Ranjit (42), a factory worker, had been experiencing blurred vision for the past six months as well as swelling in his feet and loss of appetite for three months. On evaluation, his tests revealed a fasting blood glucose of 220 mg/dl, protein in the urine, high creatinine and blood spots in the retina, confirming a diagnosis of diabetes with kidney and eye involvement. Despite having a family history, he had never got himself tested and this diagnosis came like a bolt from the blue.
Symptoms
Hunger | Dry skin | Blurry vision| Excessive thirst | Excess urination| Sores that heal slowly | Weight loss without trying | More infections than usual | Extreme unexplained fatigue | Numbness, tingling in hands or feet
Source: Centers for Disease Control and Prevention
According to statistics (2021), about half of diabetes cases in the world are undiagnosed. Globally, 87.5 per cent of all undiagnosed cases of diabetes are in low and middle-income countries. In India, for every diagnosed case, we have one undiagnosed case. Out of a total of 74.2 million diabetic persons, 39.4 million (53.1 per cent) remain undiagnosed. Since the long-term complications of diabetes are related to both duration and severity of the disease, it is imperative that the diagnosis is made early and good control is achieved to prevent complications. The indolent nature of the disease and absence of significant symptoms make the problem go unnoticed unless regular checks are done. Lack of awareness leads to situations like the above case when patients discover they have diabetes after complications have already set in.
Related complications
Diabetes is a chronic, progressive disease with a potential to cause significant morbidity and mortality, engendering immense social and economic burden. The long-term complications are due to the impact on small and large blood vessels (micro and macroangiopathy) and nerves (neuropathy). Involvement of blood vessels is responsible for the damage to the light sensitive layer of the eyes (retinopathy), protein leakage in the urine and kidney damage (nephropathy) and cardiovascular disease that includes blockages of blood supply to the heart, brain and lower limbs causing heart attacks, stroke and gangrene of limbs. Involvement of nerves leads to loss of protective sensation, which, alone or in combination with loss of blood supply, causes the devastating complication of diabetic foot ulcers with infection.
Diabetes is one of the leading causes of vision loss, kidney failure, heart attacks, strokes and limb amputations. Patients with diabetes have a three to five-fold increased risk of heart attacks, two to three-fold increased risk of stroke and 20-fold increased risk of lower limb gangrene compared to non-diabetics. In addition, people with uncontrolled diabetes because of a weakened immune system are more prone to infections, especially of genitourinary tract, lungs, skin and soft tissue (especially feet), gums and oral cavity. Tuberculosis has a predilection to affect diabetics more. The fact that patients with diabetes were more at risk during the Covid pandemic is well known.
Indian context
We Indians as a race are uniquely predisposed to develop diabetes and cardiovascular disease due to higher body fat content and specific fat distribution in the abdominal region, despite not being obese by conventional definitions. There are many hurdles in management. Overwhelming numbers, many undiagnosed, younger age at onset, poor caregiver to patient ratio, poor control because of socio-economic disparities in access to care, lack of universal health insurance, unmanageable out-of-pocket costs of modern treatment, cultural/religious influences and recourse to alternative medicine are some of the issues.
It’s a matter of grave concern that in India, complications of diabetes occur at a much younger age and progress more rapidly. According to the International Diabetes Federation (IDF) statistics (2021), with 0.6 million deaths per year directly related to diabetes and its complications, India ranks third in the world in diabetes-related mortality, after China and USA.
The solutions
Early diagnosis of diabetes and optimal treatment to achieve good metabolic control can prevent/delay complications. In a large country, periodically testing every individual (universal screening) may not be feasible. Hence, testing of the at-risk population (those having a positive family history, obesity, hypertension, heart disease and all pregnant women) and opportunistic screening (testing blood glucose at any visit to a healthcare facility) are pragmatic solutions.
Once diagnosed, good control of diabetes with an appropriate combination of medications, along with lifestyle measures, diet and exercise, is a must. Home glucose monitoring and Glycosylated haemoglobin (HbA1c) have enabled good assessment of glucose control. Periodic visits to the doctor to assess control as well as screening for complications of the eyes, kidneys, feet and heart at stipulated intervals are a must.
Delaying insulin treatment and not altering/escalating medications in the face of poor control contribute to complications. It should also be emphasised that diabetes does not mean glucose alone. Identification of associated hypertension and high cholesterol and appropriate management of these parameters are very important. This “composite metabolic control” is the cornerstone of prevention of diabetic complications.
Public health experts recommend three levels of prevention — primary prevention of diabetes that requires a concerted public effort to inculcate a healthy lifestyle from childhood itself; once diabetes has already set in, the objective of secondary and tertiary prevention is to prevent related complications or at least delay their progression.
— The writer is director,
endocrinology, Fortis Hospital, Mohali
