Dr. Tony P Joseph

Consultant Endocrinologist

GG Hospital and Sree Gokulam Medical College.

Diabetes - An Unchecked Pandemic

Diabetes mellitus is a growing unchecked pandemic which has affected over half a billion people across the world. Unhealthy lifestyle including diet, lack of exercise and sedentary habits are fuelling the pandemic. Asians especially Indians have a strong genetic tendency for developing diabetes. People  with the following risk factors are at increased risk of Type 2 Diabetes Mellitus(T2DM)-who have a family history of diabetes, people with overweight/obesity, hypertension , high cholesterol or heart diseases, ladies with PCOS or diabetes in pregnancy and people having Prediabetes. Hence more frequent screening of these population is important since a large majority of these people may be undiagnosed, increasing the future risk of complications. 

Diabetes can be of various types, the main include Type 2 Diabetes Mellitus ( which constitute roughly 90% of the total cases) and Type 1 Diabetes Mellitus (which constitute around 5-10% of total cases).

Also there are various other forms of diabetes like Monogenic diabetes, Pancreatogenous diabetes, Gestational Diabetes, Endocrine causes leading to diabetes , drug induced diabetes etc., which need to be carefully looked into. Whatever be the cause of diabetes, the diagnosis is ascertained when the fasting blood sugar (FBS) is more than or equal to 126mg%, Post prandial blood sugars (PPBS) are more than 200mg% or HbA1c is more than or equal to 6.5%. There is also a Pre-diabetic zone where the patient has a strong chance of progressing to diabetes in the next few years . This is characterised by an FBS between 100-125mg%, PPBS between 140-199mg% and an HbA1c between 5.7 to 6.4%.

Prediabetes can persist for months to years before progressing to diabetes. It is a phase where intervention helps to prevent or delay the progression. Lifestyle modification with focus on atleast 7% weight loss will be extremely beneficial. Metformin can be give if people with Prediabetes who are obese or having an FBS≥110mg% or hbA1c ≥ 6%, to prevent progression to Overt Diabetes.

The management of diabetes has changed in the last few years. There is a paradigm shift from a gluco-centric approach (targeting the blood glucose alone ) to a more comprehensive approach where treatment is focussed in a more wholesome manner to control not only the blood sugars, but also the blood pressure and cholesterol with intensive lifestyle modification including diet, exercise, weight loss in overweight/obese, alcohol moderation and smoking cessation.

Uncontrolled diabetes affects every cell in the body. The diabetes related complications due to high sugars can be acute i.e. occurring when the sugars are high like Diabetic Ketoacidosis (mostly seen in Type 1 DM but can also be seen in Type 2 DM) and Hyperosmolar Coma (mainly seen in elderly and chronically ill patients). Chronic complications (those resulting from prolonged exposure to high sugars for a considerable period of time) include Microvascular (kidney, eye and nerve damage) and Macrovascular disease (heart disease, stroke and peripheral arterial disease). Also uncontrolled diabetes can cause skin and soft tissue problems, increase susceptibility for serious infections, cause poor bone health etc. So controlling the blood sugars from the onset of diabetes is very important.

Controlling Diabetes seems to be easy in the beginning, but as years passes this task becomes more difficult. Diet and exercise form the mainstay of therapy. Healthy balanced diet containing adequate amount of macronutrients like carbohydrates, proteins and fats and micronutrients like vitamins and minerals are very important. If the person is overweight or obese, weight loss should be targeted with a reduced calorie diet. Including fibre in the diet both from whole grains and also from millets , pulses, vegetables and fruits, which lower the glycaemic index of food (how rapidly the blood sugar rises) and helps control sugars better. Exercise should include aerobic (walking, jogging, swimming, sports like football, badminton etc.) and resistance training exercise. A person should dedicate atleast 30 minutes per day for 5 or more days per week for exercise and also include 15-20 minutes of resistance training for atleast twice a week. Smoking brings along with it cardiovascular diseases like heart diseases and stroke, which are already very common in people with diabetes. Smoking and diabetes combined increases the risk of cardiovascular diseases manifold. Hence smoking cessation should be emphasised. Alcohol moderation is also required in all people with diabetes.

The medications available to treat diabetes has revolutionised in the last few years. There has been a paradigm shift with the entry of medications like SGLT2 inhibitors and GLP1 analogues which in addition to good sugar control also gives weight loss, renal and cardiac protection. Also, emphasis is being laid on more hypoglycemia (low sugar) neutral agents. Insulins have also changed in the last few years to agents which have lower glycemic variability which helps reach more predictable blood sugars without hypoglycemia attacks. Insulin pumps are also revolutionising the scenario with the latest models autocorrecting for high sugars without any patient inputs and suspending the insulin delivery even when there is a chance of hypoglycemia.

Monitoring of blood sugars have also revolutionised with continuous glucose meters (CGM) giving minute to minute sugar readings. These are especially useful in people with Type 1 DM and Type 2 DM on insulin and also in people having hypoglycemias. The derived data from these CGMs i.e the Ambulatory Glucose Profile (AGP) gives a very accurate idea of the patients’ blood sugars throughout the day and help to reduce hypoglycemia and high sugars better. Time In Range (TIR) which is a component of AGP is the new parameter which is better than HbA1c in predicting glycemic control. A TIR ≥ 70% is generally believed to be equivalent to an HbA1c of 7% and hence of good control. 

Diabetes remission is a much talked about subject, but careful patient selection is very important. People with Type 2 DM having onset within 5 years and willing for substantial weight loss of >10-15% have more chance of remission. Even if remission is not achieved significant weight loss will help to reduce the dose of drugs and insulin and even will be beneficial in people having associated hypertension, high cholesterol, fatty liver, sleep apnoea etc.

Despite having all these advancements, only 25-30% of people living with diabetes have achieved their target HbA1c. There are many reasons for this which include non-compliance with medicines, fear of hypoglycemia and weight gain with up titration of drugs, cost and improper follow up and monitoring to mention a few. People with diabetes need to have regular follow up with their Endocrinologist/ Physician to monitor and adjust the dosing of drugs and also for complication screening. Lifestyle modification though sounds simple, holds a big role in controlling Diabetes.