Diabetes is a condition whereby the body is unable to control blood sugars, because there is a problem either in the production or the action of insulin. This is a hormone in the made in the pancreas and, effectively, its job is to convert our food into energy.
Without sufficient insulin, or without insulin working properly, our bodies are unable to utilise our food for energy. Food is our battery – it’s what makes our bodies work – but it only becomes that energy when the sugar from the food moves from the bloodstream into the blood cells, and it is insulin that carries that sugar across from the fluid part of the blood into the blood cells.
There are two types of diabetes: type 1 and type 2. Type 1 covers a very small percentage of all diabetics in the world – fewer than 10% – and is an autoimmune disease, meaning that the body turns on itself and kills off the cells that make insulin. We have no means of predicting who will get type 1 diabetes and, even if we did, there is no way of preventing or curing it. Somebody with type 1 diabetes is producing no insulin at all, and without insulin we can’t live, so these people need to inject insulin multiple times a day to control their blood sugar.
The majority of diabetics have type 2 diabetes, which is genetic in origin. We’re born with or without the predisposition for type 2 diabetes – it doesn’t mean we will definitely get it, but if we receive the right stimulants at the right time, then we can get it. Unlike type 1 diabetes, we can predict who is likely to get type 2 by considering their ethnicity, their family history of both diabetes and cardiovascular disease, and their waist circumference.
Type 2 diabetes is very much related to lifestyle, which is why we see many more diabetes cases today than we have previously. This is mainly because as a people, in general, are much less active and we tend to carry more weight than our predecessors did. We tend to eat a lot of refined sugar in our diets, and this will often lead to the onset of type 2 diabetes.
With type 2 diabetes, the main problem is what we call ‘insulin resistance’. Even though the body is producing insulin, it’s not really capable of utilising it effectively, so the body has to produce increasing amounts of insulin in order to get the sugars under control. If this goes on for too long, then the pancreas can become tired and then have a problem with producing sufficient insulin.
Among the places where we see the most diabetes is in countries that have developed quickly. For example, in the Middle East, where countries such as Kuwait developed rapidly with the advent of the oil industry, the traditional lifestyle and diet has been largely replaced with fast and processed food, as well as increasing car ownership, meaning less physical activity. Genetics haven’t caught up in such a short space of time, so the increase in type 2 diabetes is exaggerated in countries where there has been such rapid change.
In some people, prevention is possible, but for the majority of people the onset of type 2 diabetes can be delayed significantly, often by decades. The key is leading a healthy lifestyle, by eating healthily, losing weight and being active. Activity is so important because the more active we are, the less resistant to insulin we are.
With a healthy lifestyle, someone with type 2 can manage their condition and get to a position where they don’t need any outside treatment. It isn’t a cure, so if previous unhealthy habits return then blood sugar levels are going to go back up. A very high percentage of people with type 2 diabetes don’t need to suffer if they change their lifestyle significantly enough.
Type 2 used to be called ‘mature onset’ diabetes, because almost all those who developed it were in their late sixties and seventies. We cannot say that anymore and the average age of onset for diabetes comes down year on year, to the extent that now our lifestyles are often so unhealthy that we even have children developing type 2 diabetes, which was previously unheard of.
Whether a person has type 1 or type 2 diabetes, the symptoms are the same, but with type 1 these are much more obvious. That is because the speed of onset of diabetes is very different in each case, with a type 1 patient presenting with diabetes within weeks of onset, as their lack of insulin occurs very quickly.
The two most common signs of either newly diagnosed or uncontrolled diabetes are passing a lot of water and the need to drink a lot. When there’s too much sugar in the body, it tries to produce more insulin to lower the level of sugar in the blood, but if you are not producing insulin or it is not functioning then the body can’t do that. Instead, it tries to get rid of the sugar by passing it out through the kidneys. As sugar is very absorbent, it takes lots of water with it, so we become thirsty to replace the water and avoid becoming dehydrated.
As I mentioned before, sugar is our battery. It’s our energy, but you still have to keep living, even if you can’t use that sugar. So the body turns to its own fat stores and starts breaking those down in order to get some energy out of it. Obviously, that leads to very rapid weight loss, which tends to happen with type 1.
The problem with type 2 diabetes is that the onset is very slow, so people who are diagnosed will certainly have had it for months, perhaps even for years. The person with type 2 diabetes has reached a high sugar level over maybe the previous 18 months, so the body has adapted very slowly and the patient doesn’t recall how much better they were feeling a year or two earlier. Often, our patients only realise how poorly they had been feeling a couple of weeks after starting their treatment.
It is quite common that people with type 2 diabetes are diagnosed incidentally when they have a routine health check for insurance, for example, or have a blood test in preparation for a hospital procedure. Also, sadly, another way that diabetes is often diagnosed is when the patient presents with a complication of diabetes, such as a
black toe or a sight problem, or they might have shown some kidney problems in a blood test. At that point, the patient will have had diabetes for a long time, without any treatment, and that is when complications can occur.
Often, when someone is diagnosed by their general practitioner, their doctor may prescribe tablets and suggest a follow up in, say, six months. However, it is best if the patient is educated on how to manage their diabetes from day one.
Diabetes is very much a self-management condition, but obviously this can only happen with knowledge. Education really is the key, but sadly many people don’t receive that education and then they and their doctors are puzzled at why their control isn’t very good.
When people come to our practice at the London Clinic, they would first see our specialist – consultant in endocrinology and diabetes Dr Richard Sheaves – who would spend an hour with them to talk through their condition, the type of diabetes they have and what their blood sugar reading means. My role is then to talk more about day-to-day management of diabetes, most importantly starting with understanding the patient – who is the patient? What do they do for a living? What do they like to do for leisure? What treatments might suit them best and what might they struggle with?
Generally, patients will monitor their blood sugar on a daily basis, often on multiple occasions. Monitoring is the biggest issue for patients, as it is irritating to constantly having to measure your blood sugar, and when you have to prick your finger for a blood test it’s also painful.
Fortunately, these days we have technology such as continuous glucose-monitoring sensors that can sit under the skin and monitor blood sugar every five minutes, send that information to your phone. At all times patients can their blood sugar levels, and that’s a huge educational tool – in a short period the patient can learn exactly what foods affect their blood sugar, by how much and for how long. In the first few weeks of using a sensor a patient will learn more than they would have done previously in a year or two, which has changed the lives of so many people. For example, patients may not need to give up particular foods completely, but can learn what is a sensible portion size for them.
Insulin pumps are also making a big difference to patients’ lives. An insulin pump is a small device that you can wear that infuses insulin constantly, right under the skin, which the patient controls with their phone or a handset. It’s a very complex way of managing diabetes and, when used in combination with glucose-monitoring sensors, can mean a type 1 patient would only need to inject insulin every three days, at the time when the pump is changed.
This has also led to the development of a hybrid system – an artificial pancreas, essentially – with pumps that can connect directly to a sensor, so that the patient doesn’t have to make the decisions on a constant basis about how much insulin should be administered. This means they can keep their blood sugar within normal limits almost all the time.
For more information on diabetes services at the London Clinic, visit www.thelondonclinic.co.uk/services/conditions/diabetes
