Diabetes Mellitus - Part 3
How can we prevent complications of Diabetes Mellitus?
by Dr. Tan Chee Eng
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Introduction
A common misconception by many patients is that Type 1 (insulin requiring) diabetes mellitus is worse than Type 2 (non insulin requiring) diabetes mellitus. They associate the need for insulin in treatment with severity of the disease and some even associate insulin with kidney failure since they have seen many patients on dialysis using insulin. This misconception stems from the fact that patients who are poorly controlled, end up with kidney failure and eventually need insulin. Both Type 1 and Type 2 diabetes mellitus have the same risk of developing complications if the disease is not managed properly.
Diabetes mellitus can be associated with a number of complications such as heart attacks, strokes, blindness, kidney failures, damage to nerves, amputation of limbs and proneness to infections of skin, urine tract and lungs. Most of the complications result from poor control of the blood sugar as well as the duration of diabetes. Therefore, any one who has uncontrolled diabetes for many years will be more susceptible to complications of diabetes. On the other hand, good glucose control will go a long way to prevent complications and some patients with diabetes for more than 20 years can be free from complications because they are well controlled. However, I must emphasize that it is not just the blood sugar that needs to be well controlled but includes the blood pressure and cholesterol levels.
Heart attacks
Patients with diabetes have three or four times greater risk of suffering heart attack compared with another person without diabetes. Two individual with the same level of cholesterol or blood pressure, one with diabetes and the other without, do not carry the same risk for heart attacks. The individual with diabetes will always carry 3 to 4 times greater risk. For that reason, most national guidelines for diabetes target a much lower level of cholesterol (LDL-cholesterol less than 2.6 mmol/l or 100 mg/dl) and blood pressure (BP less than 130/80 mmHg) compared with non diabetics.
It is not enough to for individuals with diabetes to measure their blood pressure or cholesterol against the population norms but must target at levels appropriate for diabetes. In most instances, medication is needed to control both the blood pressure and cholesterol because of the stringent target. Obviously, the blood glucose must also be tightly controlled if one is to reduce the risk of heart attacks.
Heart attacks in diabetic patients can sometimes be atypical in presentation and pain may be masked because of damage to the nerves. In addition, diabetic patients suffering heart attacks may not do as well and are more susceptible to complications such as abnormal heart rhythms, water in the lungs and even death. Therefore, it is always better to prevent heart attacks because the prognosis is much better. Furthermore, the quality of life in an undamaged heart is much better than one after a heart attack.
Strokes
Diabetic patients are also prone to strokes especially if blood glucose is not well controlled, blood pressure is high or cholesterol not treated. The same principal as for preventing heart attacks hold true for prevention of strokes.
Blindness and other eye complication
Chronically elevated blood glucose will result in damage to the blood vessels in the retina (back of the eye where vision takes place). In the early stages, there may only be leakage in the blood vessels but at a later stage, new vessel formation takes place. Such new vessels are friable and prone to burst, resulting in immediate loss of vision. Patients with diabetes need to have their eyes checked for abnormal blood vessels in the retina, at least once a year. Those with pre-existing eye problems may require more frequent reviews. Patients are also more prone to cataracts and glaucoma (raised eye pressure) and all these can be picked up during annual reviews. Good glucose control will prevent complications of the eyes.
Kidney Failures
One of the most feared complications is kidney failure, which is again closely related to the degree of glucose control and duration of diabetes. In the early stages, kidney problems can present as leakage of albumin (protein) from the urine. This can be easily picked up by a simple urine test (urine for microalbuminuria). If protein leak is detected early, medications can be used to reverse this process. Again, tightening of glucose control will also help in preventing further kidney damage. Many patients assume that kidney failure will present with symptoms and since they are feeling well, there is nothing to worry. Sadly, by the time that symptoms of kidney failure are obvious, it is irreversible and dialysis or kidney transplant are the only options. Therefore, it is far better to detect kidney damage early and treat aggressively before it become irreversible.
Nerve damage (neuropathy)
A number of patients with diabetes will notice increasing numbness of the hands and feet, often accompanied by tingling sensation. These are indications of damage to the nerves by uncontrolled diabetes. When the damage to the nerves is substantial, perception of pain may be reduced. Hence, some diabetic patients end up with trauma to the feet caused by sharp objects because they could not feel the pain after stepping on them. This may lead to a whole host of other complications such as infections of the wound and sometimes even amputation of limbs because of poor healing. In the early stage, use of medication can also help reduce the nerve damage but critical to the intervention is good glucose control. Damage to nerves supplying the intestines and stomach can also lead to changes in bowel habits.
Infections
Patients with diabetes are also more prone to infection in various parts of the body, including skin, urine tract, vaginal tract, lungs. They may also be prone to fungal infection, especially in part of the body which are prone to sweating. The sweat of the diabetic patients may have increased sugar contents and become ideal culture medium for fungal growth. Likewise, the urine tract is also prone to infection because the urine carries more sugar contents and is conducive for bacterial growth. One common adage is that diabetics get common infection (usual bacteria) in uncommon areas (e.g. Prostate, sinuses) and they get uncommon infection (rarer form of bacteria or fungus) in common areas (eg urine tract, lungs).
Another fear among diabetic patients is poor wound healing after surgery or injury. This is true if diabetes is poorly controlled and complications have set in. Amputations resulting from wound that refuses to heal are a consequence of seeking treatment late or poorly controlled diabetes. However, the diabetic who is well controlled need not fear wound breakdown or overwhelming infection because they would be able to mount the right response to rid the body of any infection.
Erectile dysfunction
It has been estimated that at least one out of every two men with diabetes will have some form of erectile dysfunction. The problem is often the result of damage to nerves and blood vessel necessary for normal erection. Sadly, many male diabetics suffer in silence because they fail to realise that it is a part of diabetes complication. Therefore, they need to be able to discuss such matter with their attending doctors as treatment is readily available. Some patients are embarrassed by such problems, afraid that doctors would see them as being promiscuous. Others assume that it is part and parcel of aging and therefore inevitable. Doctors should be willing to help patients with erectile dysfunction because it affects the overall well being of the patients as wells as their motivation to keep diabetes under control. Again, good glucose control will help prevent or delay erectile dysfunction.
Conclusion
Diabetic patients need to realise that good glucose control, well controlled blood pressure and desirable cholesterol levels are all part of the strategies to prevent complications of the disease. Many assume that if they do not feel unwell even if their glucose is out of control, then it really does not matter. Let me stress that good diabetes control is vital and sensible. By the time that patients feel unwell or present with symptoms, it may be too late to reverse the complications of diabetes. Prevention is definitely better than treating the complications after it has surfaced.
If you have any queries regarding this article, you may email the author at tceendo@singnet.com.sg.