A Malaysian Epidemic?

Diabetes mellitus is a group of metabolic diseases characterised by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. The effects of diabetes mellitus include long–term damage, dysfunction and failure of various organs.

Diabetes mellitus may manifest itself with characteristic symptoms such as thirst, polyuria, blurring of vision, and weight loss. In its most severe forms, ketoacidosis or a non–ketotic hyperosmolar state may develop and lead to stupor, coma and, in absence of effective treatment, death. Often symptoms are not severe, or may be absent, and consequently hyperglycaemia sufficient to cause pathological and functional changes may be present for a long time before a diagnosis is made.

The long–term effects of diabetes mellitus include progressive development of the specific complications of retinopathy with potential blindness, nephropathy that may lead to renal failure, and/or neuropathy with risk of foot ulcers, amputation, People with diabetes are at increased risk of cardiovascular, peripheral vascular and cerebrovascular disease.

The development of diabetes is projected to reach pandemic proportions over the next 10-20 years. International Diabetes Federation (IDF) data indicate that by the year 2025, the number of people affected will reach 333 million – 90% of these people will have Type 2 diabetes. In most Western societies, the overall prevalence has reached 4-6%, and is as high as 10% -12% among 60-70-year-old people.

The annual health costs caused by diabetes and its complications account for around 6% -12% of all health-care expenditure. According to the IDF’s World Diabetes Scorecard, Malaysia has a national plan for diabetes in place with policies on sugar and access to healthy food.

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As of the end of year 2013, following were the statistics for Malaysia:

Adult population (20-79): 18,919,440
Diabetes cases (20-79): 1,913,240
Diabetes raw national prevalence: 10.11%
Diabetes expenditure /person with diabetes:USD468
Diabetes related deaths (20-79): 24,049
Number of people with undiagnosed diabetes (20-79): 1,035,060

Types of Diabetes Mellitus

Type 1 Diabetes Mellitus:

Also known as insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes develops when the body’s immune system destroys pancreatic beta cells, the only cells in the body that make the hormone insulin that regulates blood glucose. This form of diabetes usually strikes children and young adults, although disease onset can occur at any age. Type 1 diabetes may account for 5% to 10% of all diagnosed cases of diabetes. Risk factors for type 1 diabetes may include autoimmune, genetic, and environmental factors.

Type 2 Diabetes Mellitus:

Also known as non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes, may account for about 90% to 95% of all diagnosed cases of diabetes. It usually begins as insulin resistance, a disorder in which the cells do not use insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce insulin. Type 2 diabetes is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity. Type 2 diabetes is increasingly being diagnosed in children and adolescents.

Gestational Diabetes:

A form of glucose intolerance that is diagnosed in some women during pregnancy. It is also more common among obese women and women with a family history of diabetes. During pregnancy, gestational diabetes requires treatment to normalise maternal blood glucose levels to avoid complications in the infant. After pregnancy, 5% to 10% of women with gestational diabetes are found to have type 2 diabetes. Women who have had gestational diabetes have a 20% to 50% chance of developing diabetes in the next 5-10 years.

Other types:

– LADA (Latent Autoimmune Diabetes in Adults): LADA is a form of autoimmune (type 1 diabetes) which is diagnosed in individuals who are older than the usual age of onset of type 1 diabetes. Alternate terms that have been used for “LADA” include Late-onset Autoimmune Diabetes of Adulthood or “Slow Onset Type 1” diabetes. About 80% of adults apparently with diagnosed Type 2 diabetes but with GAD auto-antibodies (i.e. LADA) progress to insulin requirement. The potential value of identifying this group at high risk of progression to insulin dependence includes avoidance of using metformin treatment and early introduction of insulin therapy.

Some of the characteristic features of LADA are:

Patients usually aged 25 years or older
Initial control achieved with diet alone or a combination of diet and oral anti-diabetic medication.

– MODY (Maturity Onset Diabetes of Youth): Originally, diagnosis of MODY was based on presence of non-ketotic hyperglycemia in adolescents or young adults in conjunction with a family history of diabetes. However, genetic testing has shown that MODY can occur at any age and that a family history of diabetes is not always obvious.

Some of the characteristic features of MODY are:

Patients usually aged 25 years or younger with a strong family history of diabetes (at least 2 to 3 generations affected)
Patients show normal blood pressure and lipid profiles.

Within MODY, the different subtypes can essentially be divided into 2 distinct groups: glucokinase MODY and transcription factor MODY. Glucokinase MODY requires no treatment, while transcription factor MODY requires low-dose sulfonylurea therapy.

– Secondary Diabetes Mellitus: Secondary causes of Diabetes mellitus include:

Acromegaly
Cushing syndrome
Thyrotoxicosis
Pheochromocytoma
Chronic pancreatitis
Cancer

Drug induced hyperglycemia: e.g. atypical antipsychotics, beta-blockers, calcium channel blockers, corticosteroids, fluoroquinolones, niacin, phenothiazines, protease inhibitors, and thiazidediuretics.

-Prediabetes: Impaired glucose tolerance and impaired fasting glucose: Prediabetes is a term used to distinguish people who are at increased risk of developing diabetes. People with prediabetes have impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Some people may have both IFG and IGT. IFG is a condition in which the fasting blood sugar level is elevated after an overnight fast but is not high enough to be classified as diabetes. IGT is a condition in which the blood sugar level is elevated after a 2-hour oral glucose tolerance test, but is not high enough to be classified as diabetes. Progression to diabetes among those with prediabetes is not inevitable. Studies suggest that weight loss and increased physical activity among people with prediabetes prevent or delay diabetes and can help to bring blood glucose levels to normal. People with prediabetes are already at increased risk for other adverse health outcomes such as heart disease and stroke.

Management of Diabetes Mellitus:

Diet is a basic part of management in every case. Treatment cannot be effective unless adequate attention is given to ensuring appropriate nutrition.

Dietary treatment should aim at:

ensuring weight control
providing nutritional requirements
allowing good glycaemic control with blood glucose levels as close to normal as possible
correcting any associated blood lipid abnormalities

Exercise: Physical activity promotes weight reduction and improves insulin sensitivity, thus lowering blood glucose levels. Together with dietary treatment, a programme of regular physical activity and exercise should be considered for each person. Such a programme must be tailored to the individual’s health status and fitness.

Oral Anti-diabetic Medication: If glycaemic control is not achieved with lifestyle modification within 1–3 months, oral anti-diabetics should be initiated. Your healthcare practitioner would determine and prescribe the ideal therapy in the required dose.

Combination of Oral Anti-diabetic Medication and Insulin: If targets have not been reached after optimal dose of combination therapy for 3 months intermediate-acting or long-acting insulin may be added to the therapy.Combination of insulin and oral anti-diabetic agents has been shown to improve glycaemic control in those not achieving target despite maximum combination of oral anti-diabetic agents. Here too your healthcare practitioner would determine and prescribe the ideal therapy in the required dose.