What causes diabetes?

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Although much has been written and discussed about diabetes, many remain unaware what causes blood glucose levels to rise in the body, and its consequent implications.

Impaired glucose levels is one of the conditions that is connected to Syndrome X.

Diabetes management is wrought with various misconceptions, with many diabetics believing their medications can cause heart attacks or that just avoiding sugary food or drinks will help improve their condition.

These misconceptions affect compliance to medications, which in turn result in poor glucose control, says endocrinologist Dr Stanley Liew Choon Fong.

Dr Liew explains that diabetes occurs when the pancreas, an organ located behind the stomach that is responsible for the production of hormones called insulin and glucagon, is not working as well as it should. These hormones play a vital role in regulating glucose levels in the blood to support important organs such as the heart, kidney and brains.

Tips on living well with diabetes

  • People with diabetes know that they need to take control of their eating habits because blood sugar levels in the body are directly affected by the foods we eat.
  • A diabetic diet is an eating plan that is high in nutrients and fibre, low in fat, sugar and salt, and moderate in calories
  • The only difference is that you need to pay more attention to your food choices
  • Controlling carbs: If you have diabetes, excessive intake of carbohydrates will lead to high blood sugar levels and poor control of diabetes.
  • Load up on greens: Loading up on vegetables, especially green leafy ones, will assist in blood sugar and weight control, and promote a healthy heart.
  • Choose wisely when eating out: Reduce your food portion size by requesting for less noodles/rice, and avoid dishes with thick gravy or fried foods with flour/bread coating
  • Order more vegetables and have a serving of fruit for dessert.
  • Regular mealtimes: For individuals who are on fixed doses of insulin and/or taking oral medication for diabetes, it is important to maintain regular mealtimes to prevent fluctuation in blood sugar levels and to optimise the effects of the medication.
  • Be active: The reason exercise is so important is because it increases cell sensitivity towards insulin. This means that cells are better able to use any available insulin to take up glucose during and after each physical activity.
  • You can start slowly with a 30-minute brisk walk three times per week and work your way towards a more intensive regime.
  • This helps you to have better blood glucose control and maintain a healthier body weight.
  • If you have diabetic complications such as heart disease, nerve problems or kidney failure, seek the advice of your doctor or an exercise specialist about appropriate exercises to do.
  • Shoes that fit: Comfortable footwear is also important as diabetes causes nerve insensitivity in the feet.
  • Poorly-fitted shoes can lead to foot complications such as ulcers, blisters or corns.
  • Stick to medications: In order to ensure blood sugar targets are achieved, most people with type 2 diabetes will require oral medication and/or insulin, along with living a healthy lifestyle.
  • Keeping clinic appointments: You need to take a proactive role in the management of your healthcare in order to prevent or delay the development of diabetic complications.
  • It is very important to follow the medication dose and timing prescribed by your doctor. It is dangerous to skip medication, or adjust medication dosage and timing without checking with your doctor.
  • Self-monitor blood sugar levels: Regular monitoring of your blood glucose gives you a basic understanding of how your diet, medication and physical activity affects your body and how you can manage it.
  • In general, individuals with diabetes should have comprehensive physical examinations once a year and have their diabetes assessed at least every three to six months.
  • Too little sleep can increase the risk of diabetes, and if you already have diabetes, sleep deprivation can lead to poor blood sugar control.

The pancreas is also responsible for digestion and the conversion of food to energy, he adds. As such, people with diabetes often experience fatigue and lethargy despite eating well.

Other symptoms include frequent thirst and hunger, reduced libido, weight loss, and increased need to urinate, especially in the night, leading to poor sleep and daytime sleepiness.

Diabetes, which results from prolonged elevated glucose levels in the blood, affects the entire body, and can cause multiple complications such as kidney failure, diabetic retinopathy, gangrene and heart disease.

In Malaysia, diabetes is the leading cause of stroke, heart disease, blindness, leg amputation and kidney failure.

The first NHMS conducted in 1986 reported a diabetes prevalence of 6.3 per cent among adults aged 30 years and below, rising to 8.3 per cent in the second NHMS in 1996 and 14.9 per cent in the third NHMS in 2006.

The most recent NHMS shows diabetes prevalence at 20.8 per cent, which means approximately one in five adults or 2.6 million Malaysians now suffer from diabetes.

This figure is said to be dramatically under-reported as it is believed that for every one person diagnosed with diabetes, there is at least one other who remains undiagnosed. This would mean another 2.6 million Malaysians out there walking the diabetic landmine.

As a result, many people who have diabetes or impaired glucose tolerance, a precursor to diabetes, do not find out until much later and suffer from more complications.

More children are also presenting with type 2 diabetes. Suddenly, a condition that can take half a lifetime to develop has become a young person's problem. Even more surprising, about 15 per cent of people with type 2 diabetes are not overweight, according to the National Institutes of Health. But their average-weight bodies are hiding a dark secret.

"My youngest patient with type 2 diabetes is an 11-year-old boy," notes Dr Liew.

Regulating blood glucose levels

Diabetes management involves keeping blood glucose levels at an optimal level. Diabetic patients need to be actively involved in monitoring their daily blood glucose levels to ensure it remains below 7.8 mmol/L to prevent damage to key organs such as the heart, kidneys and eyes.

Dr Liew usually recommends a combination of lifestyle changes and medications to help keep blood glucose levels in check.

Lifestyle changes include exercising at least 30 minutes daily, keeping an ideal weight, stopping smoking, diet change and stress management.

The old rule of thumb is the average person has diabetes 10 years before diagnosis. Symptoms from diabetes usually come when the disease is much more advanced.

By that point, many of the simpler lifestyle interventions we want to try and emphasise might be less effective, because the sugar levels are running high, or there has been some damage to the kidneys or blood vessels.

"Either lifestyle changes might not be enough, or we just cannot afford the three to six months' duration to allow these patients to go home and 'experiment' various lifestyle modifications, as this will be at the expense of a looming heart attack or even limb amputation," stresses Dr Liew. This is where medications play a pivotal role in helping diabetics achieve the necessary glycemic control.

He explains that medications for diabetes are divided into different classes, each performing a different function. Sometimes, diabetic patients need to be on a combination of medications at any one time in order to achieve the best results.

Diabetic medications work to stimulate the pancreas to produce more insulin and release glucose from the liver to provide energy. At the same time, your doctor may also provide heart medications that help to prevent heart attacks, as diabetes increases the risk of heart attacks by 48 per cent.

The problem with most diabetes medications is that it tends to cause hypoglycaemia, a condition where blood glucose levels dip to dangerous levels.

Hypoglycaemia, characterised by hunger, shaking, palpitations, nausea, pallor and sweating, is a medical emergency as the patient can develop confusion, seizures or lose consciousness.

Therefore, management of diabetes has to be tailored to individual needs. In most cases, the benefits of tight glucose control must be weighed against any potential complications such as recurrent hypoglycaemia," stresses Dr Liew.

"Different classes of diabetic drugs work differently. For instance, DPP-4 inhibitors slow down the breakdown of incretin hormones and the risk of hypoglycaemia is low," observes Dr Liew. This is especially so in the elderly, in whom a low blood sugar level can have disastrous consequences.

The effects of new drugs such as gliptins, which is a DPP-4 inhibitor, are aplenty. The focus is to reduce the problems of hyperglycaemia, but we are seeing other positive effects such as a better tolerability profile, lower risk of hypoglycaemia and no weight gain. This newer class of drugs do not increase the risk of cardiovascular disease and currently large clinical trials are underway to provide a clearer picture if they reduce this risk, adds Dr Liew.

This is of course all good news for the diabetic patient as we can then use these drugs in patients with underlying cardiovascular disease in whom drug choices may have been previously limited.

Diabetes requires a lifetime of care, hence patients and their caregivers need to be constantly motivated to control their blood glucose levels.

People with risk factors such as a family history of diabetes, obesity, sedentary lifestyle, smoking and high blood pressure need to get themselves tested for diabetes after the age of 40 for early detection.

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