On the sidelines of a diabetes conference, I pen this piece to commemorate World Diabetes Day (November 14), as my contribution to the ongoing efforts to increase awareness of the disease. World Diabetes Day was created by the World Health Organization and International Diabetes Federation in 1991 and has since been marked annually. This year’s theme is “Access to Diabetes Care: If not now, when?”.
Diabetes is a chronic progressive disease that is characterized by high blood sugars and subsequent damage to major organs in the human body. My patients say Diabetes is also known as “asikyire yare3” (Twi), sikli hela (Ga), sikri baalung (Dagaare) sukli dor/ adudorvivi dor (Ewe), and asegyele ewule (Nzema). Almost all of these languages refer to Diabetes as the “sugar disease”, quite literally. Is this truly a disease from sugar?
The number of persons with diabetes has been increasing consistently over the past few decades at least. According to the International Diabetes Federation (IDF), there are about 433 million (1 in 11) adults between the ages of 20-79 years living with Diabetes worldwide as of 2019. This number is expected to increase to over 700 million by 2045. About 3 in 4 people with diabetes live in low and middle-income countries. The scary and worrying aspect of this alarming trend is that about half of this population is undiagnosed and will likely present later when the disease has caused significant damage to multiple organs. The IDF also estimates that the Africa region will see about a 160% rise by 2045. In Ghana, it is estimated that about 281,000 adults have diabetes.
Diabetes caused about 4.2 million deaths worldwide in 2019 alone- in comparison, COVID-19 accounts for about 4.9 million since 2020 (almost 2 years). Data from multiple sources suggest that diabetes is one of the leading reasons for hospital attendance, admission, and deaths in Ghana. Diabetes was responsible for about 10% ($ 760 billion) of the global health expenditure. About 10% of global health expenditure goes to diabetes care, totaling $ 760 billion; the cost of care for diabetic patients is high because of complications associated with the disease.
Diabetes is simply a condition that develops when the body’s control mechanisms for blood sugar fail. Any food eaten is broken down into smaller units that can be absorbed, e.g., carbohydrates to glucose (simple sugar). This sugar is the main source of energy for the body, but the excess from the consumed food needs to be stored. The key (insulin) needed to open the locks of the storage units (liver, muscles etc.) is usually absent in type 1 diabetes or defective in type 2 diabetes.
These excess sugars now stay in the blood for too long and affect major organs in the body. Currently, type 2 diabetes is the commonest form of diabetes, affecting about 90-95% of all persons living with diabetes. When diabetes is not well controlled it leads to organ damage (involving the eyes, brain, heart, kidneys, nerves, etc.). The complications we usually see are strokes, poorly healing wounds which often result in leg ulcers and amputations, chronic and end-stage kidney disease, blindness, heart attacks, and other diabetic emergencies.
Growing up, it was commonplace to think that diabetes was “a rich man’s disease”. Now we all know “poor or not so rich people” who have diabetes. The reason is simply because our lifestyles have changed drastically and have put all of us at risk. The major risk factors of type 2 diabetes include being overweight or obese, increasing age (over 45 years), a family history of diabetes, race (Black or African American), sedentary lifestyle, high blood pressure, high cholesterol, prediabetes, polycystic ovarian syndrome. I always get asked in the clinic “Doctor, is it because of the sugar I eat every day?” or “Why me? I don’t even eat sugar!”. The answer lies not only in the sugar we eat, or don’t, but also in the heavy carbohydrate meals combined with little or no activity and our family history.
Many people with diabetes do not have any symptoms and are usually diagnosed through screening. The lack of symptoms usually influences the health choices of such persons in a negative way because they do not see the need to engage in aggressive lifestyle changes or take medications. Others come to the hospital complaining of increased or excessive thirst, hunger or urination, weight loss, recurrent infections, blurred vision, fatigue, or unusual sensations in the legs. It is unfortunate that some people only know about their diabetes when they present to the hospital with a complication like a stroke, heart attack, or infection of the leg.
Diabetes can be easily diagnosed by blood tests. The fasting blood sugar, random blood sugar, and glycated haemoglobin are specific tests that can be used. Usually, the practitioner needs one abnormal test result and classic symptoms (mentioned above) or 2 abnormal test results to confirm the diagnosis of diabetes. There is also a need to do other tests to screen for or confirm the presence of organ damage at diagnosis or routinely at annual visits.
The overall principles of managing diabetes are to prevent complications and improve quality of life by controlling blood sugars and other associated risk factors. Management of diabetes has become patient-centered and multidisciplinary because of the evidence of better outcomes. People with diabetes need to discuss their goals of care, their preferences in terms of foods, exercise, and medications with their care provider. Diabetes Self-Management Education and Support is a key element in management because it empowers the person with diabetes to understand his condition and take personalized decisions that improve their condition. It is, however, sad that currently there is probably only one or two such programs that meet internationally acceptable standards in Ghana. The person with diabetes will however benefit from any education sessions in the clinic and learning from appropriate sources. Self-Management includes blood glucose monitoring, taking of medications, dietary changes, physical activities, foot care, problem-solving skills, and sound adapting abilities. Ultimately managing Diabetes is a 24/7 job and the role of an empowered patient cannot be overemphasized.
Lifestyle changes have been a cornerstone of diabetes management and these include diet, exercise, weight loss and reducing or stopping smoking/alcohol consumption. Dietary recommendations focus on reducing carbohydrate intake overall and choosing carbohydrates with more fibre, as well as cutting down on refined sugars, highly processed foods and fatty foods. Eating more vegetables especially green leafy and fruits is beneficial Exercise is another important aspect since it promotes usage of blood glucose thereby reducing its quantity in the blood. Exercise has the additional benefits of keeping you in shape, improving your mood, sleep, and energy. Many authorities recommend at least 150 minutes of moderate-intensity activity spread over 3 or more days per week.
Medications have undeniably managed blood sugars more effectively especially if combined with lifestyle changes. There are many classes of medications used for diabetes management and they work by different mechanisms to promote sugar uptake and usage, or pushing it out through the kidneys. Insulin is one of the main treatment options for people with diabetes, usually very early in type 1 and later in type 2. It is important to note that many persons with type 2 will need insulin eventually due to the progressive nature of the disease (and not as a form of punishment or threat for poor control, as patients may think). There are many oral medications including metformin, glimepiride, pioglitazone, empagliflozin, dapagliflozin, liraglutide, etc., which are used in different combinations to achieve the target.
Other risk factors associated with diabetes also need to be managed i.e., control of blood pressures, cholesterol, obesity, etc. Annual screenings are recommended for early identification of complications in people with diabetes in the form of foot exams, yearly eye exams and kidney tests. Lastly, it is important to emphasize that diabetes can be prevented or delayed with appropriate lifestyle changes. Talk to your doctor and get screened!
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The author, Dr Daniel Osafo Darko, MGCPS is a Family Physician/Diabetologist in Training
Nyaho Medical Centre.