Control of diabetes is not only control of blood sugar

Prof Upali IIIangasekera

World Diabetes Day is held on November 14 every year to commemorate the birth anniversary of Sir Fredrick Banting, the Canadian doctor and scientist who was the first to introduce the drug insulin for use in human beings. This infact could be considered to be the greatest discovery in the care of diabetes as it has contributed to saving of millions of human lives as well as preventing disability. This day will be commemorated all over the world including Sri Lanka with the main theme of increasing the awareness of the illness and its complications. This letter is written with the objective of correcting a misconception in the minds of patients that control of diabetes is only control of blood sugar.

Diabetes is only one of several risk factors which contribute to death from cardio vascular disease (CVD) which includes heart attacks and strokes. Infact CVD is the commonest cause of death from all causes worldwide followed by cancer and infections. Those with diabetes are two to three times likely to suffer from CVD compared to the general population.

However diabetes is not the most important risk factor for CVD. High blood pressure, smoking, diabetes, physical inactivity, over weight, high cholesterol, alcohol abuse, childhood underweight and indoor smoke from solid fuels (like cooking with firewood) are the risk factors ranked here in the order of importance. In other words in a patient with diabetes and high blood pressure if one achieves control of blood sugar only without attending to the blood pressure the chances of this patient getting CVD is extremely high. Therefore one should look at a patient with diabetes concentrating on his or her overall cardiovascular risk.

Risk factors

How does one assess the overall cardio vascular risk (particularly a heart attack and a stroke) in a patient with diabetes? In a majority of patients with diabetes it doesn’t occur on its own but is invariably associated with other risk factors such as high blood pressure, high cholesterol and more recently it has been found that the presence of proteins in the urine and poor oral (mouth) hygiene also could be considered to contribute to the risk.

Healthy diet

This means that when a patient with diabetes presents to a doctor for the first time all these factors should be looked into both during clinical examination and when carrying out blood tests. Infact since nearly 50 percent of patients who present for the first time have at least one of these complications, it is mandatory that all these aspects are looked at however much healthy the patient appears to be.

The important clinical features that should be looked at includes measuring the blood pressure accurately, examining the mouth for oral hygience, examining the inside of the eye with an instrument called an ophthalmoscope and examination of the feet.

The basic lab tests include the blood sugar, blood cholesterol and the presence of protein in the urine called ‘microalbumin’.

If these clinical and lab tests are abnormal all of them need to be treated all at the same time. This is called the ‘multi-factorial’ approach and should be practised by all doctors who care for patients with diabetes and the patients in turn should insist that these aspects are addressed to by their doctors. However due to limited resources both financial and human in the state sector, the private sector too should provide these services at low cost since it has been found that this illness affects not only the rich but even the poor in our country. What are the consequences if such an approach is not practised? They will be detrimental both to the individual family as well as to the country since large amounts of funds will be needed to treat complications of diabetes such as heart attacks, strokes, amputation of limbs, kidney failure and blindness.

Finally one should not forget the place of lifestyle measures in the prevention of cardio vascular risk. These include adequate physical exercise, maintain normal weight, healthy diet, abstinence from smoking and limited consumption of alcohol and avoiding mental stress. Most of these measures could be adopted with no extra cost which would be tremendously beneficial in a developing country such as ours with limited resources.

The writer is the founder President, Sri Lanka Diabetes Association (Kandy branch), Managing Director, Kandy Diabetes Centre