Otumdi Omekara, MD., MPAHA - Member of Society of Physician Entrepreneurs
The idea of living with diabetes mellitus may not sound very plausible when one considers the ravaging nature of uncontrolled diabetes. But it has been reported by the American Diabetes Association (ADA) that life style changes alone can reduce the risk of diabetes by up to 91 %. A diabetic patient’s quality of life is not usually significantly altered until the disease gets complicated.
Neither does diabetes get complicated until it is left uncontrolled. The tricky thing about uncontrolled diabetes is that it shortens life expectancy by up to 13 years; takes the lives of 300,000 Americans yearly (NIH); claims $130 billion from US health care budget yearly (a quarter of Medicare budget). A lot of the cost goes into the treatment and rehabilitation of patients with eye, heart, brain, peripheral nerve fiber, kidney and limb complications of diabetes.
Currently the United States has a diabetes epidemic, with over 23.1 million Americans having diabetes, and probably another 23.1 million remaining undiagnosed (NIH). Ninety percent (21 million adults) of these diabetics have Type 2, while the rest (10 %) are children with Type 1 diabetes.
Type 1 diabetics have no insulin production from their pancreas and are therefore insulin dependent. The pancreatic beta cells are commonly destroyed early in life by viral infections or autoimmune diseases. As a result, they easily build up blood glucose levels high enough to put them into ketoacidotic coma if they miss their insulin injections
Type 2 diabetics either produce insufficient insulin or normal quantity that the body tissues respond poorly to (resistance). This usually happens after age 45 when the aging pancreatic beta cells are no longer able to meet the normal insulin demand of the body. Adults also tend to become less active at this stage, too busy to manage their diets.
The leading cause of insulin resistance today, in the United States, is obesity among both adults and children. Unfortunately diabetes produces no early dramatic symptoms. It requires a high index of suspicion to start monitoring a patient as a potential diabetic.
Diabetic screening of the general population starts once any of the criteria laid down by ADA is met. A primary care practitioner is encouraged to become suspicious of any patient who:
§Has a family history of diabetes
§Has a body mass index of greater than 25 (obesity)
§Has an inactive or sedentary lifestyle
§Has African American, Asian American, Hispanic American, Native American, or Pacific Islander ethnicity
§Has had diabetes in pregnancy or given birth to a 9lb baby;
§Has blood pressure of 140/90 mmHg or more
§Has good cholesterol (HDL) equal to or less than 35mg/dL or bad cholesterol (LDL) equal to or higher than 250 mg/dL
§Has had a fasting blood glucose (FBG) test result of 100 mg/dL – 125mg/dL
§Has had a history of vascular problems or has a polycystic ovary syndrome.
Blood glucose monitoring is a key surveillance factor in the US diabetes epidemic control. ADA recommends that people who are 45 years and above should have their blood glucose checked every three years, while only obese younger people with additional risk factors should be tested every year. Pre-diabetic patients (FBS of 100mg/dL – 125mg/dL) are taught how to test their own blood sugar and blood pressure at home with various brands of electronic glucometers and sphygmomanometers supplied free of charge by their health Medicare through their insurance companies. They are followed up every three months for a laboratory fasting blood glucose (FBG) test and hemoglobin A1C check. Normally the blood glucose level rises after food and drops back to normal after
The HbA1C test is used to monitor compliance because it documents what the steady plasma glucose level has been over the last 90 – 120 days. The steady plasma glucose level over that period is reflected in the percentage glucose of the population of HbA1C, which has been shown to increase with persistent high level of blood glucose.
The FBS testing goal is to monitor lifestyle (workout) and dietary habits in such a way as to keep the fasting (pre-breakfast) blood glucose level below 100mg/dL. Only when the FBS rises above 125mg/dL despite active lifestyle and good diet, is oral diabetic medication option considered.
The goal of HbA1C testing is to keep it at or below 5%. HbA1C levels between 5.7% and 6.4% correspond to the prediabetic stage. From 6.5% and above the patient is considered for oral diabetic medication.
Oral diabetic medications are generally used at stimulate a weak pancreas, reduce insulin resistance or reduce intestinal absorption of glucose. The choice of oral diabetics pills will depend on the diagnosis. Because some adults are both obese and above 45 years, combination of pills are frequently use to both stimulate the pancreas and combat insulin resistance caused by the obesity. Down the road, some adult diabetics end up depending on insulin injections like young diabetics because the oral drugs have stopped working for them.
Preventive management of diabetic complications involves
§Monitoring the blood pressure with PCP supervision to keep it at or below 130/80
§Keeping bad cholesterol below 400mg/dL with lifestyle changes, diabetic dieting, and prescription medications
§Monitoring the kidneys for the slightest hint of protein in urine.
§Monitoring vision, with eye care providers for the earliest signs of diabetic retinopathy
§Protection of feet against painless injuries due to numbness of extremities. Medicare mostly covers podiatric visits for diabetic patients.
Understanding that diabetes hardly gives any warning symptoms until it gets complicated helps every person at risk to appreciate the need to watch his/her blood glucose jealously. Once the complications set in, they tend to show up in virtually every organ of the body. Compliance with all the monitoring schedules just discussed has been shown to make living well with diabetes mellitus a very achievable goal.