(First of two parts)
Over lunch last week, we had an interesting chat with Dr. Angel Araneta, a diabetes expert based in Bacolod City. Angel and wife Mariz came to Manila for a reunion of sorts of our Viber group we informally call Cruise Mates.
The group, consisting of 18 doctors—mostly couples—and some friends, loves to travel together. But I guess the name was more due to the common mindset or philosophy of the group members that we could cruise through our life journey despite its daunting challenges, equipped with a healthy, positive attitude and the emotional support of family and real friends.
Angel, who’s well known for his wit and expertise, is frequently invited to lecture in medical circles on diabetes and its complications. While practically everyone in the group enjoyed the chocolate and ube cakes we had for dessert (some of us even asked for a second serving), he gently set his dessert plate aside, without making a big fuss about it.
We were quick to notice though and teased him that he was making us feel guilty. He was just being consistent in walking his talk; and he expressed alarm once more at the rapidly increasing prevalence of diabetes in the country and worldwide.
He updated us on recent studies showing that what were previously thought were borderline but still nondiabetic levels of blood sugar and glycated hemoglobin (HbA1c), are associated with some risks already among Asians including Filipinos. The same goes for the weight in relation to the height, referred to as the body mass index (BMI). A BMI of 25 is still considered normal among Caucasians, but this level is already associated with increased risks of developing heart attacks, strokes and other cardiovascular complications among Filipinos and Asians.
Type 2 diabetes mellitus (T2DM) is really a major public health threat, responsible for the death of scores of thousands in the Philippines every year. It is considered a lifestyle disease, since one’s type of lifestyle (unhealthy diet, lack of exercise and unmanaged stress) is responsible for the contributory factors of T2DM.
Angel and other experts are alarmed at the increasing prevalence worldwide, particularly in Southeast Asia, and it looks like the Philippines is one of the hot spots that have to be closely monitored. In fact, diabetes is a major culprit why we also have an increasing rate of end-stage kidney disease requiring lifelong dialysis or kidney transplantation.The big problem in the management of T2DM is that patients usually have no symptoms for a good number of years, and many remain undiagnosed; or if diagnosed, they do not take their prescribed medicines because anyway, they don’t have any symptom. Little do they realize that slowly, their heart, kidneys, brain, eyes, nerves and arteries are slowly being affected leading to irreversible damage and complications like heart attack and heart failure, stroke, kidney failure, blindness and leg gangrene requiring amputation—just to name a few.
Early treatment and control of T2DM is beneficial and leads to a good “legacy effect.” A legacy effect means that early diagnosis and treatment can lead to long-term benefits in preventing the dreaded complications of T2DM caused by injury to the small blood vessels (microvascular) and big blood vessels (macrovascular).
Examples of microvascular complications are kidney disease (nephropathy) and eventual failure, nerve injury or neuropathy, and eye problems leading to blindness (retinopathy). Examples of macrovascular complications are narrowing of the heart and brain arteries leading to heart attack and stroke.
To diagnose T2DM early, the various medical organizations of diabetes experts came up with screening guidelines for early detection, and they recommend this be done if one or more of the following are present: sustained blood pressure (BP) equal or more than 140/90 mmHg; obesity; and aged 40 and up.
Elevated BP and obesity are common accompanying problems of T2DM. They usually cluster together; hence, when found together, they’re called “Metabolic Syndrome.”
Why 40 years of age as a cut-off age? That’s the age beyond which the incidence of T2DM shoots up remarkably, based on the findings of a local survey, the National Nutrition and Health Survey.
The American Association of Clinical Endocrinologists (AACE), which also has a local chapter (AACE-Philippines), emphasizes the following underlying principles as the basis for management of T2DM:Blood sugar target, reflected by the blood test called HbA1c, should be individualized based on age, life expectancy, comorbidities, diabetes duration, hypoglycemic risk, etc.
Self-monitoring of blood sugar levels at home by the patient can serve as an important guide for adjusting medications.
Patient-related and medication-related factors should be considered in prescribing the most suitable antidiabetic therapy for a patient.
To prevent hypoglycemia and reduce the risk for weight gain are accompanying priorities for any antidiabetic therapy. Since the main goal in the management of T2DM is to prevent complications, the following approaches are also considered important:
Yearly dilated eye examinations (funduscopy) to determine any damage of the nerves (retinopathy);
Annual microalbumin determination in the urine to determine the earliest sign of kidney involvement;
Foot examinations at each visit, checking the pulses and determining any sign of poor circulation in the legs and feet;
HbA1c every three to six months to determine if target blood sugar levels are attained (which should be individualized depending on age, life expectancy, other concomitant problems);
Blood pressure preferably less than 130/80 mmHg, and even lower if there is kidney involvement already (diabetic nephropathy); and
Statin therapy to reduce low-density lipoprotein cholesterol, even if the cholesterol levels are average or even normal.Physicians need to reexamine their current goals and treatments to prevent serious long-term complications, some of which may be related to the treatment and inappropriate aggressiveness in lowering the blood sugar to near-normal levels. We’ll tackle this next week. INQ
(To be continued)