Commentary: Unable to look sideways? Unusual signs of diabetes often unnoticed, ignored or denied

SINGAPORE: A patient once consulted me because his eyes could not look sideways.

He was surprised when I said we needed to check his blood glucose level, as part of routine medical tests, as this symptom could suggest diabetes as a possible cause.

Some diabetics may not display common symptoms, making it a silent, dangerous disease, says Chairman of Healthway Medical Group's Medical Board Philip Koh.

And just as I suspected, his subsequent test results revealed he had diabetes.

Diabetes, as a condition where the body produces insufficient insulin resulting in high blood sugar levels, can give rise to a wide array of acute and less commonly talked-about but related complications such as blindness and kidney failure.

In this man’s case, his diabetes had damaged blood vessels and nerves, and paralysed muscles in his eyes that control eye movements. He recovered after a few months after receiving treatment and practising ways to place his diabetes under control.

Many people like him have seen me for complaints seemingly unrelated to diabetes, including multiple episodes of skin abscesses, numbness in their fingertips and blurring vision. They did not exhibit any common symptoms and yet were eventually diagnosed as diabetics.

A DREADED DISEASE

In his 2017 National Day Rally speech, Prime Minister Lee Hsien Loong highlighted diabetes as a serious national problem facing Singapore. While the disease is well-known and often cautioned about, the increasing frequency of its diagnoses paints a sobering picture.

Today, one in nine Singaporeans has diabetes. This figure is three in 10 or those over 60. In 2014, about 440,000 Singapore residents aged 18 years and above had diabetes, and this number is estimated to grow to 1 million in 2050.

As a family physician for more than 20 years, I have diagnosed my fair share of diabetes patients.

But like what Mr Lee mentioned in his speech, one main challenge dealing with this dreaded disease is it hardly has any clear symptoms in its early stages, and often presents itself in many diverse and surprising ways.

Patients might ignore early symptoms and simply go on with their lives despite experiencing discomforts like increased fatigue, or attribute these to other reasons like stress at work or the hot weather.

Common symptoms include increased thirst, unexplained weight loss and tiredness – signs that often go unnoticed as patients do not feel sick and consult a doctor. Years could go by before one finds out about their condition.

The body is also very adaptable to change, meaning diabetes can be silent because symptoms only show after significant damage has been inflicted.

Without early diagnosis, medical intervention and proper management, diabetes can eventually lead to disabilities and other life-threatening diseases even though it is not fatal in the short term.

Many with diabetes also suffer from high cholesterol and high blood pressure. If they smoke, diabetes compounds their risks of heart attack, stroke and kidney.

Those who suffer from diabetes may experience substantial organ damage by the time they start treatment, owing to diabetes remaining undetected for years.

PREGNANT WOMEN AT RISK

Pregnant women would do well to heed caution where gestational diabetes afflicts many non-diabetic pregnant woman, usually in the second or third trimester of pregnancy.

About 10 per cent of pregnant women suffer from this condition. Raging pregnancy hormones increase as the pregnancy advances and counteract the action of insulin.

Thankfully, it can be discovered during the early pregnancy screening, and insulin injections can keep the pregnancy viable.

But gestational diabetes poses risks to both foetus and mother, including greater risks of early labour or premature birth and low blood sugar in the baby soon after birth.

Both mother and child also face increased chances of developing diabetes later in life.

POTENTIAL DIABETICS IN SELF-DENIAL

The most worrying segment of diabetics are those at high risk but also in huge denial even when they experience glaring symptoms of this disease.

I have met many overweight and obese patients who continue to make unhealthy lifestyle choices and live lives of inactivity, despite having a family history of diabetes, which increases their susceptibility to the disease.

So many engage in excessive eating and lead sedentary lifestyles, without any effort to exercise.

A 2016 study led by the National University Hospital and Janssen Pharmaceuticals, found that Asians are more prone to Type 2 diabetes than our Western counterparts.

Asians are more prone to develop diabetes at much lower levels of obesity because they are unable to mount an appropriate insulin response to a glucose load, the study shows.

Furthermore, Singapore’s rapid development has led to changes in our daily lifestyles – causing the average Singaporean to become less active and eat more high-caloric diets. Both these habits further exacerbate the risk of obesity, and consequently, diabetes.

LIVING WELL WITH DIABETES

Despite all this, the prognosis isn’t all bad. Even though diabetes can present itself in surprising ways, the disease can be managed and controlled once detected.

I was impressed with one patient’s commitment in changing his lifestyle that allowed him to lose 10kg of his initial bodyweight of 75kg in one year.

The patient, Mr Chan, managed it by waking up one hour earlier every day to go for brisk walks, cutting out all sweet drinks, replacing his favourite roti prata breakfast with a slice of wholemeal bread, and cutting down his rice intake.

Today, Mr Chan is on just one basic medicine for his diabetes, and has it well under control.

Having diabetes is not a death sentence. It is more like a life sentence.

Most diabetics can live comfortably without suffering the dire complications of diabetes by making sensible healthy food choices, committing to regular exercises, and adhering to daily medicine.

But early detection is a critical first step and being mindful it can manifest in many ways should give us cause to be more vigilant.

Dr Philip Koh is Chairman of the Medical Board of Healthway Medical Group. He is also a Family Physician who practices at Healthway Medical Tampines Clinic.


Taken from this article:
Commentary: Unable to look sideways? Unusual signs of diabetes often unnoticed, ignored or denied

Not just sugar: You might be eating your way to pre-diabetes and not even know it

Lose weight? Exercise? Maybe another day, you tell yourself, tucking into your plate of chicken rice and washing it down with some "dinosaur" drink. Sure, the weighing machine has been displaying higher numbers of late, and you’ve had to upsize your clothes – the way you’ve been upsizing your fast food meals.

But you’re feeling fine, so everything’s okay, right?

That’s the insidious thing about pre-diabetes, the stage before it becomes full-blown Type 2 diabetes. There are no symptoms, no signs that your pancreas isn’t producing enough insulin for your body to make use of sugar. There are also no indications that the excess sugar is building up in your blood stream, leading to higher-than-normal blood sugar levels but not high enough for a diagnosis of Type 2 diabetes.

One in seven people in Singapore have pre-diabetes, and 50 per cent of patients with Type 2 diabetes do not even know they have the condition.

HEART DISEASE, KIDNEY DAMAGE AND ERECTILE DYSFUNCTION

Pre-diabetes, in itself, is a sign of diabetes and the accompanying elevated blood sugar level only shows up in blood tests. As for those pre-diabetes symptoms that you may have read about on the Internet – hungrier and thirstier than normal, weight loss despite eating more, going to the bathroom more frequently, and feeling more tired than usual – they "already point to a more advanced stage of diabetes," said Dr Vivien Lim, Gleneagles Medical Centre’s endocrinologist.

A blood test done in the doctor's office is the definitive way of finding out where your blood sugar levels stand. Doctors usually test for the impaired glucose tolerance (IGT), impaired fasting glucose (IFG) or both. According to the World Health Organization, you have pre-diabetes if your fasting blood glucose ranges from 6.1mmol/L to 6.9mmol/L. Diabetes is defined as equal to or greater than 7mmol/L.

Any food that increases the risk of being overweight or obese will predispose you to diabetes.

About one in seven people in Singapore have pre-diabetes, and 50 per cent of patients with Type 2 diabetes do not even know they have the condition, said Dr Lim.

Here’s why it doesn’t pay to ignore your blood sugar levels. When the bloodstream gets flooded with sugar, it can cause damage to the vessels that supply blood to the vital organs. This is because high levels of sugar in the blood turn the life-sustaining liquid into a damaging soup that causes the blood vessels to harden over time.

A cascade of problems can follow. At first, the high blood sugar level saps your energy, makes your vision blurry, and messes with your mood and concentration. From there, it is a slippery slope to cardiovascular disease, heart attacks, strokes, kidney damage and, if you’re male, erectile dysfunction.

You will be more susceptible to infection, blindness, and nerve damage. You’ll heal from injuries slowly, if at all, putting simple cuts at risk of turning into situations that require amputations.

NOT JUST SUGAR – IT’S YOUR WEIGHT

Diet is a big part of the pre-diabetes equation. But it goes beyond cutting down on sugar and desserts, and swapping white rice for brown one. It is also about the char kuay teow, nasi lemak (especially when paired with fried meats), nasi or mee goreng, and orh luak you’ve scarfed down, said Dr Lim.

"This is an area that is prone to misconceptions,” she said. "We know that being overweight or obese predisposes one to diabetes. Hence, any food that increases the risk of being overweight or obese will predispose you to diabetes."

And the experts have the research to substantiate it.

Type 2 diabetes is caused by excess fat in the liver and pancreas, according to Professor Roy Taylor of Newcastle University, who spent four decades studying the lifestyle condition. The excess fat in the liver causes the organ to respond poorly to insulin and produce too much glucose. The excess fat in the pancreas leads to the cells that produce insulin to fail.

But you are not doomed to a lifetime of insulin shots if you have been diagnosed with Type 2 diabetes. Losing less than 1g of fat from the pancreas through diet can re-start the normal production of insulin, said Prof Taylor.

"The good news for people with Type 2 diabetes is that our work shows that even if you have had the condition for 10 years, you are likely to be able to reverse it by moving that all-important, tiny amount of fat out of the pancreas," he said in the Science Daily article.

Without intervention, at least 35 per cent of those with pre-diabetes will progress to Type 2 diabetes within eight years.

The same reversal can also be said of pre-diabetes, according to Dr Khoo Chin Meng, senior consultant with the Department Of Endocrinology at the National University Hospital.

“Studies have shown that those who lose weight or reduce their waistlines within a year of receiving a diagnosis of pre-diabetes are significantly more likely to return to normal glucose tolerance than adults who don’t,” he said. Without intervention, at least 35 per cent of those with pre-diabetes will progress to Type 2 diabetes within eight years, he added, citing the Prediabetes Appropriate Care Guide.

Exercise will also help to re-sensitise the body to absorb sugar from the blood, said Dr Lim. However, she cautioned that not every patient with pre-diabetes will succeed in reversing it. “Having weight loss does not necessarily guarantee pre-diabetes reversal. And, in general, it is likely to occur only in those who are overweight or obese.”

ARE YOU AT RISK OF PRE-DIABETES?

As it turns out, there are individuals who are at higher risk of developing pre-diabetes than others. As established earlier, those who are overweight or obese (a BMI higher than 30) belong to this group, said Dr Khoo. Certain ethnic groups, such as Indians and Malays, are more prone as well. Other factors include a family history of diabetes, a history of cardiovascular disease, hypertension, gestational diabetes, polycystic ovary syndrome, and/or being over the age of 40.

“If you have multiple risk factors, that should alert you to screen for pre-diabetes,” said Dr Khoo. If you don’t have any risk factors, screening for diabetes is recommended for age 40 and above. Weight is again a big indication of risk; those with obesity should consider getting screened at an even younger age, he said.


Taken from this article:
Not just sugar: You might be eating your way to pre-diabetes and not even know it

Commentary: Just because you're thin doesn't mean you're healthy

SYDNEY: According to the Australian Institute of Health and Welfare, 63 per cent of Australian adults are overweight or obese.

But it’s much harder to estimate how many are within a healthy weight range but have poor diets or sedentary lifestyles. These can cause significant health problems that will often be missed because the person appears to look “healthy”.

Your diet, not your body weight, is the best indicator of internal well-being, says one observer.

Obesity statistics often take estimates of body fat using body mass index (BMI). Although BMI isn’t perfectly correlated with body fat percentage, it’s a quick and easy method for collecting data using just the person’s height and weight.

If the BMI is higher than 25, a person is considered “overweight”. If it’s above 30, they’re considered “obese”. But BMI doesn’t tell us how healthy someone is on the inside.

Using additional lifestyle measures, such as diet and exercise frequency over the last year, a recent report from the Queensland Health department estimated 23 per cent of those who are not currently overweight or obese are at risk of being so in the future.

These figures indicate that the percentage of unhealthy-weight individuals does not accurately capture the percentage of unhealthy-lifestyle individuals, with the latter number likely to be much higher.

NOT ABOUT STAYING LEAN

Many people think if they’re able to stay lean while eating poorly and not exercising, then that’s okay.

But though you might appear healthy on the outside, you could have the same health concerns as overweight and obese individuals on the inside.

When considering risk factors associated with heart disease and stroke or cancer, we often think about health indicators such as smoking, cholesterol, blood pressure and body weight.

But poor diet and physical inactivity also each increase the risk for heart disease and have a role to play in the development of some cancers.

So even if you don’t smoke and you’re not overweight, being inactive and eating badly increases your risk of developing heart disease.

Little research has been done to compare the risk diet and exercise contributes to the development of heart disease in overweight versus skinny but unhealthy individuals.

However, one study measured the risk of different lifestyle factors associated with complications following acute coronary syndrome – a sudden reduction in blood flow to the heart.

It found adherence to a healthy diet and exercise regime halved the risk of having a major complication (such as stroke or death) in the six months following the initial incident compared with non-adherence.

UNHEALTHY DIETS BAD FOR YOUR BRAIN TOO

Recent research has also shown over consumption of high-fat and high-sugar foods may have negative effects on your brain, causing learning and memory deficits.

Studies have found obesity is associated with impairment in cognitive functioning, as assessed by a range of learning and memory tests, such as the ability to remember a list of words previously presented some minutes or hours earlier.

Notably, this relationship between body weight and cognitive functioning was present even after controlling for a range of factors including education level and existing medical conditions.

Of particular relevance to this discussion is the growing body of evidence that diet-induced cognitive impairments can emerge rapidly — within weeks or even days.

For example, a study conducted at Oxford University found healthy adults assigned to a high-fat diet (75 per cent of energy intake) for five days showed impaired attention, memory and mood compared to a low-fat diet control group.

Another study conducted at Macquarie University also found eating a high-fat and high-sugar breakfast each day for as little as four days resulted in learning and memory deficits similar to those observed in overweight and obese individuals.

These findings confirm the results of rodent studies showing specific forms of memories can be impaired after only a few days on a diet containing sugar water and human “junk” foods such as cakes and biscuits.

BODY WEIGHT NOT THE BEST PREDICTOR OF INTERNAL HEALTH

Body weight was not hugely different between the groups eating a healthy diet and those on high fat and sugar diets. Negative consequences of poor dietary intake can occur even when your body weight has not noticeably changed.

These studies show body weight is not always the best predictor of internal health.

We still don’t know much about the mechanisms through which these high-fat and high-sugar foods impair cognitive functioning over such short periods.

One possibility is that our blood glucose levels change from eating high-fat and high-sugar foods. Fluctuations in blood glucose levels may impair glucose metabolism and insulin signalling in the brain.

Many people use low body weight to excuse unhealthy eating and physical inactivity. But body weight is not the best indicator of internal well-being.

A much better indicator is your diet. When it comes to your health, it’s what’s on the inside that counts. Yu really are what you eat.

Dominic Tran is a postdoctoral research associate at University of Sydney. This commentary first appeared on The Conversation. Read it here.


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Commentary: Just because you're thin doesn't mean you're healthy