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Mind the sugar overload

JOAN CHEW on 12 Mar 2015

The Straits Times


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Longstanding high blood glucose levels can affect all parts of the body, with damage to nerves causing the greatest drop in quality of life 


More than 30 years ago, Mr T Murugian Raman learnt he had type 2 diabetes only after he was in a diabetic coma for three days.


This life-threatening condition occurs when blood sugar levels are either dangerously high (hyperglycaemia) or dangerously low (hypoglycaemia), to the point where they cause the person to be unconscious.


When he woke up, all he wanted to do was to puff at a cigarette, recalled the 68-year-old former heavy smoker, who now has to battle a host of diabetes-related complications.


At first, he required an insulin injection just once a day. But his diabetes was poorly controlled and more medications had to be added.


In 2012, the father of one underwent a coronary artery bypass graft surgery to improve his blood supply to the heart.


Years of high blood-glucose levels can damage blood vessels and nerves, making diabetes a key risk factor for cardiovascular disease.


Two years ago, Mr Murugian developed a nerve problem called peripheral neuropathy, which causes pain in his feet. The nerve damage has now progressed upwards to his hips, disrupting his sleep at night and making it unbearable for him to stand on his feet for up to eight hours a day as a porter, so he recently quit his job.


When out shopping, he also has to stop several times to sit and rest his painful legs. He leads a largely sedentary lifestyle at home, watching television and reading newspapers - a far cry from the past when he ran two hours a day and took part in marathons.


Mr Murugian said with a tinge of sadness in his voice: "I overlooked my diabetes in my younger days. Now, it is too late as the damage to my body has already been done."


A landmark study on the associations between various diabetes-related complications and health-related quality of life involved 396 patients with diabetes and 2,205 healthy participants.


The study, published in the journal Clinical Endocrinology in 2013, showed that the quality of life in patients with diabetes is affected mainly by the presence of complications, not diabetes per se.


In fact, diabetics without any complications had scores that were similar to those of normal individuals, the authors wrote. This was after adjusting for factors such as age, gender and concurrent medical conditions such as cancer.


Associate Professor Tai E Shyong, head of endocrinology at the National University Hospital and one of the study authors, said diabetes does not make a person feel any differently, unless one experiences hyperglycaemia or hypoglycaemia - short-term complications which are reversible.


Among all the long-term complications assessed, peripheral neuropathy was associated with the greatest reduction in quality of life, both physically and mentally.


Its impact was greater than for coronary heart disease, stroke and retinopathy (damage to the retina).


Few studies have examined the whole spectrum of complications for a comparison of how they each affect the quality of life.


In the study, the more severe the neuropathy, the lower the quality of life.


Peripheral neuropathy affects the nerves supplying the extremities of the body. It is believed that the longer nerves are more susceptible to damage by high blood-glucose levels. The symptoms vary according to which type of nerves have been damaged. They can range from numbness, a feeling of pins and needles, to severe shooting pains.


The authors found that the reduced qualify of life had more to do with a drop in patients' ability to perform physical tasks in their daily lives than any pain they may have experienced.


The findings prompted fellow author Kavita Venkataraman, assistant professor at the National University of Singapore's Saw Swee Hock School of Public Health, to embark on another study last year.


She is now recruiting 220 diabetics with peripheral neuropathy and plans to put half of them through regular physiotherapy sessions to strengthen their legs, for a total of eight weeks. The aim is to see if such intervention would improve their ability to carry out daily functions.




Diabetes is a growing problem here. The latest National Health Survey conducted in 2010 found 11.3 per cent of adults, aged 18 to 69, suffered from the chronic ailment, up from 8.2 per cent in 2004.


Research led by the National University of Singapore's Saw Swee Hock School of Public Health has forecast that one in two Singaporeans in 2050 will face the risk of getting type 2 diabetes.


The prevalence of diabetes-related complications - led by renal and cardiovascular complications - has also increased between 2005 and 2008, according to data from the National Healthcare Group diabetes registry, which was published in a local medical journal in 2010.


Dr Teh Ming Ming, a consultant at the department of endocrinology at the Singapore General Hospital, said it is not uncommon for a long-term complication to be the first clue that someone has diabetes.


As it is difficult to determine the onset of the silent metabolic disease unless one undergoes regular screening, those who are diagnosed late may have developed some complications, he said.


He warned that some changes occurring in the body are harder to reverse.


Peripheral neuropathy can also lead to foot infections, foot ulcerations and amputations when patients are unable to feel pain from the foot injury and are treated late.


The good news is that when the elevated blood glucose is brought down to normal, the nerve damage may stabilise, he added.


Diabetes can be controlled with diet, exercise and medication, but many patients fail to achieve the optimal haemoglobin A1c (HbA1c) level of less than 7 per cent. The HbA1c gives a picture of one's overall blood sugar control over the past two to three months.


Doctors said newer types of diabetes drugs, which simplify the medication regimen, should help patients stick with their treatment.


For instance, the latest Janumet XR combines two pills, sitagliptin and metformin, into one so patients take this once instead of two or three times daily.


It works by addressing the insulin deficiency from pancreatic beta cells, insulin resistance and overproduction of glucose by the liver.


Dr Ben Ng, a consultant endocrinologist at Mount Elizabeth Novena Specialist Centre, said research has shown that patients with various medical conditions including diabetes, who are non-compliant with their medicine, are three times more likely to die in two years, compared with those who comply with their medication.


The real challenge, doctors said, is to convince patients to take their medicine diligently and undergo regular screening even when they feel well.


Prof Tai pointed to another local study, published in the journal Plos One in November, which showed that treatment with medication in diabetes was not associated with any adverse effect on health-related quality of life.


He said: "You should take your medicine today to prevent any complications that may come five or 10 years later. These are what will really hurt you, not the diagnosis of diabetes."


Source: The Straits Times © Singapore Press Holdings Limited. Reproduced with permission.

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