physician office visits were diabetes related. Remember, these numbers reflect only the population in the United States. Globally, the statistics are staggering.

Diabetes is the third leading cause of death in the United States after heart disease and cancer.

Diabetes is usually classified into four classes:

Type 1 - Insulin deficient. The onset of this type is usually in childhood;

Type 2 - Insulin is not acting properly in these individuals (insulin resistance). The amount of insulin may be low to high. Onset is usually after 30;

Type 3 - Occurs in specific diseases such as Down's syndrome and some cancers

Gestational diabetes - which develops in pregnancy and requires active control for the wellbeing of mother and child.

By 2030 more than 360million worldwide will have diabetes.

Symptoms of diabetes

The early symptoms of untreated diabetes are related to elevated blood sugar levels and loss of glucose in the urine. High amounts of glucose in the urine can cause increased urine output and lead to dehydration which in turn causes increased thirst and water consumption.

The inability of insulin to perform normally has effects on protein, fat and carbohydrate metabolism. Insulin is an anabolic hormone, that is, one that encourages storage of fat and protein.

A relative or absolute insulin deficiency eventually leads to weight loss despite an increase in appetite.

Some untreated diabetes patients also complain of fatigue, nausea and vomiting.

Patients with diabetes are prone to developing infections of the bladder, skin, and vaginal areas.

Fluctuations in blood glucose levels can lead to blurred vision. Extremely elevated glucose levels can lead to lethargy and coma.

How is diabetes diagnosed?

The fasting blood glucose (sugar) test is the preferred way to diagnose diabetes. It is easy to perform and convenient. After the person has fasted overnight (at least eight hours), a single sample of blood is drawn and sent to the laboratory for analysis. This can also be done accurately in a doctor's office using a glucose meter.

Normal fasting plasma glucose levels are less than 100 milligrams per deciliter (mg/dl).

Fasting plasma glucose levels of more than 126 mg/dl on two or more tests on different days indicate diabetes. A random blood glucose test can also be used to diagnose diabetes. A blood glucose level of 200 mg/dl or higher indicates diabetes.

What are the chronic complications of diabetes?

These diabetes complications are related to blood vessel diseases and are generally classified into small vessel disease, such as those involving the eyes, kidneys and nerves (microvascular disease), and large vessel disease involving the heart and blood vessels (macrovascular disease). Diabetes accelerates hardening of the arteries (atherosclerosis) of the larger blood vessels, leading to coronary heart disease (angina or heart attack), strokes, and pain in the lower extremities because of lack of blood supply (claudication).

Eye Complications

The major eye complication of diabetes is called diabetic retinopathy. Diabetic retinopathy occurs in patients who have had diabetes for at least five years. Diseased small blood vessels in the back of the eye cause the leakage of protein and blood in the retina. Disease in these blood vessels also causes the formation of small aneurysms (microaneurysms), and new but brittle blood vessels (neovascularisation). Spontaneous bleeding from the new and brittle blood vessels can lead to retinal scarring and retinal detachment, thus impairing vision.

To treat diabetic retinopathy a laser is used to destroy and prevent the recurrence of the development of these small aneurysms and brittle blood vessels.

Cataracts and glaucoma are also more common among diabetics. It is also important to note that since the lens of the eye lets water through, if blood sugar concentrations vary a lot, the lens of the eye will shrink and swell with fluid accordingly. As a result, blurry vision is very common in poorly controlled diabetes.

Kidney damage

Kidney damage from diabetes is called diabetic nephropathy. The onset of kidney disease and its progression is extremely variable. Initially, diseased small blood vessels in the kidneys cause the leakage of protein in the urine. Later on, the kidneys lose their ability to cleanse and filter blood. The accumulation of toxic waste products in the blood leads to the need for dialysis which involves using a machine that serves the function of the kidney by filtering and cleaning the blood.

Nerve damage

Nerve damage from diabetes is called diabetic neuropathy and is also caused by disease of the small blood vessels. In essence, the blood flow to the nerves is limited, leaving the nerves without blood flow, they get damaged or die as a result (a term known as ischemia). Symptoms of diabetic nerve damage include numbness, burning, and aching of the feet and lower extremities.

Healthy eating & physical activity

Healthy eating, along with medicine, if prescribed, and regular physical activity, can help lower your blood sugar. Eating healthily is key to reducing the risk of health complications from diabetes.

Changing the way you eat can be hard. So make changes slowly. Start by adding high-fibre foods including fruits and vegetables. Eat less meat and fewer sweets.

Regular physical activity can lower blood sugar by decreasing insulin resistance. It can also reduce your risk of heart disease and high blood pressure. Plus, it will help you manage your weight.

If your doctor says you need to lose weight, do it slowly. Work together to come up with a meal plan that will help you lose about one pound a week.