Improving Diabetic Care in Malaysia

(image credit : The Star)

By Dato’ Dr. Lee Yan San
(Consultant Physician & Medical advisor to Penang Diabetic Society)

Diabetes Mellitus is becoming more common and is a major cause of severe medical complications and early death. Fortunately, although diabetes cannot be cured, it can be controlled and those who are well controlled can enjoy good living and even normal life span.
Here are some facts which may help to improve diabetic care in Malaysia.

Regular follow up by your doctor is essential to avoid any chronic diabetic complications. I have noticed that many of those who do not have regular follow up by doctors or self treated with poor control are now under treatment for chronic complications of diabetes. Pharmacists are qualified only to explain how the drugs work and its side effects but are not qualified to advice on treatment, and should leave this to the doctors.
Since Type2 diabetes is now much more common and is responsible for many chronic complications due to poor control which can be avoided, I shall stress on Type2 diabetes in this article.

Some Salient Points on Diabetes
Young Diabetics are usually Type 1 and those who started having Diabetes at an older age (especially after 40 years of age or so) are usually due to Type2.
Management of Type 1 diabetes and Type 2 are completely different. There is urgency to
treat Type 1 diabetes which requires urgent Insulin treatment to avoid having acute complications
like ketoacidosis leading to death if untreated. It is important to be certain that the patient do not
have Type 1 diabetes as they do not response to oral medications and require Insulin treatment.
Type 2 diabetes:
Type 2 diabetes is a slow onset metabolic disorder characterised by defect in insulin action (such as insulin resistance) and abnormality in insulin secretion. It develops very insidiously over months and even years until clinical symptoms make patient aware of it. To avoid finding out that your have Type 2 diabetes before complication arises, you should have a post prandial (after food) blood sugar taken routinely. For Type 2 diabetes, it is helpful to have post prandial blood sugar taken as in many early cases fasting blood sugar can be normal in spite of you having Type 2 diabetes.
Type 2 diabetes are often diagnosed during routine examinations.
In established Type 2 diabetes, the basal liver glucose output is increased. In fact, some researchers even believe that the liver may be the prime defect in Type 2 diabetes and are looking into this possibility!
Pancreatic -cell failure:
Unlike Type 1 diabetes where there is complete destruction of the pancreas, Type 2 diabetes still have some pancreatic (-cell) function. The main abnormality is impaired glucose-induced insulin secretion.
Insulin is normally secreted by the pancreatic -cell in two phases in response to as little as 90mg% of glucose in the blood in a normal person. The first fast phase which releases a larger amount of insulin is from granules containing already made insulin in response to the level of glucose in the blood.. This is followed by the slower second phase of newly synthesised insulin.
The main abnormlity in Type 2 diabetes is the absence of the first phase. In such patients, the pancreas cannot response to a heavy glucose load but is able to cope with small even intake of carbohydrate. This is a very important fact for good control. Patients must be advised to take small frequents meals and spread out their food intake to achieve good control.
However, in the late stages of Type 2 diabetes there is exhaustion of -cell reserves and thus very little insulin is secreted. At this stage, patient will need insulin treatment.
Insulin Resistance:
Insulin resistance is presently considered one of the more important factor in Type 2 diabetes especially in the obese. Insulin resistance leads to reduce ability of insulin to promote glucose uptake in muscle and fat cells thus patients will need more insulin. Insulin resistance ultimately also suppresses liver glucose production after meals. Exercise will reduce insulin resistant.
Presentation of Type 2 Diabetes:
Blood glucose is so easy to do and should be done at the slightest suspicion to avoid missing Type 2 diabetics in the elderly.
Many diabetics present with infection especially skin infection and PTB infection. New cases of Tuberculosis infection must always be screened for diabetes.
Management of Type 2 Diabetes
Type 2 diabetes has a very insidious onset and may be prevented by proper diet, exercise and weight management. Both genetic factor and environment are important in the development of Type 2 diabetes. Two large trials have recently shown that it is possible to interrupt progression to diabetes by rigorous correction of diet and exercise in susceptible individuals.
The United Kingdom Prospective Diabetes Study (UKPDS), the largest and longest study of patients with type 2 diabetes, conclusively demonstrated that improved blood glucose control in these patients reduces the risk of developing retinopathy and nephropathy and possibly reduces neuropathy (nerve damage).
UKPDS also showed that aggressive control of blood pressure in diabetics, significantly reduced strokes, diabetes-related deaths, heart failure, micro-vascular complications, and visual loss.

Criteria for good control
During the earlier days, we do not have Glycocylated Haemoglobin (HbA1c) test to help us in our management. (For every percentage point decrease in HbA1c (e.g., 9 to 8%) there is a 35% reduction in the risk of micro-vascular complications.) We therefore have only to rely on blood sugar levels.
As for blood sugar level, from my experience and logically, I feel that for Type2 diabetes, we need to rely more on Post Prandial Blood sugar readings rather than only fasting blood sugar for better control.. It stands to reason that it is no use having good fasting level but the rest of the day, blood sugar levels are way above11 mmol/l mainly from uncontrolled diet. (I have in fact received a number of referrals from ophthalmologists whose patients have poor diabetic control with various eye complications. Many of them in fact do have regular diabetic follow up by doctors before but have just rely on fasting blood glucose alone as an indicator of good control but when I did their random blood sugar after meals, the level was astonishing high; some even over 20 mmol/l! No wonder they are having such complications of diabetes. This is because in such patients the abnormality is mainly caused by defective insulin secretion in the pancreas in response to sugar in addition to insulin resistant. During fasting, when there is no food intake, the pancreas is able to cope since the pancreas is still able to secret some insulin at a time.)

It is better to give the lay person a target for control and I usually tell them that they should try to have the blood sugar level in the 5-8mmol/l range at all time. I am usually not too worried about the Fasting blood sugar being a little above the target level occasionally if non of the 2 hour post-prandial blood sugar goes above 8. Nowadays with the availability of HbA1c, I also try to aim at HbA1c below 7 and if possible below 6.5 as recently recommended which will also reduce risk of coronary and stroke but it is often more difficult in the more elderly patients whom I am very concerned of hypoglycaemic attacks which may further damage their already poor mental function.
I encourage diabetics to buy a glucometer and do their own monitoring. Most of the tests should be two hours after each meal. They can also do tests on waking before taking breakfast, 2 hours after each meal and just before going to bed. Unfortunately, most patients do not want to do their own monitoring. I usually ask such patients to come and see me randomly 2 hour either after breakfast or after lunch. On the appointment day, they are advised to stick to their usual daily routine and activities including taking their normal usual meals so that the reading will reflect their everyday situation as much as possible. I try to keep their 2hr post prandial blood sugar range between 5-8 mmol/l. None of the readings must go above 8 mmol/l. From all the reasearchs, you can avoid complications if blood sugar is leass than 10mmol/l. Recently, it was discovered than if blood sugar at all time is less than 8mmol/l, you can also avoid getting heart attacks and stroke.

Recently, researchers have agreed that it may be better to focus on lowering the after-meal blood sugar instead of just the fasting blood sugar to bring down HbAlc values thus better control.
A study using 25,000 subjects over a period of 7 years also showed that increase mortality risk was much more closely associated with 2hr pp than fasting blood sugar in Type 2 diabetes.
The main factor for poor control in my opinion is not just medication but doctors not spending enough time explaining to patients patiently what diabetes are all about and how to control their diet and encourage exercise. Patient’s understanding of the underlying pathology and problem will made them more likely to follow the doctor’s advice and thus have better control. They will understand why we stress so much on diet and exercise. Constant reminders of the proper diet and adequate exercise are very important.

Diet, Exercise & Weight Reduction
Diet and exercise should form the main stay in managing Type 2 diabetes. Patient should be encouraged to be active and involved in regular exercises. They should avoid any weight gain through inactivity. In some recent studies (Chinese & Finnish studies) as much as 58% can be prevented from getting Type 2 diabetes with diet and exercise. They were found to have increased -cell mass in the pancreas.
If patient is obese, the first line of treatment should be concentrated on loosing weight. Weight reduction can usually be achieved by increased activity and reduced calorie intake. Weight reduction itself often is enough to control the Type 2 diabetes as obesity causes insulin resistant.

Diabetics should avoid taking sugar completely. Fine starch should be avoided as it is easily digestible and turn into sugar thus lead to peaking of blood sugar. It is best for diabetics to take starch containing a lot of fibres such as whole meal bread and unpolished rice. Patients should take a high fibre diet with large amounts of vegetables. They should avoid heavy meals and space out their intake into small frequent meals.

Oral Hypoglycaemic agents
We shall need to use oral hypoglycaemic agents if diet, exercise and loosing weight is not sufficient to control the diabetes.

Treatment with Insulin
Insulin treatment is required for Type 1 diabetes. For Type 2 diabetes, it may be necessary if diet and oral hypoglycaemic agents are not sufficient for good control. Many types of Insulin are now available and your doctor will choose one that will be most appropriate to your life style.

Monitoring
Monitoring is important and you should have a home monitoring gadget to make sure that
your diabetes are well control over 24 hours.. There are five times you can monitor your blood sugar which is fasting, 2 hours after breakfast, lunch and dinner and before going to bed. Do not just do fasting blood sugar but alternate the time to make certain your diabetes is well control 24 hours and not just in the morning when you wake up. Doing post-prandial blood sugar will also help you control your diet.