A few years ago, The Time magazine ran a report on the global diabetes epidemic. It was predicted that as AIDS posed a major health problem in the latter part of 20th century, so is diabetes in the early part of the 21st century. This is of course true as is seen so far. The incidence of diabetes in Malaysia has increased from 6.3% in 1986 to 8.3% in 1996. This is a staggering increase within a short space of time. In fact, 50% of the people suffering from diabetes is going to come from Asia by 2010, a short 6 years from now. Why is there a global epidemic and what can we do about it?

Lina (not her real name) is 53 years old. She is working fulltime in a bank and also a mother of 3 children. She has been successful in her career and she is also a capable mother of 3 children. She has hardly had time for herself in the last 10 years when the demand for her career has been mounting. Her priority has always been her family and career. Thus when she was diagnosed to have diabetes 2 years ago, she just shrugged her shoulders and got on with life. She thought as long as she is taking her medication, has diabetes should be controlled. It came as a surprise when a small cut in her left foot was not healing. It became worse and she has ended up in hospital having tried to treat it with some antibiotics and washing it with some antiseptic solutions herself initially. In fact, the infection has spread from the foot to the whole leg after just a week and her diabetes was very high. Lina was quite fortunate, the infection settled after intravenous antibiotic and control of her diabetes. After 10 days in hospital she was discharged and she has begun to appreciate the need for good diabetic control to prevent complications.

Lina is but one of the many examples that many doctors see today. Not only are there more and more people with diabetes, there is also a tendency for patients to be younger. In fact there is an increasing number of teenagers who are diagnosed to have diabetes. Lina’s room mate in the hospital was a 17 year old girl who was admitted with an abscess in the buttock. She was not known to have diabetes until she was admitted to the hospital for the abscess.

Fortunately, optimal diabetic control was quickly achieved with adjustment of her diet and lifestyle. Lina begins to pay attention not only to what she eats but also the diet of the whole family. In fact there is a major change in the whole family’s lifestyle. Both she and the husband are working full time and they ate out most of the time. Now, Lina is making an effort to prepare meals at home after work. For Lina, the most difficult thing is exercise initially. She has never been keen on exercise and on top of that, finding time in her busy routine is almost impossible. Now she rearranged her routine and managed to squeeze in half an hour of brisk walking 4X times a week. She is beginning to get use to her new lifestyle, she is certainly lighter and fitter and she claims to be more energetic than before. Furthermore, she is now taking less diabetes medications than before and yet her diabetes control is excellent.

Is diabetes a death sentence?
It is well known that diabetes can give rise to a variety of complications. Risk of heart attack and stroke is increased by more than 2-3X. The feet may be affected and they may develop ulcers like in Lina’s case or even gangrene requiring hospital admissions and sometimes even amputation at a last resort when the ulcer become worse. It is also the most common cause of permanent blindness and kidney failure necessitating renal dialysis. Furthermore, more than half of the middle aged men who have diabetes may suffer from erectile dysfunction. (See table 1). The risk of complications conferred is even higher for women than men particularly the macrovascular complications eg heart attacks, stroke and foot ulcers.

Thus, not only the complications of diabetes reduce life expectancy but it also reduces the quality of life in many patients. Furthermore, there is also additional burden, both social as well as economical, placed on the family in terms of providing care and medical therapy needed to treat the patients. There is also a wider ramification for the community as well as the whole nation given that there will need to be an increase in medical and nursing expenditure; coupled with a reduced income in the case of the patients and their family from loss of work, as well as the nation in terms of loss of tax revenue and precious human resources in the work force.

All the complications of diabetes mentioned can be prevented. Good diabetic control, as well as lowering high blood pressure and high cholesterol levels is the main stay of prevention of complications. Regular check up and monitoring with an endocrinologist or physician would help to trouble shoot problem(s) and not only to treat them effectively as they arise but more importantly, to prevent these complications. Thus, diabetes is only a death sentence if we allow it to be. (See table 2).

Lifestyle
One of the reasons for the increase in the incidence of diabetes is due to the major alteration of lifestyle in less than one generation. Malaysia has progressed economically and with that many social changes. Urbanisation with the ensuing lifestyle changes resulting in less physical activity is said to be one of the major causes for the exponential growth in diabetes. ‘Cocacolonisation’ and ‘Ninetendonisation’ are the terms coined to describe the fast food culture and the computer game culture prevalent among our younger folks. Thus the management as well as the prevention of diabetes demands a major adjustment of lifestyle not only in diet but also in terms of physical activity.

As demonstrated in Lina’s case, diet and exercise has played a major part in controlling her diabetes. Can it also prevent diabetes? One study from the US has shown that 150 min of exercise a week has reduced the risk of developing diabetes by a staggering 59% over a 3-year period in a group of high risk individuals. This study, as well as many others from China, Europe and the US has demonstrated that appropriate dieting and consistent exercise have produced significant and encouraging protection against diabetes. There are also other studies which have shown that certain drugs can also prevent diabetes and this is particularly so in those obese or overweight individuals who lost weight. Nevertheless, the degree of protection is still less than what was shown with diet and exercise.

We need not advocate reversing the economical progress to prevent diabetes but we need positive effort to address this problem which threatens to drain resources as well as having a negative impact on individuals and families.

At the end of the day, there needs to be a desire to implement the lifestyle changes at individual levels. Healthy eating and regular exercise coupled with stopping smoking will not only control diabetes and reducing the risk of developing diabetes, it will also reduce the risk of heart disease which is presently the single largest cause of death in Malaysia.

Table 1: Long term complications of diabetes.

1. Big vessel diseases:
   1) coronary heart disease causing heart attack and heart failure
   2) Cerebrovascular disease causing stroke, transient ischaemic attack
   3) Peripheral vascular disease causing foot ulcer and gangrene
   
2. Small vessel diseases:
   1) Nerve damage causing numbness in the hands and feet, erectile dysfunction
   2) Kidney damage causing protein leakage in the urine and kidney failure
   3) Retinal damage in the eyes causing permanent blindness

Table 2: What we must do if we have diabetes:

1. Stopping smoking -smoking causes further blockage of the big vessels and making the diabetic complications to appear earlier and more severe.
    
2. Diet adjustment -to reduce fat especially animal fat intake
   - cut out all processed sugar
   - maintain a healthy and ideal body weight
    
3. Exercise regularly.
    
4. Medications prescribed must be taken on a daily basis according to instructions.
    
5. Regular check up by doctor not only for diabetic control but also blood pressure as well as lipid levels. Each patient should be examined for complications for early intervention and treatment.
    
6. Blood glucose monitoring to maximize diabetic control.