Diabetes: The Power to Prevent and Control

Winter 2005 CSANews Issue 57  |  Posted date : May 25, 2007.Back to list

As a public school student in Kingston, Ontario, I recall being given a reading assignment about diabetes. I became totally immersed in the book about Dr. Frederick Banting and Charles Best in their 1921 discovery of insulin. Their successful experiments providing pancreatic extracts to diabetic dogs which had had their pancreas removed, paved the way the following year for the first successful treatment for humans with diabetes. Up until that time, children who developed the disease rarely lived to adulthood, succumbing to extreme emaciation, coma and death.

It was not until the late 1950s, when I had started medical school, that it became clear that there were really two distinct forms of the disease; type 1 diabetes, which usually began at a young age and is entirely dependent on insulin injections and type 2 diabetes, usually presenting after age 40 and usually treatable with the new oral hypoglycemic medications in conjunction with lifestyle and dietary modifications.

What is Diabetes?
Diabetes is a metabolic disorder in which the production of insulin, a hormone produced by pancreas, is either partially or completely impaired (type 1) or the body's cells requiring it to properly transport glucose into the cells become unable to use insulin efficiently (type 2). Insulin resistance, as found in type 2 diabetes, accounts for more than 90 per cent of cases.

Today, in Canada, there are more than two million diabetics and the number of persons with type 2 diabetes is growing at an alarming pace. One of the major risks is excess weight due to inactivity and poor dietary habits. While type 1 diabetes cannot be prevented, there is increasing evidence that we can reduce our risk for the development of type 2 diabetes and the vascular complications that make it such a deadly disease. What is even more alarming is the fact that probably as many as one-third of people do not know that they have it, as elevated blood sugars may precede symptoms by many years.

Symptoms indicative of diabetes can be gradual and mild, such as increased thirst and urination, increased appetite, weight loss, vision abnormalities and fatigue or, especially in type 1, more sudden and severe symptoms of extreme weakness, mental confusion or loss of consciousness.

Symptoms of diabetes include, but are not limited to, the following:

  • Excessive and frequent urination
  • Increased thirst and appetite
  • Unintentional weight loss
  • Blurred vision
  • Fatigue and weakness
  • Recurring or persistent infections of the bladder, skin, or gums
  • Numbness or tingling in feet and hands


Prevention
The single most important way in which to help prevent the development of type 2 diabetes is by avoiding excess weight gain or, if necessary, losing weight. Individuals should maintain a normal weight by careful control of their diet, as well as through daily exercise. Most organizations agree that 30 minutes of "brisk but comfortable" walking or similar exercise is helpful not only in the prevention of diabetes, but also in reducing blood pressure, improving circulation and reducing the risk of osteoporosis. If diabetes is diagnosed, professional dietary education is necessary and the majority of individuals will require one or more oral anti-diabetic medications. Persons with type 2 diabetes who have difficulty controlling their blood sugars with oral agents will often be given insulin injections as well to improve control of the glucose metabolism.

Diabetes and High Blood Pressure
Diabetes is often preceded by high blood pressure by many years, even by decades. As a result, screening for diabetes should begin at the onset of the development of high blood pressure. Because high blood pressure is a significant risk factor for coronary heart disease and stroke, aggressive management of any elevation of BP in a diabetic is essential. In addition to weight control and exercise, medications will be prescribed to maintain blood pressures below 130/80, as compared with non-diabetics, who should maintain levels below 140/90. Automated home devices to accurately measure blood pressure are now perfected and provide an excellent monitoring tool to assist one's physician in achieving these goals. They are especially useful for snowbirds who may not have regular office monitoring while away. Often two, three, or even four medications may be necessary to achieve optimal levels. In addition, cholesterol control is essential. Along with dietary restriction of cholesterol and trans-fatty acids, a "statin," a type of cholesterol-lowering drug, is almost always prescribed.

Diabetes Facts
Today, 90% of diabetes cases are due to obesity. Since 1960, obesity among adults has increased by 15%.

The first treatment for people newly diagnosed with type 2 diabetes is lifestyle changes, such as improvements in diet and exercise.

Over time, type 2 diabetes usually worsens, oral medications become less effective, and more than 1/3 of people must add insulin injections to their treatment regimen.

At least 1/3 of people with type 2 diabetes do not know they have it.

In a recent study, nearly ¾ of participants with diabetes had high blood pressures that exceeded the recommendations.

Aggressive blood pressure management can cut the risk of heart attack and stroke in people with diabetes. People assigned to tight blood pressure control experience a significant reduction in stroke, heart failure, visual problems, and deaths related to diabetes.

Additional Complications
It is estimated that almost 80 per cent of diabetics develop, or die of, arteriosclerosis – narrowing of the arteries leading to the brain, the heart and the extremities. Most diabetics die from heart attacks and strokes, not from the disease directly.

Accordingly, special attention directed at preventing, as well as controlling, arterial disease is as important as maintaining normal blood sugars. Seniors practising poor dietary habits, lack of exercise and inadequate weight control may be unknowingly exposing themselves to risks. Early detection of abnormal glucose levels increases the opportunity for aggressive management of high blood pressure and elevated cholesterol levels, both of which are risk factors for cardiovascular conditions. Annual medical examinations should include a fasting blood sugar test after the age of 50, and sooner if risk factors are present. An elevated level will lead to more definitive tests to confirm diabetes.

Because coronary artery disease, angina and heart attacks are so much more prevalent in diabetics, any chest pains or tightness, shortness of breath or other symptoms suggestive of heart disease must be immediately and thoroughly investigated. Early intervention with medication and possibly angioplasty and stenting may prevent a myocardial infarction (heart attack). This urgent attention is also true for any signs or symptoms of a Transient Ischemic Attack (T.I.A. or Little Stroke), or leg pain when walking, suggestive of impaired circulation to the lower extremities.

Diabetics are also vulnerable to various degenerative conditions in the eyes, called diabetic retinopathy. The development of laser therapy in the early 70s for some of these conditions was a major breakthrough. Because diabetics are at greater risk for retinal aneurysms, hemorrhages and retinal detachments, annual examinations by an ophthalmologist is recommended, as well as immediate care if new and sudden changes occur with vision.

Diabetic neuropathy, another complication of diabetes, results in degeneration of peripheral sensory nerves causing various degrees of tingling, numbness or pain in the extremities or face. Diabetes can also cause kidney damage in the form of diabetic nephropathy and requires careful monitoring and treatment with drugs and, in later stages, possibly dialysis or renal transplant.

Skin care is essential in diabetics, as they are more vulnerable to infection. This is especially true of elderly persons with poor circulation in their legs. Early and aggressive medical management of any sores or infections is essential to prevent further spread or gangrene.

Diabetes and Travelling
When planning their winter vacation, snowbirds with diabetes should have their annual health examination and any routine tests performed well in advance of their departure. This will allow for any further testing to be done and any changes made in treatment or medications, prior to the stability period as required by most insurance policies, usually 90 days. Snowbirds who are unable to attend their own physician for proper monitoring and treatment of their condition because of their trip, are well advised to seek a personal physician at their vacation site for this purpose if they are spending more than a month away from home.

Although routine monitoring of their diabetes and any associated disorders will be at their own expense, unexpected emergency care should be covered by their travel health insurance, and having a physician familiar with their medical history will be an asset if an emergency should arise. It is essential that diabetic patients be certain that their policy covers them for all medical emergency conditions that might arise while away.

In summary, it is vitally important that those of us who do not have diabetes can go a long way in preventing the development of type 2 diabetes through maintenance of normal weight and exercise. For those with the disease, precise and careful monitoring of their blood sugar, aggressive management of the known complications of the disease, and careful attention to lifestyle and weight control will give the best "insurance" for living a full and productive life.

Frederick Banting received the Nobel Prize in physiology and medicine in 1923 for his famous discovery, and he was knighted. He was killed in an airplane crash in 1941 on his way to a wartime mission. Dr. Charles Best had a long and distinguished career, receiving numerous awards and honorary degrees. I had the profound pleasure of meeting him in the early 70s, before his death on March 31, 1978 at Toronto General Hospital.

These two great Canadians made a lasting impression on me and have been so immensely important to diabetic persons throughout the world!

Dr. MacMillan, Medical Director of Medipac International Inc., has recently been awarded Honorary Membership in the Canadian Medical Association, the professional organization representing Canada's 60,000 medical practitioners. This award is presented to "persons who have distinguished themselves by their attainments in medicine, science, the humanities or who have rendered significant services to the Association."

Dr. Robert MacMillan
Robert MacMillan's distinguished medical career has spanned private practice, public service, teaching, the business sector and community activities.

A graduate of Queen's University, Dr. MacMillan was a family physician in Peterborough, Ontario from 1965 until 1982 when he joined the Ontario public service as Regional Coroner for Eastern Ontario. In 1987 he moved to the Ministry of Health, where he first served as Assistant Deputy Minister responsible for Community Health and then as executive director of the Health Insurance Division (OHIP).

In 1993 he left the public service and until 2002 was medical director for a major Canadian travel health insurer. Since 2003 he has been a medical consultant for Medipac International Inc., a major insurer of Canadian travellers, where he advises on underwriting principles and lectures on health promotion and disease prevention.

In addition to academic appointments at Queen's University and the University of Toronto, Dr. MacMillan has been active in professional associations. He was a founding member and president of the Travel Health Insurance Association of Canada, and is a director and life member of the Canadian Institute of Law and Medicine. In addition to serving as the chairman of the board and 100th president of the Ontario Medical Association, he is a past president and life member of the Ontario Coroners' Association. His extensive volunteer work includes St. John Ambulance, which named him a Serving Brother in the Order of St. John's. He also has served on the Board and several committees of the Canadian Medical Association.