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Prevention of Complications of Diabetes: an emphasis on hypoglycaemia

“The patient with diabetes who knows more lives longer” Elliott P. Joslin

Diabetes refers to a group of metabolic disorders characterised by hyperglycaemia. One (1) in every four (4) adults in CARICOM countries has diabetes; type 2 diabetes is more prevalent than type 1 diabetes in St Lucia. Diabetes (type 2) can be considered a lifestyle and inherited disease, complications of which can affect every major organ system of the body. The disease increases mortality at least two fold.

In general, we all should eat healthy meals, and remain physically active. We aim for good health, rather than a particular body mass index, but weight loss is key to reducing insulin resistance. Here are a few things you may not know about insulin and hypoglycaemia as you aim for increased self-education and empowerment in the management of diabetes.

Insulin, introduced in 1922, saved the life of fourteen year old Leonard Thompson in Toronto, eleven year old Elisabeth Hughes Gossett in Washington and then men and women throughout the world with type 1 diabetes. The transformative change in life expectancy and quality of life among this population, which was at the time admittedly smaller, resulted in all four scientists involved eventually sharing credit in the historically renowned Nobel Prize in Physiology or Medicine in 1923. These scientists: Banting, Best, Macleod and Collip, sold their patents to the University of Toronto for $1, allowing lifesaving insulin to be available worldwide.

Insulin should be administered carefully because an excessive dose can result in hypoglycaemia. Precipitous adjustments in insulin doses should be avoided. In most cases, basal and rapid-acting insulin can be increased by two to four units at a time. Physicians who follow this protocol rely on clients to admit to any non-adherence or poor health literacy or numeracy. Hypoglycaemia may cause:
Changes in cognition
Ischaemic cerebral damage
Increased cardiovascular risk
Oxidative stress (linked to cancer, atherosclerosis, myocardial infarction)
Cardiac arrhythmia
A decrease in confidence in and adherence to, insulin.

In addition, mixing of hypoglycaemics is not recommended, such as a combination of insulin and a sulphonylurea such as Daonil or Diamicron. Studies indicate an increase in mortality with this combination.

The benefits of intensive blood glucose control early after diagnosis are greater than intensive control after years of elevated blood glucose. This is not counter-intuitive; still here are some reasons why:
Early control of blood glucose allows for better control in the years that follow, as well as fewer complications referred to as “metabolic memory”.
Hyperglycaemia may be fatal for persons who have mostly Type 1 diabetes due to ketoacidosis.
Chronic hyperglycaemia may be fatal to persons with Type 2 diabetes if a hyperosmolar state develops.
Weight loss, extreme fatigue, blurred vision, (skin) infections and other symptoms such as polyuria reduce quality of life.
Complications are more likely to occur: peripheral neuropathy, autonomic neuropathy including gastroparesis, peripheral arterial disease and amputations, kidney disease, retinopathy and blindness, erectile dysfunction, depression, dementia and stroke. This list is not exhaustive.
Acute neuropathy and other adverse outcomes as mentioned below

Blood glucose levels should be lowered gradually to avoid hypoglycaemia but also iatrogenic conditions. In rare cases, rapid correction of blood glucose can result in treatment-induced neuropathy “insulin neuritis”. This is an acute neuropathy associated with severe neuropathic pain and or symptoms of autonomic neuropathy. The condition is treated symptomatically and usually alleviates with time. The same cannot be said of cardiovascular events, diabetes-related retinopathy and mortality rates which are higher after intensive correction of long-standing untreated diabetes. Thus, rapid reductions in glycaemia after long-standing hyperglycaemia may be associated with poor outcomes; early diagnosis and management is preferable.

Variability in blood glucose levels throughout the day (glycaemic variability) may also be associated with poor outcomes. A certain amount of variability is expected but this is increased in persons with diabetes and becomes defined as pathological when cardiovascular risk increases. Cellular oxidative stress promotes numerous medical conditions; hypoglycaemia may occur at an increased frequency with glycaemic variability.

Blood glucose fluctuations can be detected by blood glucose testing at seven useful points in the day – paired readings with meals and at night (or using a continuous glucose monitor). Average blood glucose targets are individualised but the A1C is less helpful when blood glucose fluctuates too widely and may even appear normal. If you take medications for diabetes, please take your medications as prescribed and communicate your concerns with your diabetes physician.

Later control of blood glucose is not as beneficial as early control, but the second best time to make healthful changes is now.

 

World Health Day 2017

About World Health Day

On April 7th last year the theme of World Health Day was Diabetes. This year’s theme was one to which diabetes is linked because this disorder can affect decision-making abilities, memory and self-management. This disease can make persons unable to function effectively or to participate in family or community life. Indeed, depression can also contribute to diabetes and the presence of one disease requires screening for the other. The disease burden of both conditions is higher for persons in low and middle income countries and the prevalence of these diseases continues to increase annually at an alarming rate; over 300 million persons are estimated to have depression globally whereas 415 million persons are estimated to have diabetes.
Depression is a mood disorder that, for at least two weeks, includes loss of interest or pleasure in usual activities or depressed mood and four of the following:
• suicidal thoughts,
• loss of energy or fatigue,
• weight change,
• unintentional purposeless movement/ slow movement,
• feelings of worthlessness,
• poor concentration or indecision,
• insomnia or hypersomnia.
There is often not just one cause of depression. Stressors triggered by adverse life events may cause an unchecked downward spiral due to isolation, negative self-criticism and poor coping choices. Abused substances such as narcotics and alcohol can increase the risk of a depressive disorder. Depression may also be genetic, especially among first degree relatives. In fact, research is ongoing about genes related to the serotonin system linked to depression.
The World Health Organisation’s recent campaign for World Mental Health is entitled “Depression: Let’s talk”.  This slogan underscores a few truths, one of which is that not many persons really talk about depression, that the stigma of mental health issues extends to this condition in spite of the statistics that one in six persons are affected in U.S. and that clinical depression may be the largest contributor to disability worldwide.

The symptoms or signs may be difficult to discern and may be attributed to moodiness, something a person can “snap out of”, or weakness. Persons with depression may subsequently be exposed to greater cruelty due to pervasive misunderstandings. Furthermore, seeking help is a difficult step for persons who suffer from depression, who may be faced with disinterest, absence of true empathy or compassion or incorrectly applied resources. Is medication needed? A psychiatrist? A psychologist? A counsellor? A support group?
The World Health Organisation describes depression as a black dog. While we may not appreciate this characterisation of our favourite colour or pet, the metaphor is effective. Depression can be aggressive and hijack a person’s life or can be made to “heel” and taught new tricks. Caregivers should understand their own boundaries, offer support and introduce their loved one to someone who has the training or the expanse of compassion or life experience to be helpful. While cognitive behavioural therapy and mindful meditation can help to change patterns of negative thought, most of all persons with depression should hold on to hope and look forward to no more black dog days.

 

WORLD DIABETES DAY!!

 

Happy World Diabetes Day!!

World Diabetes Day is recognised internationally on November 14th with the aim of raising diabetes awareness. The theme for World Diabetes Day 2016 is ‘Eyes on Diabetes’. The IDF message for this year is promotion of screening for diabetes and for complications of diabetes.

In 2015 IDF noted that 1 in every 11 adults worldwide has diabetes, totalling 415 million, with about half undiagnosed. The IDF further predicts that, by 2040 if nothing is done an estimate of one in ten adults worldwide will have diabetes(642 million).

 

Update on the Diabetes Cure

Diabetes currently has no cure.

If there was a permanent cure for diabetes, physicians would retrieve it from the ends of the earth for their clients, urging governments to mobilise, to seek charitable donations to take it to third world countries.

If there was a magic herb, supplement or probiotic pill that was tested and proved, there would be nothing that physicians would not do to avoid seeing clients lost to follow-up, losing limbs and vision and mobility, from seeing parents wrenched with anxiety to manage their little ones; to avoid the suffering from depression, inability to cope and premature death. Diabetes can be managed successfully, but complications may be dire and life-changing.

There are few persons alive who can say that they do not know someone with diabetes or do not have diabetes themselves; one in eight adults in the North America-Caribbean region are persons with diabetes. The International Diabetes Federation’s predictions of 415 million persons worldwide with diabetes in 2015, with projections to 642 million by 2040 underscore the global emergency that diabetes has become. St. Lucia has a prevalence estimated at 10.9% and ranks #41 in the world by prevalence.

There is currently no cure for diabetes but remission is possible for some persons. Remission is defined as clinical symptoms and clinically detectable diabetes while not taking medications or ongoing surgical/immunosuppression options for at least one year. A cure, however, restores the natural production of insulin and normalises blood glucose levels without any other risks or negative effects.

Remission of type 2 diabetes may occur in certain circumstances:

  1. Promotion of insulin sensitivity:

A person who is insulin-resistant needs more insulin to keep blood glucose within normal range. Conversely increasing insulin sensitivity will reduce insulin requirements and can normalise blood glucose levels. That is the rationale behind the use of medications and administering insulin to control blood glucose.

Medications such as metformin and pioglitazone have been proven to increase insulin sensitivity and can prevent the onset of diabetes from a state of pre-diabetes. In addition, certain foods and meal plans improve insulin sensitivity and can reduce blood glucose; even if remission does not occur, the benefits extend beyond diabetes management. Meal plans such as the DASH (Dietary Approaches to Stop Hypertension) diet and the Mediterranean diet which emphasise meals rich in fruits and vegetables, low in saturated fat and high in nuts and pulses, not only improve insulin sensitivity but consequently reduce the incidence and improve the management of type 2 diabetes, and many other illnesses.

Weight loss by means of these meal plan changes and possibly low calorie diet (Diabetes remission Clinical Trial) may potentially allow remission of diabetes when diagnosed early. Similarly, physical activity – aerobic and resistance exercise – is key to primary and secondary prevention of diabetes, hypertension, obesity, cancer, obesity, osteoporosis, depression, that is, reduces incidence and allows effective management.

Molecular research such as galectin-3 studies are currently being conducted; removing Gal-3, a protein that is involved in inflammatory processes, removed insulin resistance in mouse models. This research has great potential.

  1. Avoidance of beta cell destruction such as the proposed vaccine for type 1 diabetes.

  2. Promotion of beta cell recovery, regeneration or growth such as stem cell replacement of beta cells and pancreatic transplantation, but both of these methods have had the challenge of being destroyed by the human immune system. If a solution to autoimmune destruction is found, this can lead to a cure.

Diabetes can be managed successfully with lifestyle interventions – improvements to meal plans and physical activity, as well as medications including insulin. Physicians are keeping up to date with the promising research and options for persons with diabetes and other chronic illnesses. Information, methods and medications that reach our clients must be safe, efficacious and proven. Then the discerning physician will individualise management to the challenges, other illnesses, motivation and health literacy of the client so that no person with diabetes ever feels more like a disease than like themselves.

Diabetes in the Twentieth Century

Diabetes was rare before the twentieth century.  Management of Diabetes started with severe caloric restriction for mere survival of patients with type 1 diabetes.

Banting and Best, Mc Cleod and Collip, discovered and purified insulin from the canine pancreas.  In 1935 diabetes with insulin resistance was distinguished from type 1 diabetes.

Longer acting insulins were marketed from the 1930s while the first generation of sulphonylureas (a class of oral medications) was introduced in the 1950s.

Prior to the 1960s blood glucose was tested using doctor’s office or home urine kits with test tubes.  The first blood glucose meter from Aimes Diagnostic appeared in 1969 and at the time weighed three pounds and cost US$650.

The single use syringe was introduced in 1961 and this replaced reusable needles that became blunt with time and were sterilised by boiling in water for 20 minutes.

The first portable insulin pumps appeared in the late 1970s and these weighed over one pound and had to be carried in a backpack.

Some important clinical studies happened in the late 20th century.  The DCCT from 1983 to 1993 showed that tight blood glucose control is beneficial to prevent complications such as retinopathy and nephropathy.

The most commonly recommended oral medication for type 2 diabetes, Metformin, was approved for use in 1995 and researched continued on rapid acting insulin and alternative oral medications.

PWD Pt2

Between the ages of 7 and 8 James Quander was told the only thing he was born to do was to die. However, he lived longer than persons who had diabetes were expected to. Mr. Quander was born in 1918 and was diagnosed with type 1 diabetes just before he turned 6 in 1924, shortly after insulin was introduced to the market.
James Quander was a black American whose family had been in the United States since the late 1600s. Mr. Quander graduated from Garnett Patterson Junior High in 1933 and Paul Laurence Dunbar High School in 1936, Washington’s then segregated schools. He worked his way through Miner Teachers College (now part of the University of the District of Columbia) by selling ice cream and had two newspaper routes during the great depression, where he graduated with a degree in Chemistry. In 1940 Mr. Quander was hired by the U.S. post office, persevered past racial inequalities and worked for many federal agencies as a computer programmer, statistician and economist until his retirement in 1973. In 1971 he was ordained by the Washington Archdiocese as a permanent deacon in the Roman Catholic Church, becoming one of the first 16 men in the restoration of what had been suspended for 800 years.
Mr. James Quander kept his diabetes a secret for over 60 years because of pervasive misunderstandings about the nature of the disease. He was self motivated, setting high goals; a determined, and disciplined individual. Mr. Quander was described as a medical miracle, one of the longest survivors of diabetes in the US.
Mr. James Quander passed away at the age of 86, surviving with diabetes for over 80 years. He left behind four children, 11 grandchildren and one great-grand child. Rohulamin Quander, a retired judge, wrote a book about his father called “Quander Quality:The True Story of a Black Trailblazing Diabetic“.

Diabetes and Management tools

After the diagnosis of diabetes, there are a few diabetes-related tools that you will either have to purchase or have access to. I recommend buying a glucose meter, but before you do this, be sure you have access to the meter test strips; because this is the real source of expense. You need to check your blood glucose readings several times per day, if your blood glucose is poorly controlled. You will also need lancets to use each one, just once, and you may also need a lancing device as well. If you take insulin you may need an insulin pen or pump.

To ensure accurate readings, be sure that your test strips have not expired and try not to leave your meter and test strips out in the sun. There may be a calibration code or a control solution that you can use to ensure that your meter is well calibrated especially when you open a box of new test strips. Compare your meter to your doctor’s and ask for help if you need to. Remember that your blood pressure monitor, pedometer and an A1C meter may all be part of your arsenal in diabetes management. Also be sure to have a container for your sharps such as your needles or lancets.

Diabetes and Personality

A person’s personality may or may not be modifiable, but an understanding of the relationship between an aspect of personality and adherence to diabetes management plan is quite useful.  This can allow modifications to education, counselling methods and behavioural therapy.
More than one study use a measure called the NEO Personality Inventory with personality dimensions such as neuroticism, extroversion, agreeableness and conscientiousness, openness to experience, and the respective facets.
Both among persons with type 2 diabetes and adolescents with type 1 diabetes, conscientiousness was associated with better glycaemic control. Neuroticism is usually associated with guilt, decreased coping abilities with stressors but surprisingly neuroticism was also associated with better glycaemic control. Further, a high level of altruism was linked to less successful control of blood glucose.
Do persons who care more about the needs of others neglect their own self-care? Does worry and useful “emotional distress” predict increased motivation? Studies are ongoing.
Whatever your personality, your diabetes physician can work with you.

Diabetes and the Elderly

Diabetes occurs more frequently with advancing age, especially for persons who become more sedentary with age. There is an increase in fatty tissue and a decrease in muscle mass with age, which accompanies a decrease in physical activity. The elderly person with diabetes may be affected by other illnesses, known as comorbidities and the use of many medications, known as poly-pharmacy. Hypoglycaemia may occur more often due to liver and kidney disease and also due to hypoglycaemic unawareness. Hypoglycaemia can affect functioning and vision and can increase falls and fractures; complications of diabetes may also be more frequent, such as kidney dysfunction and heart disease. Our elderly persons with diabetes may benefit from a less restrictive meal plan with a level and intensity of physical activity dependent on physical condition. Insulin is often required for elderly persons with diabetes and this requires family involvement and and support, and self monitoring of blood glucose at home.