Diabetic dilemma- Nepali Times

Diabetes Mellitus which manifests as increased blood sugar in the patients is so rampant in Nepal that even nuances in the treatment have become important. Some years ago a robust trial (United Kingdom Prospective Diabetes Study, UKPDS) in over 5,000 diabetic patients revealed that with 'tight' blood glucose control, eye problems, kidney problems and nerve problems were significantly decreased. The study population was Type 2 diabetics just like the vast majority of diabetics seen in Nepal, who are affected by the disease (not early but later in their lives).

As we are increasingly starting to find out in Nepal, uncontrolled diabetes more commonly requires dialysis due to kidney failure, eye surgery for retinal hemorrhages, and even amputations for nerve and vasculature related problems. In other words, conscientiously controlling blood sugar leads to fewer complications of the kidneys, eyes and nerves. In medical parlance these are called "microvascular" complications. Unfortunately in medicine what may seem to be an obvious cause (high blood sugar) and effect (complications) does not always pan out.

Indeed, as revealed in the same UKPDS trial what the tighter control of blood sugar did not do was decrease macrovascular complications in other important organs that diabetes has a serious impact on, namely the heart and the brain. So, despite a good control of blood sugar, the rates of heart attacks and strokes in these patients did not improve, although there was a decrease in kidney and eye problems. However, there was a silver lining in the study.

Hypertension or high blood pressure usually goes hand in hand with diabetes. Hypertension is an important risk factor for both heart attacks and strokes. So, those diabetics in the study who had proper control of blood pressure clearly had fewer strokes and heart attacks independent of their blood glucose control.

The "take home message" for diabetics is that it is important to keep both the blood pressure and blood glucose under proper control so that the important organs (including the heart, brain, eyes, kidneys) that diabetes affects are protected.

Furthermore, unlike high blood sugar in a patient which usually manifests with excessive urination, thirst, and hunger, high blood pressure may essentially have no symptoms to start with until there is that catastrophic stroke or heart attack. The prevention of both diabetes and hypertension with "way of life" changes also needs to be emphasised.

1. Dr. Jyoti Bhattarai

I would like to thank Dr. Basnet for bringing up the topic of diabetes in Nepali Times. The most important thing about diabetes is the knowledge that you can prevent costly debilitating diseases like blindness, kidney failure, leg amputation, heart attack and stroke, by controlling diabetes and other associated problems like high blood pressure, cholesterol, tobacco abuse, and physical inactivity. There is significant lack of awareness about this fact among Nepalese. In our society, we spend money in trying to treat ( though inadequately), those costly complications like kidney failure etc) whereas practically nothing is being done in primary prevention, which would be much cost -effective in a country like ours. Few examples are trainning health care workes, medicine shop keepers, in preventive health , and subsedizing medications for diabetes and high blood pressure for poor patients . Thought of as a rich man's disease, diabetes now affects all levels of society, and sadly poor and lower middle class population are more likely to end up with devastating problems, than the rich who can afford regular care.

Posted on: 17 JULY 2011 | 2:10 PM NST

2. Prof Satyan Rajbhandari,UK

Thank you for publishing this important message. In Nepal diabetes treatment has mainly centred around blood glucose control with very little emphasis on treatment of other factors like high blood pressure, smoking and raised cholesterol. Most people with diabetes die due to heart attack and all these factors play important role in it. There is a need to make doctors and patients aware of alphabet strategy for diabetes care which is commonly used in the UK.

A = Advise (Smoking, diet & exercise); B = Blood Pressure; C = Cholesterol & Creatinine care; D = Diabetes Control (HbA1c); E= Eye care; F = Foot care; G = Gaurdian drugs (statins, ACE inhibitors, Aspirin).

Posted on: 21 JULY 2011 | 3:26 AM NST