A bitter sweet problem

The global incidence of diabetes is increasing. It has already affected 2.8 per cent of the total population and this is expected to increase to 4.8 per cent in 2008. In absolute figures this works out to an increase to 366 million from 171 million. These projected figures are expected to hold good even if the all-pervading epidemic of obesity, inactivity and urbanisation remains static.

Frightening statistics, these. Aware of this, the medical community has put a great deal of time and effort into the elucidation of cause and effect.

What really causes diabetes? No one still has an answer. Everything has been blamed — heredity, genes, the environment, upbringing, breast-feeding, immunisation and immunity. Infection with viruses, especially those of the coxackie group, chemical toxins and even some allergens found in cow’s milk are believed to precipitate the development of antibodies to the cells in the pancreas that produce insulin. This leads to destruction and an eventual decrease in the total number of cells left to produce insulin.

Whatever the cause, the end result is the same. The blood sugar goes up and produces macro vascular complications in all the organs of the body. This predisposes a person to the development of stroke, heart attacks and even amputation of a limb. At the micro level, it affects the eyes, the kidneys and the nerves.

Before the discovery of insulin, diabetics led a miserable existence, controlled with an almost intolerable rigid regimen of diet and exercise. Many succumbed to infection or developed fatal biochemical abnormalities because of the high, uncontrolled sugar.

The discovery of insulin changed all that. It helped diabetics achieve control and this in turn has reduced the risk of eye, kidney, nerve and cardiovascular diseases. Diabetics are beginning to live longer and healthier lives.

Diabetes is now a more accepted as a lifestyle disease. Control with diet and exercise is preferred, and this can now be individualised. Patients can play a greater role in the control and management of the disease.
The diet is no longer regimentalised as people are now able to modify their eating according to their needs. A 1,500 -2,000 calorie-a-day diet split over six meals probably helps to achieve good control.

There is no need to totally avoid food such as rice, bread, cereal and starchy vegetables. Instead, spread out the total content in six small meals instead of three big ones.

A total of five fruits or vegetables can be eaten daily and an extra piece of fruit when the hunger pangs are unbearable.

There is no real need to feel guilty if you have eaten a sweet. Moderation is the key. Cheating once or twice a week is acceptable. Just remember that sweets push up the sugar rapidly.

Initially, for a (young or old) diabetic with some pancreatic function, a controlled sensible diet and regular exercise may be enough to manage the escalating sugar level.

Later oral medications may have to be added. Here too, patient friendly developments have occurred. Sustained release, long-acting medications or the newer once-a-day medications are now available.

After five-six years on tablets, control often begins to slip. At this point in time, switching to insulin is a realistic, sensible long-term option. The old allergy-causing painful pork and cow insulins have now been replaced with human insulin analogues. They are painless, can be long or short acting, dosages are smaller, and absorption is good. There are no more ugly lumps, bumps or disfiguring atrophic areas betraying the sites of insulin injections.

The old syringes and needles, too, have been replaced with ultra light “pens” (available for between Rs 200-300). The medication comes in a cartridge, very much like pen refill cartridges. If even that is a problem, for a slightly higher price a “use and throw” disposable version is available.

For those with poor coordination and eyesight, the numbers indicating the dosage in the pens are large. It is difficult to withdraw too much or too little as it preset. The pens “lock” and only the required amount of insulin is injected each time.

Visits to the physician or the lab may be difficult and time consuming. That probably means the blood values are probably only done once in every couple of months. This type of control is not satisfactory. At that time a glycosylated haemoglobin (HbA1c) value (normal 3.7-5.1) can be checked instead. This reveals control over the past couple of months.

It is better to achieve individualised good day-to-day control with tailored minor adjustments in diet, medication and injections. This is now easily done with home glucometers (Rs 1,500), now available with a three-year guarantee. Sugar levels can be checked once or twice a day so that an erratic indulgent meal or lack of physical activity never pushes the diabetes out of control.

Are you diabetic? You hold your life (with a little help) in the palm of your hand.

By Dr Gita Mathai who is a paediatrician with a family practice at Vellore,India. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

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