The theme of the World Diabetes Day, 2016, is Eyes on Diabetes. This year the focus is on screening to ensure the early diagnosis and treatment of type 2 diabetes to reduce the risk of serious complications.
Diabetes is a huge burden and it keeps growing. There were 415 million adults with diabetes in 2015 and this number will grow to 642 million by 2040. About 12% of the global expenditure on health is spent on diabetes. However, one in two adults is undiagnosed. A healthy lifestyle can prevent or delay the onset of type 2 diabetes in up to 70% cases.
Usually, the delay in diagnosis leaves one or more complications already in a patient. In many countries, diabetes is the leading cause of blindness, cardiovascular disease, kidney failure and lower-limb amputation. The global health spending to treat diabetes and manage complications was estimated at USD 673 billion in 2015.
At the focus scientific research center (FSRC), a part of phamax, we invited three specialists to share their views on diabetes and related complications.
Here is what Dr Harish Kumar N, Consultant Ophthalmologist at Vasan Eye Care Hospital, Bangalore, had to say.
Diabetic Eye Disease:
Diabetes is becoming the leading cause of preventable blindness in the world, especially in India. It can be attributed to the exponential increase in the number of diabetics. Lack of awareness and poor disease control are leading India to the title of the ‘Diabetic Capital of the World.’
The duration of the disease and the control of blood sugar have a direct impact on ‘diabetic eye disease.’ Other risk factors are high blood pressure, kidney disease and high lipids in the body.
Diabetes affects small vessels in the body known as ‘Micro-angiopathy’ and in the eye it is called ‘Diabetic Retinopathy’. Diabetic retinopathy (DR) is becoming the most common retinal disease.
Diabetic patients are also at a higher risk of developing high pressure in the eye called ‘Glaucoma’, a slow, progressive condition which damages the Optic Nerve, the nerve of vison, irreversibly. Early treatment can slow down the rate of progression and minimize the nerve damage, which helps to maintain useful vision for the rest of the patient’s life. In advanced disease conditions, the optic nerves are damaged completely, resulting in a loss of vision.
The movements of the eye are controlled by the muscles around the eye ball, which are connected to the nerves originating from the brain. Although rare or unlikely in most cases, a blockage in the tiny blood vessels supplying to these nerves leads to the loss of function of that muscle. It results in double vision due to the loss of coordinated eye movement. The recovery is generally good and full with proper and timely medication.
Diabetes is not curable, but most of the complications due to diabetes are preventable. Control of blood sugar and diet, exercise and control of other risk factors with a yearly eye examination by an ophthalmologist reduces the risk of visual disability.
Dr Harish also outlines that, though scary, the eye-related problems due to diabetes can be prevented with early detection, proper management and frequent visits to an ophthalmologist.
The other most common set of complications diabetics face are kidney disorders. We asked Dr Anoop Gowda, Consultant Nephrologist, to shed some light on the topic.
Diabetic Kidney Disease
Diabetes is the most common cause of kidney failure, accounting for nearly 44-52% of the new cases in dialysis units worldwide. The cost of care is roughly INR 30,000 per month.
Spectrum of kidney disease in diabetics – The most important among diabetic kidney disease (DKD) is diabetic nephropathy, followed by renal artery stenosis, diabetic cystopathy, papillary necrosis etc.
Over several years, DM albumin begins to leak into the patient’s urine. This is the early stage called Microalbuminuria. The kidney’s filtration function usually remains normal during this period.
As the disease progresses, more albumin leaks into the urine, and as it increases, the kidneys’ filtering function usually drops. The body retains various wastes as filtration falls. The blood pressure often rises as well as the kidney damage develops.
How do different diabetics progress?
For people with type 2 diabetes
About 12 in 100 people have Microalbuminuria and two in 100 have gross proteinuria when they are diagnosed with diabetes for the first time. This is not because diabetic kidney disease occurs straightaway but because many type 2 diabetics do not have their malady diagnosed for quite some time after its beginning. Of the people who do not have any kidney problem when diabetes is diagnosed, Microalbuminuria develops in about 15 in 100 people and proteinuria in five out of 100 people within five years.
How do we go about with this?
India cannot afford to treat these patients with quaternary care as then the entire health budget of the union government will be enough for kidney disease alone. So, primary care and prevention alone are the answers.
What to do?
Kidney specific care
Next, we interacted with Dr Murali Krishna, Associate Professor and Peripheral Vascular Surgery in-charge at Sri Jayadeva Institute of Cardio Vascular Sciences and Research, Bangalore. He deals with the most severe and debilitating complication of diabetes daily – peripheral vascular disease. Here are some excerpts from what he had to say:
Peripheral Arterial Disease (pad) and Diabetes Mellitus (dm)
PAD is one of the most common manifestations of DM. It is one of the many end-organ failures caused by DM and with neuropathy and infection of the foot, it is a leading cause of morbidity and economic loss, probably more than coronary artery disease (CAD) and cerebrovascular disease (CVD) together.
Fifty percent of all extremity amputations occur in diabetic patients. The prevalence of PAD in diabetics is four to five times higher than in the general population (3-6%). Diabetic PAD is a more aggressive disease and occurs in younger patients. The rapid progression of ‘early’ critical limb ischemia (CLI) to gangrene occurs in 40% of diabetics as opposed to 9% in nondiabetics. A sudden progression from intermittent claudication to CLI occurs in 35% of persons with DM (19% in nondiabetics), with a 21% risk of major amputation as against 3% in nondiabetics.
PAD as a risk factor is a higher indicator than CAD and CVD for systemic atherosclerosis. The TASC II (Trans-Atlantic inter society consensus) guidelines recommend that any patient with ABI (Ankle brachial index) < 0.9 should be considered at risk for systemic atherosclerosis. ABI might be the easiest screening tool to identify these patients at risk and submit them to the best medical therapy.
In the US, 150,000 per year require amputation for their legs. In India, this figure is likely to be much higher. PAD can be diagnosed easily by clinical examination, ABI, arterial duplex and peripheral angiogram inputs planned for revascularisation. One should always attempt revascularisation and limb salvage, rather than going for primary amputation because perioperative deaths for amputation are 8-20%, whereas for revascularisation deaths they are 2 to 5 %. In patients who undergo amputation, 40% die within two years, and a second amputation is required in 30% of the patients. Also, only 50% of the patients with amputations below the knee and 25% of the patients with above the knee achieve full mobility. So, revascularisation by either bypass procedures or intervention is essential to attain functional limb salvage in majority of the patients. This can be sustained by risk factor modification and foot care.
Even high risk patients do well with the vascular reconstruction procedure rather than amputation. Hence, every attempt should be made to avoid major amputation in these patients.
So, as you can decipher from what the experts say, all is not doomed when one is diagnosed with diabetes or with a complication of the disease. Early screening for diabetes, proper management and keeping an eye on complications by frequently visiting your doctor can help you lead a longer and complication free life.
This World Diabetes Day, let us keep an eye on the disease and minimize the complications, lessening the huge burden on the economies worldwide.