Diabetes Mellitus -Find Out All You Need to Know

Diagnosed with Diabetes? Here are the most important issues to know.

Diabetes Mellitus, is most certainly a complex multi-system disorder characterized by hyperglycemia (high blood sugar), which may lead to several life threatening complications that can reduce quality of life and increase mortality. Diabetes disease includes dysfunction of beta cells (of the pancreas), adipose tissue, skeletal muscle and liver.

There are two types of Diabetes:

Type 1 diabetes (T1D), which usually gets diagnosed in younger individuals where the initial diagnosis is often when the patient presents with very low glucose and extreme weight loss. Although the diagnosis is called juvenile diabetes, because it often occurs in younger individuals, it can occur at any age.

The second type o DM, is more prevalent and called, Type 2 diabetes (T2D). It is characterised by varying degrees of beta cell dysfunction in addition with insulin resistance. There exists a strong association between obesity and type 2 diabetes mostly through pathways of food intake and energy expenditure.

The risk of developing diabetes or its complications represents interactions between genetic susceptibility and environmental factors including availability of nutritious food and other social determinants of health. This article provides information of everything you need to know about diabetes.

1. How is it diagnosed?

Diabetes is diagnosed by performing a blood test to test your fasting glucose levels. Fasting should ideally be done overnight. According to the World Health Organization, a fasting glucose level of > 7mmol/L confirms a positive diagnosis for Diabetes.

If fasting levels of glucose fall within this range: 6-6.9mmol/L, the condition is termed impaired fasting glucose. It is recommended, for this condition, to follow up with a fasting oral glucose tolerance test (OGTT), to either confirm or reject a diabetes diagnosis. For this test, the patient is expected to fast overnight, then drink a 300ml glass of water mixed with a 75 grams of glucose solution. Blood glucose levels are then tested before drinking the solution and a 2-hour interval thereafter. A value of 11mmol/L at the two-hour interval confirms the diagnosis for diabetes.

Diabetes can also be diagnosed by testing the level of glycated hemoglobin or HbA1c in the body. Hemoglobin are red blood cells in the body. Glucose in the blood stream binds to hemoglobin when it is transferred (thus called glycated hemoglobin). So, the higher the amount of glucose in the blood stream, the more of it binds to hemoglobin. The HbA1c test measures the average percent of glucose bound to hemoglobin over the preceding 2-3-month period. The diagnosis of Diabetes is confirmed if the glycated hemoglobin is more than 48 mmol/mol or >6.5%.

The utilization of tests to measure glucose in the urine or random blood glucose tests to diagnose diabetes is unreliable and not recommended as diagnostic tests

1. How can it be treated?

The treatment for Type I Diabetes is always Insulin which has to be injected into the skin.

The amount of insulin that needs to be injected into the skin will be determined by the health care specialist or provider. Easy to set and utilize Insulin Pens are now widely available to make injecting insulin worry-free and relatively painless.

Type II Diabetes is treated with oral medication that may be required for a long time and strict adherence to the treatment guidelines as prescribed by the doctor or physician, is recommended.

1. Can I die from it, is it fatal?

Yes, Diabetes can be fatal.

More importantly, living with uncontrolled or poorly controlled Diabetes can severely affect quality of life.

If glucose control in a Diabetic remains unsuccessful, irregular and inconsistent, serious complications can occur.

The most dangerous complication that can occur is when glucose levels are too low for an extended period of time, is the development of a condition called Diabetic ketoacidosis (DKA). The patient may go into a coma and die. It is a serious condition that requires immediate medical attention. Treatment will usually require immediate intravenous glucose.

Other complications that may occur, mostly relates to high levels of glucose in the blood stream, for long periods of time. When there is too much glucose in the blood, the blood becomes sticky and sluggish and tends to clot especially in the very tiny blood vessels (causing micro-vascular disease). There are blood vessels in every single organ of the body, and so Diabetic complications can literally affect every single organ. Disease however will begin in the peripheries where the small vessels are, and may affect not only the peripheral vessels, but the nerves as well.

Other common Diabetic complications include, kidney disease, eye disease, poor healing wounds ad decreased circulation in the feet and legs especially, and cardiovascular disease.

1. Why has Diabetes become so common?

The number of people who have been diagnosed with Diabetes has increased all over the world. In year 2014, the number of people diagnosed with Diabetes consisted of 8.5% of the population (this is termed prevalence of Diabetes), compared to 2019, when the prevalence increased to 9.3% of the population had Diabetes.

Every year, the number of people living with Diabetes has increased. According to the World Health Organization in the year 1980, 108 million globally had Diabetes and this number increased to 422 million in 2014. The International Federation of Diabetes estimates that in 2021, this number had increased even further to 537 million people.

The most common risk factor identified, to be associated with the increased prevalence and incidence (the number of new cases) of Diabetes all over the world, is Obesity.

Being overweight or obese is thought to account for between 80%-85% of the risk of developing Diabetes.

Obesity is largely a lifestyle disease, and is linked to the type of foods we consume daily and the levels of physical activity we partake in, on a daily basis.

Eating large amounts of calorie-dense, nutrient-deficient foods and living a sedentary lifestyle are the two biggest and most important reasons for developing obesity.

1. I have Diabetes, what should I do?

If you have been diagnosed with Diabetes, it is highly recommended to:

• Live a healthy lifestyle by eating a balanced, nutritious diet, incorporating vigorous physical activity into your day, do not smoke any tobacco or tobacco products and do not drink any alcohol.
• Learn how to keep your glucose levels well regulated (so it does not go too low or too high). If you are able to test your random venous glucose regularly, it is advised to aim for levels between 7mmom/L and 9mmol/L. To keep your glucose well regulated, your diet should focus on consuming foods with low levels of glucose.
• Attend your scheduled check-ups with your health care providers. This may vary from 2-3 monthly, to 6 monthly, depending on the severity of the Diabetes.
• Make sure that full health checkups are done regularly, and includes: blood pressure checks, cholesterol checks, Body Mass Index (BMI) calculations and HbA1C checks to measure compliance to medication.

1. What are the important health numbers related to Diabetes I should be aware of?

Remember these numbers:

• Diabetes is diagnosed as a fasting glucose level of > 7mmol/L or a venous HbA1C level of >6.5%. A level of random glucose of > 11mmol/L may also be indicative of a Diabetes diagnosis
• A level of 6mmol/L-6.9mmol/L is impaired fasting glucose and may be at risk for a Diabetes diagnosis. A fasting oral glucose tolerance test is thus recommended.
• When measuring random glucose levels for monitoring purposes, aim to keep glucose levels between 7mmol/L and 9mmol/L.
• Blood Pressure levels should ideally be < 130mmHg/90mmHg
• BMI should be <25
• Fasting Total Cholesterol should be < 5.2mmol/L (or 200mg/dL)

1. You can live a happy, long, healthy and productive life with a Diabetes diagnosis.

Yes, it is possible to live a good quality of life as a Diabetic. It simply means that careful attention should be given to regulating the amount of glucose in the bloodstream at all times. The cornerstone to optimal glucose regulation is diet and targeted medication. Speak to your healthcare giver if you have any concerns.

The International Diabetes Federation estimates the prevalence of Diabetes in ages 20-79 years in South Africa to be approximately 7%, with a total of over 2,2 million people living with the disease. The proportions of people with diabetes have been growing steadily over the years. This growing prevalence of diabetes (and other non-communicable diseases) is closely linked to rapid cultural and social changes, ageing populations, increasing urbanisation, unhealthy eating and reduced physical activity. Epidemiological evidence suggests that, without effective prevention and control programmes,the burden of diabetes is likely to continue to increase globally.

The vast majority of cases of diabetes fall into two broad etiopathogenetic categories. One category is type 1diabetes, accounts for only 5–10% of those with diabetes, the cause of which is an absolute deficiency of insulin secretion. Individuals in this category of diabetes are often younger in age and can be identified by serological evidence of an autoimmune pathologic process occurring in the pancreatic islets and by genetic markers. In the other, much more prevalent category, type 2 diabetes, the cause is a combination of resistance to insulin action and an inadequate compensatory insulin secretory response.

Type 2 diabetes is an insidious disease and initially usually asymptomatic, resulting in persons not seeking early medical attention, so that 30-85% of cases of specifically type 2 diabetes are undiagnosed. At eventual diagnosis, approximately 20% of patients will have complications of disease. During this asymptomatic period, it is possible to demonstrate an abnormality in carbohydrate metabolism by measurement of plasma glucose in the fasting state or after a challenge with an oral glucose load.

The characteristic symptoms of diabetes include: polydipsia, polyuria, and weight loss. Other symptoms may include blurring of vision, general body weakness and lethargy, susceptibility to especially skin infections, recurrent urogenital tract and respiratory tract infections, pruritus vulvae and poor wound healing. Symptoms may not be severe, or may even be absent.

Being overweight and/or obesity is a very strong risk factor for developing type 2 diabetes due to the development of insulin resistance. In addition to a BMI >25, the following factors places an individual at increased risk of developing diabetes:

• Physical inactivity
• Hypertension (BP >140/90 mm/Hg)
• Family history of diabetes (1st degree)
• Dyslipidaemia (serum high-density lipoprotein < 0.9 mmol/L or triglycerides > 2.82 mmol/L)
• Polycystic ovarian syndrome
• High-risk ethnic group (those of South Asian descent)
• Cardiovascular disease history
• History of gestational diabetes or a baby >4 kg at birth
• Impaired glucose tolerance previously diagnosed
• other conditions associated with impaired glucose tolerance

A diabetes diagnosis should only be confirmed with a formal laboratory test, preferably by repeating the same test on a different day. Diabetes can be confirmed with the following tests:

• A random plasma glucose of > 11.1 mmol/L if classic symptoms of diabetes are present or patient is in hyperglycaemic crisis or,
• A fasting plasma glucose of > or equal 7.0 mmol/L or,
• A two-hour plasma glucose >11.0 mmol/L during a oral glucose tolerance test or,
• A glycated haemoglobin A1c (HbA1c) of > or equal to 6.5%

If left untreated or if glycaemic control is suboptimal, complications can include acute hypo- or hyperglycaemia or long-term target organ damage, including retinopathy, nephropathy and neuropathy.

Special note about Diabetes prevalence in South Africa

Significant disparities exist between different population groups with regards to prevalence of diabetes.

People of Asian/Indian descent have the highest prevalence of around 17%. Urbanized Black people have a prevalence of 6%, with urbanized black females particularly at risk. The White and Coloured population also have a prevalence of around 6%.

What is HbA1c?

The term HbA1c refers to glycated haemoglobin. It develops when haemoglobin, a protein within red blood cells that carries oxygen throughout the body, joins with glucose in the blood, becoming 'glycated'. By measuring glycated haemoglobin (HbA1c), clinicians are able to get an overall picture of what the average blood sugar levels have been over a period of weeks/months.

For people with diabetes this is important as the higher the HbA1c, the greater the risk of developing diabetes-related complications.

HbA1c targets

The HbA1c target for people with diabetes to aim for is: <6.5%

Note that this is a general target and people with diabetes should be given an individual target to aim towards by their health team.

HbA1c can be used to confirm a diagnosis of diabetes according to the following WHO recommendation:

When should HbA1c levels be tested?

Everyone with diabetes mellitus should be offered an HbA1c test at least once a year.

A third Type of Diabetes is called Gestational Diabetes

What is Gestational Diabetes?

Pregnant women who have high blood glucose levels during pregnancy and never had diabetes before are said to have gestational diabetes mellitus (GDM). According to a 2014 analysis by the Centers for Disease Control and Prevention, the prevalence of gestational diabetes is as high as 9.2%.

The aetiology of gestational diabetes is poorly understood, but it is thought that hormones from the placenta that help the baby develop, block the action of the mother's insulin in her body. This phenomenon is known as insulin resistance. As a result, the mother may need up to three times as much insulin.

Gestational diabetes starts when your body is not able to make and use all the insulin it needs for pregnancy. Without enough insulin, glucose cannot leave the blood and be changed to energy. Glucose, thus builds up in the blood to high levels.

Pregnant women with the risk factors listed below, should undergo a 72g oral glucose tolerance test (OGTT) at booking and at 24-28 weeks gestation to screen for GDM.

Risk factors for GDM:

• Repeated glycosuria
• Previous GDM
• Family history of diabetes (1st degree)
• Obstetric history of stillbirths of unknown origin, previous congenital anomalies, and suspicion of polyhydramnios in present pregnancy
• History of birth weight infant > 4.5kg
• Obesity (BMI > 30 kg/m2)
• Women of South Asian/Indian descent

How Gestational Diabetes Can Affect Your Baby

Gestational diabetes affects the mother in late pregnancy, usually around 24-28 weeks. Because of this, gestational diabetes does not cause the kinds of birth defects sometimes seen in babies whose mothers had diabetes before pregnancy.

However, untreated or poorly controlled gestational diabetes can affect the baby. During gestational diabetes, the pancreas works overtime to produce insulin, but the insulin does not lower blood glucose levels. Although insulin does not cross the placenta, glucose and other nutrients do. Thus, extra blood glucose goes through the placenta, giving the baby high blood glucose levels. This causes the baby's pancreas to make extra insulin to get rid of the blood glucose. Since the baby is getting more energy than it needs to grow and develop, the extra energy is stored as fat.

This can lead to macrosomia, or a "fat" baby. Babies with macrosomia face health problems of their own, including damage to their shoulders during birth (shoulder dystocia). Because of the extra insulin made by the baby's pancreas, newborns may have very low blood glucose levels at birth and are also at higher risk for breathing problems. Babies with excess insulin become children who are at risk for obesity and adults who are at risk for type 2 diabetes.

Diabetes and Co-morbidities

HIV and Diabetes

The incidence of diabetes is increasing in the HIV population on antiretroviral (ARV) therapy, and therefore need to be screened regularly for diabetes. Current estimate is that approximately 2.6% of patients have both diabetes and HIV.

Risk Factors for HIV+ persons developing diabetes:

• Classic DM risk factors
• HIV itself: viral load, CD4 count, and duration of disease. It is believed that the HI virus itself and fluctuating viral loads causes chronic inflammatory state, leading to insulin resistance.
• Rapid weight gain after catabolic state. During catabolic phase of HIV, patients lose lean muscle mass; when they gain weight it is mostly fat that replaces the lost tissue. This overwhelms the secretory capacity of the beta cells of the pancreas, which leads to insulin resistance.
• Co-infection with Hepatitis C – this has been identified as a non-traditional risk factor for developing Type 2 diabetes. The Hepatitis C virus is associated with insulin resistance, mainly at the level of the liver.
• Dyslipidaemia with lipotoxicity
• Lipodystrophy
• Iatrogenic factors – biggest cause for dysglycaemia – due to the ARV drugs themselves and drugs that are used for opportunistic infections.

TB and HIV

The prevalence of TB is considerably higher among people with diabetes than in the general population. People with diabetes have a triple risk of developing tuberculosis. It is thought that due to the weakened immune system as a result of the chronic disease, people with diabetes are thus more susceptible to TB infection. A large proportion of people with diabetes as well as TB is not diagnosed, or is diagnosed too late. Early detection can help improve care and control of both.

People diagnosed with Diabetes:

• Should have regular screening for TB:
  • At time of diagnosis and at every follow up,
  • Should be asked about a cough lasting for more than 2 weeks, loss of weight, night sweats and fever.
• With one or more symptoms, should be investigated for TB
• Confirmed TB requires immediate initiation of treatment

Self - Management of Diabetes

Patients with Diabetes should:

• Become aware of the signs and symptoms of hypo- and hyper-glycaemia in order to take action before it is too late
• Never miss their regular check ups which should include assessment of:
  • Feet
  • Eyes
  • Kidney function
  • Blood pressure
  • Cholesterol levels
  • BMI and waist circumference
  • HBA1c where appropriate
  • Hearing
  • Lifestyle – including diet and physical activity routine
• Adhere to the medication prescribed by their health care practitioner

References:

American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus

URL: http://care.diabetesjournals.org/content/27/suppl_1/s5.full.pdf+html

American Diabetes Association. What is Gestational Diabetes? http://www.diabetes.org/diabetes-basics/gestational/what-is-gestational-diabetes.html

Amod A, Ascott-Evans BH, Berg GI, Blom DJ, Brown SL, Carrihill MM, Dave JA, Distiller LA, Ganie YN, Grobler N, Heilbrunn AG, Huddle KRL, Janse van Rensburg G, Jivan D, Joshi P, Khutsoane DT, Levitt NS, May WM, Mollentze WF, Motala AA, Paruk IM, Pirie FJ, Raal FJ, Rauff S, Raubenheimer PJ, Randeree HAR, Rheeder P, Tudhope L, Van Zyl DJ, Young M; Guideline Committee. The 2012 SEMDSA Guideline for the Management of Type 2 Diabetes. JEMDSA 2012;17(2)(Supplement 1): S1-S95

International Diabetes Federation. Prevalence of Diabetes in South Africa.

URL: http://www.idf.org/membership/afr/south-africa

World Health Organization. Use of Glycated Haemoglobin (HbA1C) in the Diagnosis of Diabetes. Geneva, 2011