The prevalence (diagnosed cases) of Diabetes has reached alarming levels and some clinicians are advocating that it is now a pandemic. The prevalence worldwide is reported by WHO (World Health Organization) to be approximately 11 percent in 2021. The US reported a prevalence of about 10.5 percent and Canada reported 8.8 percent. The startling statistic is that Guyana is estimated to have a prevalence of 21.4 percent in women and 15.1 percent in men (BMJ open Diabetes Research and Care, vol.8, issue 1.). In the Caribbean, the overall prevalence is about 9.5 percent.
These reported statistics must be understood to be only the diagnosed number of cases. It does not include the vast number of undiagnosed cases that exists worldwide, especially in poorer places and localities where health care is deficient.
What is Diabetes?
Diabetes mellitus is essentially the malfunctioning or nonfunctioning of the receptors for the hormone, insulin. Insulin is released by the beta cells of the pancreas. Food, after being ingested, and upon reaching the duodenum (the first part of the gut after the stomach) results in a messenger(hormone) being sent to the pancreas to release insulin. Insulin is an anabolic hormone, meaning it is responsible for the uptake of digested sugars and fats into specific cells in the body. The receptors for insulin are mostly on fat cells and muscles cells. Diabetes Mellitus, therefore, is the inability to take up simple sugars into the muscle cells and far cells, resulting in the accumulation of the simple sugars in the blood. The muscle system is the second largest organ system in our body and accounts for the uptake and removal from the blood, of a large portion of the ingested and digested simple sugars. So, failure of adequate functioning of the insulin receptors on the muscle cells and fat cells, not only prevent the uptake and removal of the sugars from the blood but also will “rob” the muscle and fat cells of a vital source of energy.
The dangers of failing insulin receptors
The failure of the insulin receptors to function adequately or normally results in the digested sugars remaining “stranded “in the blood and not being able to pass into the muscle and fat cells. This leads to an accumulation of the sugars in the blood. This explains the well-known problem of “high blood sugar”.
This excessive amount of sugar in the blood can now bind to the hemoglobin part of the red blood cells and produce what is referred to to as glycosylated hemoglobin or HbA1c. The glycosylated hemoglobin is a “sticky” product and does not move easily along the blood flow. It is easy to stick to the walls of blood vessels especially small capillaries, and thereby form blockages in the small blood vessels (figure 2). This can lead to ischemia of the organs being supplied. This ischemia (flow impairment and the deficiency of oxygen supply) can now cause organ damage over time, for example, the eyes (figure 1), kidneys, the heart and even the brain. It also can cause flow impairment in the lower extremities and the resulting danger of swelling and the risk of gangrene (figure 3).
It is essential to minimize the level of the glycosylated hemoglobin (HBA1c) and so prevent the blockage of small vessels and the resulting complications, such as loss of limb, blindness, kidney failure, heart failure, stroke, erectile dysfunction, and others.
Types of Diabetes Mellitus
There are two accepted types of Diabetes mellitus:
Type One: This used to be called child onset Diabetes, because it was found mostly in young children and teenagers. This understanding is now revised to include any age. The underlying problem in Type one is the absence or deficiency in the release of insulin from the pancreas. This problem can be genetic in origin. This results in the inability to stimulate the insulin receptors and the consequent decrease uptake of sugars from the blood.
The management is insulin replacement. The injecting of insulin at the appropriate doses to achieve the normal blood sugar level that prevents an abnormal glycosylated red blood cell or HbA1C level.
Type two: This used to be called adult-onset Diabetes but now that label is revised because of the rising prevalence of type two diabetes in the younger population. In type two diabetes, there is an overwhelming release of insulin by the pancreas in response to food or because of chronic high ingestion of simple sugars. This chronic high level of insulin release now constantly stimulates the insulin receptors and lead to their desensitization, sort of a numbing of the receptors, and the consequent decrease in response by the insulin receptors. This situation is a sort of paradox, whereby amid excessive insulin, the receptors are now rendered unresponsive, resulting in the accumulation of sugar in the blood and the increase in the level of HBA1C.
The levels of insulin released by the pancreas has a genetic predisposition and explains the strong family association in the prevalence of Diabetes.
Nature and Nurture
It has been demonstrated that there is both a genetic (nature) and /or environmental (nurture) factor(s) in the likelihood of developing diabetes Mellitus. While we cannot change our genetic makeup, we can control or regulate our environment.
Decreasing the prevalence of Diabetes mellitus:
Nature: There is a growing call for screening/family history before marriage or childbearing. This is important to not only recognize the increased risk for Diabetes mellitus in children of high-risk marriages or intended childbearing, but also for other genetic diseases. This can be part of marriage counselling offered by our masjids. We can provide an early understanding of the risks and advice on mitigating the risks. While our marriage counseling mostly concentrates on Faith and relationship issues, it must be recognized that potential health issues can affect the success of marriages and positive social outcomes.
Nurture: It is within our control to shape our environment (nurture) to fulfil our desired outcomes. This is not withstanding the suffocating trend in our society and environment to redefine normalcy in lifestyle and nutrition. The food industry as well as poverty have collaborated to influence, if not engineer the rising pandemic of Diabetes Mellitus.
Lifestyle: Today’s modern society encourages a sedentary lifestyle. This lack of physical activity especially walking, and the resulting loss of muscle mass can affect the overall population of insulin receptors. Also, it is known that physical activity increases the sensitivity of the insulin receptors and promote the lowering of blood sugar.
Recommended: the use of light weights to build or strengthen muscle mass in addition to moderate walking for about 30 minutes every day or the use of a stationary bike for about 30 minutes every day. Children of Diabetics should be involved in regular physical activity /exercises as early as possible and be trained to maintain this as a permanent lifestyle.
Nutrition: it’s unfortunate that our food supply is at the mercy of profits first and nutrition last. Growing urbanization and population density have placed a great burden on food supply and its appropriate quality. The driving force behind food supply shifted from health maintenance to hunger alleviation. Quantity over quality! This shift correlates with the prevalence and the pandemic of Diabetes Mellitus (type two) and obesity, with the rising morbidity and mortality that ensued from the complications of Diabetes mellitus.
Recommended: Education from childhood about the right approach to nutrition. This should be taught in schools (countries such as Japan have already started this on a massive scale) and must become an essential part of the school syllabus and not just an adjunct and casual topic. Our Islamic schools can take the lead in providing nutrition as an ongoing part of the overall syllabus required for graduation.
Diabetics must be taught about portion control, volume of food ingested per meal. This important fact has been emphasized by the last Messenger. Muhammad (Peace be upon him), who advocated that our stomach after a meal should consist of one third solid, one third liquid and one third of air. The total caloric intake of a diabetic meal should not exceed 400 to 500 calories, with a total daily intake of 1500 to 1800 calories (based on level of physical activity). Meals should not include sugars or simple carbohydrates, hydrogenated saturated fats, but rather consist mostly of green vegetables, high fiber foods and lean meats (figure 4).
The glycemic index table should be the guide to selection of foods. The glycemic index table should be printed and posted in every kitchen. The glycemic index table can be obtained on a simple google search
Fig.4. Example of a diabetic meal
Regular and frequent eye examinations, foot care and kidney function screening are all essential to facilitate early detection and treatment of complications to prevent disease progression. The most important screening is the HbA1C which must be kept under 7. It is strongly recommended that every diabetic should be taking a small dose of an ACE inhibitor, such as Lisinopril (discuss this with your doctor which medication in this class is suitable for you). The research and evidence point to a high protective effect on the kidney by using one of this class of medications.
Conclusion
There is no medical treatment or cure for Diabetes Mellitus. Our intervention is one that is directed at management of blood sugar, that is HbA1C and the complications that can arise from a high level of HbA1C.
The management of high blood sugar is underscored by two principles: Prevention through appropriate lifestyle and nutrition, and medical intervention through drugs that help to lower blood sugar.
Fig.3. Gangrene from uncontrolled diabetes mellitus
On a social level, there must be consorted effort in our communities to educate about this growing pandemic of Diabetes Mellitus, and to secure more efficient and effective access to medications and screenings. Diabetes mellitus is not just a health issue but also a social problem.
