Tomorrow, 14 November, is World Diabetes Day. It is a global call to action in response to an exploding burden of the disease, diabetes mellitus. World Diabetes Day is no Mandela Day, in terms of its public weight of attention; there is no asking of you to contribute 67 minutes to issues concomitant to diabetes. World Diabetes Day is not World AIDS Day either – there is no celebrity concert or initiative to highlight this disease with such far reaching consequences for so many individuals across so many countries. Instead, World Diabetes Day is an ordinary day, manufactured as a disease remembrance day since 1991. On the surface, one could argue that the lack of clamor surrounding it reflects the silent and pretty anonymous nature of the natural history of diabetes. It is insidious yet dangerous. But, importantly, is deserving of your attention. Now.
I attempt with this talk to outline areas and reasons for why diabetes requires your urgent attention. I will outline the scale of the problem, and touch on the broader implications of diabetes, what diabetes actually is, and what can be done to prevent or delay its insidious development. I will attempt to provide some useful practical guidance that individuals and the community may follow.
As a young clinician, dealing with volume and complexity in clinical practice, patients present with their diverse set of medical issues. I am always given pause for thought, and this occurs on a daily basis, when a patient says: “you know doctor, aside from why I am here, I am healthy with the usual things, you know. You know, a little bit of blood pressure and a touch of sugar. But I take my medication, doctor.” My bewilderment is founded in the casual nature of these statements, and I acknowledge that perhaps I’m being judgmental, in making a claim that these interactions reveal to me a general unconcerned attitude to what is labeled as chronic diseases of lifestyle. We have normalized diseases like diabetes. A more generous appraisal of this interaction is it reaffirms that humans are remarkably resilient, and no chronic disease, including diabetes will get us down.
However, I still find this problematic, especially the kind of learned helplessness that we have become accepting of in relation to our health and wellbeing. It is a vicious circle that both medical practitioners and patients are complicit. Reviewing the scale the scale of the diabetes tsunami reflects a sobering reality. In 1985, worldwide there were approximately 30 million cases of diabetes. Fast forward to 2011, and the prevalence is 336 million. The projection for 35 years time, is that the global burden of diabetes will be 550 million in 2050. These are no mickey mouse statistics from the World Health Organisation (WHO) and International Diabetes Federation (IDF). They are crazy and scary numbers. Further, at present, three countries contribute over 50% of the burden of diabetes. China has 98 million cases, India 65 million cases and the USA 26 million cases. These countries may seem far removed from this setting but with over 80% of people with diabetes located in low and middle-income countries just like South Africa, we should share similar concern about our own backyard. As of 2012, according to Statistics South Africa, there are over 6 million cases of diabetes and whilst we are not one of the top ten countries in terms of absolute numbers of burden of disease, this statistic could crudely be interpreted that about 10% of our population has diabetes. Again, crazy and scary numbers.
The implication of the diabetes burden can be viewed on an individual, community and population level. Presently, it is labeled as a chronic progressive and incurable disease with a set of multi-organ and systemic complications. I will not delve into the medical complications except to mention that death and long-term ill health (also known as mortality and morbidity) are presently seen as eventualities of diabetes. These already exert a material effect on quality of life of diabetics and the people around them. Further the cost of diabetes to individuals and populations is immense. For example – the healthcare expenditure on diabetes in 2011 is a stunning 465 billion dollars. And with 4.6 million deaths in 2011, what the future holds is rather grim.
Accompanying diabetes are other diseases, including blood vessel and heart disease, increasing overweight and obesity, high blood pressure/hypertension, strokes. Again, the WHO estimates that 2030, these non-communicable (non-infectious) diseases will account for as much as five times as many deaths as communicable (infectious) disease in low and middle income countries. South Africa is not far off – with 58 people dying daily due to diabetes; the fifth highest cause of death in South Africa. Yet, these chronic diseases and their risk factors are infrequently diagnosed and inadequately treated. Clearly, premature disability and death could be avoided or delayed.
So let us start with the basics. What is diabetes? By WHO definition, it is a metabolic disorder of multiple aetiologies that is characterized by persistently raised blood sugar – known as hyperglycaemia – that results in disturbances of metabolism, which results in problems with insulin secretion, insulin action, or both.
There are two main types of diabetes: Type 1 – where the organ in the body, the pancreas and its cells called Beta cells, does not produce the hormone insulin.
Type 2 – represents over 90% of cases worldwide – where the insulin that is produced by the pancreas and the Beta cells exerts less and less of an effect. Note: there are other types of diabetes but this talk focuses on Type 2 diabetes.
The centerpiece in this all is insulin. What does insulin do? When we eat food, the Beta cells in the pancreas produce insulin, and insulin acts in many ways, but specifically it acts to store energy especially sugar in the liver, and to use the excess energy especially sugar and produce fat in the liver and other places.
So, normally, insulin lowers blood sugars. As you eat, the blood sugars go up and the insulin is released, to take that sugar out of the blood and to tissues. This is normal. In diabetes, where the action of insulin is deficient, one could say that diabetics are insulin resistant i.e. the target cells do not respond to their own insulin. The body recognizes this so it pumps up insulin from the Beta cells in the pancreas to get the sugars out of the way. In response to food, especially a diet in high sugar or a carbohydrate load, the body keeps doing this and what we have this persistent high levels of insulin and the accompanying insulin resistance.
As an aside, the Medical Research Council of South Africa (MRC), via national prevalence data on diet and nutrition, indicate that South African diet is 60 – 70% carbohydrate. An increasingly our diet macronutrient composition reflects the norm of developed countries with respect to its composition.
So with this in mind, and in summary, insulin causes insulin resistance. Insulin resistance causes more insulin to be released. It is a vicious circle. And so blood sugars remain elevated.
However, it takes a while to reach this point, probably 9 – 12 years. There are two phases to diabetes. A first phase – a silent slow rise in fasting sugar levels which reflects the increasing levels of insulin resistance. A second phase – where there is a sudden rise in fasting sugar – that reflects the Beta cells of the pancreas not being able to pump out more and more insulin to deal with the elevated sugars.
It is at this point that people are diagnosed as being diabetic. Simple bloods tests with these results:
A random finger prick blood sugar level of greater than 11.1
A fasting blood sugar level of greater than 7.0
A HbA1C blood level of greater than 6.5%
The first phase that I mentioned could also be labeled as a pre-diabetic phase. Where the blood results don’t reach a diabetic diagnostic level but should be cause for concern.
South Africa does not have data yet of the extent of prediabetes or insulin resistance levels in its population and therefore it can be said that we are only seeing the tip of the iceberg, and that it is a function of time before more and more are diagnosed diabetic.
If you are concerned, I would advise you consult your local medical practitioner, and especially, if you have the following symptoms: excessive thirst, abnormally high urine production, worsening vision, and fatigue. However, the absence of these symptoms does not exclude diabetes. I would still suggest you consult your local medical practitioner.
The present understanding and recommendations regarding the management of diabetes include lifestyle changes, monitoring, and medication. Medication should be a very small component of the management of diabetes but it is not in current practice. Yet the International Diabetes Federation estimates that over 70% of type 2 diabetes could be prevented through lifestyle changes.
I concur that lifestyle modification should be the mainstay of management, and we are in desperate need to refocus our attention on this neglected aspect of treatment. An evolving view in current diabetes management is that diabetes is a dietary disease that requires dietary treatment. To re-emphasise, a dietary disease, requiring dietary treatment. The physiology underpinning this is a treatment focus to reduce insulin, and not to increase insulin. In other words, as I explained earlier, diabetes is a disease of high levels of insulin as well as insulin resistance.
In practice, this lifestyle treatment of type 2 diabetes should begin by: first, reducing our dietary carbohydrate (because sugars cause the body to respond by pumping out insulin), second, by fasting intermittently.
To explain this: when we fast, and there’s no food, we decrease the insulin levels and in so doing we also help to break the vicious circle (of persistent high levels of insulin which drive insulin resistance.)
Third, by increasing our physical activity. And fourth, to eat foods that do not cause the pumping out of insulin on the same high level as sugars/carbohydrates, and that would be mean eating more natural fats.
The combination of these things will improve insulin resistance by increasing insulin sensitivity and encourage a lowering of insulin levels.
If you are diabetic and on medication, this should be followed under medical supervision.
If you are not diabetic, and wish to improve your insulin sensitivity, it would be useful to get initial guidance as to how to go about this.
There are two practical pieces of information I would like you to take home today. The first is a spoonful of sugar. The second is nutrition labels.
A spoonful of sugar equates to 5g of carbohydrate. Use this to read the food nutrition labels on food you buy and calculate how many teaspoons of sugar/carbohydrate you consume. Re-examine the liquids you consume – the liquid carbohydrates also known as sugar sweetened beverages. Look at a slice of bread or packet of biscuits or fruits or prepared soups or pasta sauces. You will be surprised at the hidden sugars we unconsciously consume. So, when you look at the food nutrition label focus on the ‘total carbohydrate’ line per serving and divide that number by 5 to get to your teaspoon of sugar per serving.
These simple acts of engaging with what we consume is the first step in making informed decisions around what we eat which may lead us to take greater control over our health, and not simply accept that a little bit of blood pressure or a touch of sugar diabetes and medication, is an eventual unavoidable reality.
The diabetes epidemic is real and urgent. The level of pre-diabetes is an unknown but armed with what now know – we can do more as individuals and a community to prevent in time, diabetes developing.