Diabetes – how do I control it?

By Dr. Muhammad Hafizullah

A month ago my sugar went out of control – more like an unruly horse. I went back to brown bread, reduced the quantity of bread to half, stayed away from rice, and refused to even touch desserts but my sugar level refused to budge. I increased the dose by fifty percent and later doubled it up. It showed a decline but still remained high. I consulted my physician who advised to undertake regular exercise. I am a fairly active person and did not expect that lack of regular exercise was such an important and deciding factor in the control of diabetes. Two weeks down the lane of regular thirty minutes walk on treadmill covering two and half kilometres helped me a lot.

My weight decreased by a couple of kilograms and the waist decreased by half an inch. But this did wonders to my sugar level. Soon, I was able to reduce my tablets by half of what I was taking and reduce it further. With regular exercise, I discovered that a little transgression in diet was well tolerated by the body. My three months sugar control, as evident by HbA1c, fell back to normal levels. The salutary effect on my blood pressure and cholesterol level was like icing on the cake. In my wisdom, the first step towards sugar control has to be proper exercise of at least thirty minutes duration and to be performed daily or at the minimum five days a week.

Diabetes is like termite but the effects do not appear forthwith. The target organs for diabetes are heart, kidneys, brain and eyes. Moreover, apparent intact health may not reveal the true state. Efforts have to be made to look for other risk factors that can conspire with diabetes and invite more trouble.

These need to be identified and appropriate steps taken to control them more aggressively. It is always useful to consult the expert in the field and keep a vigilant eye on added risk factors. Meticulous control of blood sugar as determined by three months sugar test – HbA1C remains the most reliable parameter for determining the future events pertaining to brain, heart, kidneys and eyes.

I was alarmed to learn that diabetics are members of ‘highly vulnerable’ group. Having diabetes predisposes to heart and kidney diseases besides many other problems. Blood pressure has more profound effects on diabetics as against those with no diabetes. Blood pressure and diabetes is a bad combination.

The threshold for diagnosis is much lower for high blood pressure in diabetics. Similarly treatment goals are lower for high blood pressure in diabetics. What may be normal for others is regarded as high for diabetics. Whereas the goal for blood pressure may be 140 for others it is 120 for diabetics and similarly diastolic blood pressure of 85 mmHg is regarded as high for diabetics.

In diabetics even marginally elevated level of cholesterol is regarded as an serious risk factor. Most doctors would like to bring cholesterol level below 150 in diabetics whereas for non-diabetics the aim is 180. Similarly LDL cholesterol (bad cholesterol) higher than 70 mg is regarded as elevated and drugs may be employed to lower it. In non diabetics LDL threshold level is 100 mg and the goal for treatment is the same. Diabetics are more prone to the harmful effects of cholesterol at lower levels as against non-diabetics.

Treatment of diabetes becomes easy to understand as it revolves around carbohydrate - sugar metabolism. The management entails reducing intake of carbohydrates and improving its utilisation.

Insulin is required to metabolise carbohydrates and the treatment needs enhancing total insulin by either stimulating pancreas to release more Insulin with the help of drugs or injection of Insulin. Oral drugs used for the treatment in diabetes work at three sites: stimulate pancreas to produce more Insulin, reduce absorption of carbohydrates from gut and others that increase the peripheral utilisation of carbohydrates.

These drugs can be used in incremental dosage and in combination for optimal control of diabetes. When oral tablets fail to achieve optimal sugar level then the patient is started on Insulin.

Nowadays, Insulin is introduced early in course of treatment, for optimal control. Unfortunately Insulin is destroyed by acids in stomach, so it can be administered orally and has to be injected. Insulin injected in vein acts quickly and brings down sugar level precipitously but the effects do not last for long. Insulin injected in muscles results in rapid onset with quick action and a little prolonged duration.

These two routes are employed in emergency situations when patients present with very high blood sugar. Insulin can also be given in the form of infusion trickling in slowly for steady effect. This is a better route of administration when sugar level is alarmingly high and needs regular monitoring and bringing down. Routinely, Insulin is administered in the space just below skin called subcutaneous. This has great benefit, for the effects start slowly and last for longer time. This makes it possible to control blood sugar level with two injections in a majority of patients.

Insulin was prepared from animal sources and till recently the usual sources were bovine and pig. The new genetic technology allows to produce Human Insulin from bacteria. Insulin is produced as short acting version for rapid onset and short duration of action and long acting variety which has prolonged effect. Combinations with 70 and 30 percentage and 60 and 40 percentage of long and short acting insulin are available for both immediate and prolonged action for effective control over twelve hours. Patients require two injections in the morning before breakfast and at night before dinner. Lente is long acting insulin, which has been a new addition and is being used extensively by doctors once a day at night to optimise sugar control.

In my case I started with drugs to improve peripheral utilisation and initially the response was good. After a few months I found that my sugar levels were running high. After consulting my doctor I had to add the commonly used drugs called ‘Sulphonylurea’. These drugs stimulate Pancreas to produce more insulin – flogging the tired horse. Again I started with one tablet a day but had to increase the dosage to two and then three. I was strongly advised to ‘mend my ways’ implying more adherence to the prescribed diet and regular thirty minutes exercise.

And I was warned that otherwise Insulin had to be started.