World Diabetes Day: Diabetes has caused more amputations than trauma, Dr Aremu discusses disease

In this interview with Funmilayo Aremu-Olayemi, Chief Consultant of Orthopaedics at the Federal Medical Centre, Jabi Abuja, Dr Ganiyu Aremu, speaks on the treatment and management of Diabetes. 

Why do you think diabetes is still prevalent in Nigeria with the advancements in health?

Diabetes is a disease of lifestyle, to a large extent. Even though a large percentage of Diabetic patients have a genetic basis for it. But there are ample proportions that develop their diabetes as a result of their lifestyle.

There are what we call modifiable risk factors, risk factors that, if you take care of and modify them appropriately, you can limit the way people can come up with certain diseases. 

Diabetes is one of those diseases that some factors, if well handled, will ensure that somebody does not develop it. Such factors as obesity. 

I'll mention that as number one. Because it's known that people who are oversized have a body mass index above a certain level; the normal body mass index is 18 to 25. 

Once somebody has a body mass index over 25, they may have what we call metabolic syndrome. One of the sequelae of metabolic syndrome is glucose intolerance. 

Of course, glucose intolerance is nothing but diabetes. So, the prevalence of it that appears to be rising in society actually can be traced to our change in lifestyle. 

 A lot of people now take to Western diets, eating refined foods, all kinds of snacks, all kinds of burgers, and what have you. We are deviating more from nature towards all these refined things. So I think that is one important factor. 

Other factors include heavy drinking, even smoking has been known to be a factor. Then, people who have extremely poor backgrounds, which is also facing us in Africa. 

In children who are entirely fed on cassava-based food, the hydrocyanic acid, the so-called cyanide in the cassava, has been known to destroy people's pancreas. You know, the pancreas is a source of insulin. If a sufficient volume of the pancreatic tissue is destroyed, the person can come up with diabetes as a result of insulin insufficiency. 

By and large, the type of diabetes that we have in society now, the more common type, is actually the one that results from resistance to insulin. The patient has an adequate amount of insulin in the body, but the tissue in the body is not sensitive to the insulin. 

And one of the reasons why somebody can have such insulin resistance is the metabolic syndrome I have spoken about. So, lifestyle is largely one of the reasons. 

Has there been any input from the government in fighting diabetes in any way?

Well, the only input I will say is health education, which I would say the government has not been doing enough of. Public enlightenment, campaigns, and all that. That's one aspect to be done, even from the grassroots level to the highest level of hospital, from maybe primary head centres, general hospitals, comprehensive health centres, general hospitals, and partially health centres. The campaign for public awareness about this has been very suboptimal. 

Currently, would you say more people are developing diabetes? 

 I think so, due to the factors I mentioned. Even though we shout that the country is poor and all that, a lot of people are adopting more of a Western lifestyle—eating refined foods, drinking alcohol every now and then, etc. 

What lifestyle changes can help control sugar levels?

Exercise. Exercise. Exercise. It's very important. Ensure that your body’s mass index is within the normal limit. Minimise your intake of alcohol and refined sugars and sugary foods. These are some of the measures that can help mitigate that. 

What are the latest advancements in diabetes treatments and management? 

There are many, lots of new drugs that are more effective than the traditional ones that we used to use in the past. Glucometers are now virtually everywhere, and most diabetic people have a glucometer at hand. It wasn't like that in the past. 

Having a glucometer means that you can wake up in the morning and check your blood sugar. After the day's work, you can check your blood sugar level, and you can help yourself,  to help your doctor better in caring for you. There are also a lot of new drugs that are more effective than the older ones.

How does diabetes affect other parts of the body, and what complications can arise if it is not well managed?

Diabetes is a systemic disease. This means that it can affect any part of the body. Basically, when the blood level of sugar is increased, it can have secondary effects on blood vessels; there are deposits of certain substances in the blood vessels that make them narrow. 

This can happen to blood vessels that go to any organ in the body. People with diabetes mellitus have been known to develop chronic renal disease. In fact, it is very common. 

Anybody with Diabetes Mellitus going on five to 10 years should check their kidneys constantly because one of the first organs to pack up is the kidneys. It can affect the brain. 

There is what we call angiopathy. It can be microangiopathy or macroangiopathy, but angiopathy is a disease of blood vessels. Microangiopathy means those tiny blood vessels, the venus, the capillaries, and the arteries that supply blood to sensitive parts of the body, the brain inclusive, can completely shut off. 

If blood flow to a particular area of the brain is cut off, that part of the brain will die. It undergoes what we call Necrosis, and when that happens, the patient develops a stroke. With Stoke, we have Haemorrhagic stroke and Thrombotic stroke. 

Thrombotic stroke is very common in patients who are diabetic. Whereas Haemorrhagic stroke is common in patients who are hypertensive. So, it can also affect the lower limbs.  

Of course, as an orthopaedic surgeon, I have had cause to amputate more legs from diabetic complications than from trauma itself. So, most of the time, they come with diabetic foot ulcers. 

There are a lot of other issues, and apart from a reduction in blood flow, the immunity of patients with diabetes is reduced, and blood flow to their vital organs is reduced. The fact that their immunity is reduced means that if there is an infection, it will not heal on time, and the infection has the propensity to spread. 

So, and that's why a lot of them will come with athlete foot, simple athlete foot that you would just sprinkle anti-fungal powder and it will heal up, but in diabetic patients, it will not go, and before you know it, the limb will become dead, and the gangrene will start spreading. 

Once the limb is dead, to spare the life of the person, we have to cut off the limb. I have had to do that for a lot of patients. 

Now, there are so many complications. What about sight? Diabetes is one of the things that can cause loss of sight. Corneal Opacity: Certain things can get deposited in the eyes' lenses. Before you know it, there will be visual impairment, there could be cataracts. 

Apart from that, even the blood supply to the retina, which is the sensitive part of the eye that receives the information that you look at the surroundings, can suffer inadequate blood supply and get detached, or some of the cells in the retina will die, further reducing visual acuity. So, you can think of any organ from head to toe, diabetes can affect it. 

Does genetics play any role in the development of diabetes?

 A lot of roles. Type 1 diabetes mellitus is largely genetic. I mean, type 1 means people develop their diabetes most of the time in childhood, some people from 10 years to 15 years old. 

Most of the time, type 1 diabetes patients develop the disease when they are under 40. Genetics have been known to play a vital role, and it usually runs in the family. Type 2 is also, to some extent, genetic, but lifestyle changes are associated more with type 2 than type 1.

What preventive measures can be taken to reduce the risk of developing type 2 diabetes? Apart from the exercise that you mentioned.

Exercise, reduce alcohol intake, eat minimally, and eat healthy, balanced diets. Not carbohydrates always. You can do a mix of carbs, protein, vegetables, and all that. Then, regular checks.

How does gestational diabetes impact pregnancy, and are there any long-term effects on both mother and child?

Yes. The major problem with gestational diabetes is people who have gestational diabetes actually have latent diabetes. They are more or less diabetic, but it's not clinical. 

So, when they now become pregnant, the stress of pregnancy kind of tips it over. Now, the major problem they usually have is what we call macrosomic babies. Their babies become very big, and macrosomic babies are usually healthy. 

Then apart from that, people always say that diabetes and hypertension are like twin brothers. So, alongside that, the same patient can also develop hypertension with all the associated issues with it. A certain percentage of people who have gestational diabetes almost always will go on to develop full-on diabetes even after delivery. 

What are the early signs, the early warning signs and symptoms of diabetes that people should be aware of?

Most of them start with poly. Polydipsia means a person is feeling thirsty all the time and drinking water all the time. Then, in Polyphagia, a person is eating too much. Eat heavily now, and in another two hours, you're feeling hungry again. That's eating too much. 

Then you also have Polyurea; frequent urination. Those are the classical features of diabetes. So, if somebody realises that some of these things are happening in a subtle manner, it is better for the person to go and check. Those are the early signs: excessive thirst, excessive drinking of water, excessive urination, then excessive eating.

What happens if the person does not get checked or get diagnosed on time? 

I mean, if diabetes is not diagnosed on time, some of those complications that I mentioned actually occur when diabetes has been in the body for a long time. And for a lot of people, the first thing that would call their attention to the fact that they are diabetic is a complication. 

You see, I've had several patients that come with a bad leg ulcer, and when we check their blood sugar, we realise that they are diabetic. And when we ask them, “Are you diabetic?” they say, “No, I've never been diagnosed; nobody ever told me that I was diabetic. 

So, the first ever symptom they will have will be a complication. Either sight problem, kidney problem, sometimes stroke or chronic leg ulcer that refuses to heal. 

What is the rule of insulin therapy in diabetes management, and how is it administered?

Insulin is actually an endogenous substance that our body produces. The other time I mentioned is the pancreas. There are certain cells in the pancreas we call beta cells in the islets of Langerhans. That is where insulin is produced, and every normal human being should produce an adequate amount of insulin to handle the metabolism of carbohydrates or protein or fat and oil. 

Insulin plays a role in the metabolism of all these substances. So, as I said earlier, there are two types of diabetes. The type one insulin is not even produced at all. For whatever reason, it could be genetic, it could be the fact that the disease has destroyed the pancreas. 

Tuberculosis is one disease that is known to destroy the pancreas. The pancreas can become fibrotic because of the toxic effect of diet. I mentioned cassava the other time. Apart from that, some people have an inherited tendency towards pancreatic destruction, so that the pancreas will not even produce an adequate quality of insulin or would not even produce any at all. 

For those patients with type one diabetes, there is no other treatment that you can give them other than insulin, and it does not exist as tablets; it must be given as an injection. 

Usually, what we do is titrate their insulin needs based on blood sugar. As we are giving them insulin, we monitor the blood sugar until it gets to a level of insulin that adequately controls the blood sugar. Then we leave them on that, teach them how to give themselves at home and how to monitor their blood sugar. That is for type one. 

For type two, a lot of them have insulin, but like I said the other time, resistance of their tissue to insulin. Some of them even have more than enough insulin. 

So, what we give them is usually drugs that will improve the sensitivity of their tissues to insulin and also encourage insulin to act on those receptors that it is supposed to act on. However, for those patients with type two, we don't give them insulin; we give them oral hypoglycemic drugs - drugs that reduce blood sugar. 

Now, of course, there are many different types of drugs. Now, when those people with type two diabetes have complications, like diabetic foot ulcer, kidney problems and all that, we tend to encourage them to go back on insulin. Because insulin is a growth factor. It encourages the growth of tissues, you understand. 

So, if somebody has an ulcer that is not healing, whatever type of diabetes, whether type one or type two, or a patient undergoes surgery, and you want the wound to heal on time, that patient must be on insulin. So, insulin is a very important substance in the management of diabetes. 

What are the financial costs associated with diabetes management, and how can patients, in your opinion, access affordable care in Nigeria?

To be honest, it exacts a lot of financial burden on the sufferers. Especially when the patient has to be on insulin, monitor blood sugar, and do all that. With the current state of the economy of this country. That's why we have a lot of problems: a lot of them default in their management due to a lack of funds or the inability to access health care.

How many towns have hospitals with comprehensive health care? Not many. So, I mean, assessing health care in standard private health establishments is quite costly. The financial burden can be quite enormous. 

When complications develop, it becomes a bigger problem because, at that time, some patients need dialysis. A session of dialysis presently goes as high as N100,000 in a week. How many people can afford that? That is why we encourage people to be proactive in taking care of their health. Ensure that you prevent it because prevention is easier, better and cheaper than cure. In any way, Diabetes is not curable. 

Do you think advancements in treating and managing diabetes can ever reach the level where it can be cured?

It can advance to that level; we don't know what happens tomorrow, but for today, there's no cure. Anybody who is diagnosed with diabetes has to be on treatment and monitoring for life. 

What is the impact of diabetes on children or adolescents?  Do they have these same complications as well?

All of them. I've had patients in their 20s developing diabetic foot ulcers that I've had to amputate. 

Does diabetes in any way interact with other chronic conditions and affect the body in a negative way?

 We always say that hypertension and diabetes are like evil twins. When the patient is diabetic, within three to five years, hypertension will set in almost always. The reason is because of the angiopathy that I mentioned earlier. 

Hypertension and blood pressure are products of cardiac output and peripheral resistance. Cardiac output refers to the way the heart pumps out blood, and peripheral resistance refers to the resistance of the blood vessels to the flow of blood. 

Diabetes mellitus increases peripheral resistance because of the narrowing of blood vessels. So, it doesn't allow the blood to flow through it, which is what we mean by resistance. It increases the resistance of blood to flow, so that tends to push up blood pressure. Such that most patients who are diabetic are also hypertensive. And, of course, they are evil twins. 

Hypertension can cause angiopathy stroke, diabetes can cause stroke. So, synergistically, they can work together to end the life of the patient in no time.

What are the benefits and limitations of using alternative therapy and supplements for the treatment of diabetes? You've probably heard of people selling all these supplements, so what are the benefits and limitations of using alternative therapies and supplements?

I am not an alternative medical practitioner. Therefore, what I will say is that in my own little experience, what I have noticed is that each time you are treating a patient with diabetes, they default, they don't come to the clinic. They come back later to say, “I have one drug I am using, and it's helping me, blah, blah, blah.” They are putting their health at significant risk. 

Many times, when they come, and we check their blood sugar, it will be hitting the roof, and before you know it, by the time they come back, they come back with complications, life-threatening complications, which sometimes can take their life. 

So, all those alternatives, herbal drugs, supplements and all that, I will tell you categorically, they don't work. Once a patient is diagnosed with diabetes, the patient should stick to his or her drugs and lifestyle modifications. Avoidance of certain types of diets is especially helpful, rather than relying on some panacea that is not scientific or proven. 

Does increased stress affect blood sugar levels?

Absolutely. With stress, there are some hormones we call counter-regulatory hormones in the body. You have cortisol. The level of cortisol goes up with stress. You have glucagon. The level of glucagon goes up in the blood. And a few other hormones, even adrenaline.  

All these hormones are counter-regulatory hormones because they directly counter the effect of insulin to push up blood sugar in preparation for fight or flight. Because they are called fight and flight hormones, which, I mean, somebody on that stress is always prepared for either a fight or flight.  

When you have continuous stress, persistent stress, over a period of time, even somebody who was not diabetic before can become diabetic. 

In your professional opinion, how do you think people who are diabetic without complications can prevent the complications from arising?

Maintenance of normal blood sugar. They should ensure that at all times, their blood glucose is within normal limits, which is between 3 millimoles and 6 millimoles of 6.5 millimoles per litre (mmol/L). 

Once fasting, blood sugar goes to 7, 7.5, and 8. The patient should know that he’s not controlling himself well. Sometimes, patients will come, and their blood sugar level will be reading 22 or 25. it should be maintained within that narrow limit of 3.5 to 6.5 mmol/L.

Does sleep quality in any way impact diabetes management?

Yes. Sleep is directly linked to stress. If someone is not sleeping, the system is under stress. Some of those counter-regulatory hormones I mentioned will have high levels, which would make it more difficult to bring blood sugar down with whatever drugs you are using. 

How can technology - the use of mobile apps, AI, and telemedicine, enhance diabetes management?

You can set reminders on your phone to check your blood sugar level. You can have charts to record your blood sugar levels and graphs that show when there’s a spike in your blood sugar level. Patients can also have information from the web. 

People find it easier to access information through their mobile phones than reading textbooks and all that. I think in those ways, of course, it also has a role to play.

Does living a sedentary lifestyle also predispose to having diabetes?

When you live a sedentary life, what it means is that you're not burning glucose. You're not burning your fats. So, you need more insulin to push them, and once insulin rises to a certain level, tissue may become resistant to it. So, a sedentary lifestyle is a no for anybody.

How do you think the government can contribute to the fight against diabetes?

Ensure that hospitals are available, well-manned and well-equipped. In every ward, not even local government, primary health centres, and comprehensive health centres, community health workers are well-trained in matters relating to diabetes. Very important. Because these are the people that patients will go to. 

How many people have direct access to doctors? But the community workers are everywhere in the neighbourhood. So, they should be well-trained and well-educated. 

Government should, if possible, organise workshops from time to time about non-communicable diseases and how to handle them. Diabetes falls under non-communicable diseases. 

So, diabetes, hypertension, obesity and all that. They should be part of what should be taught adequately to these people. When people in the community visit them, they are the first point of call for our people, and most of the time, they are the first and the last. 

People don't go beyond them because when they get to the hospital, there are no doctors in the hospital. Sometimes, they don't even have the money to go to a private hospital. So, I think education and enlightenment are key.

How can people use that device to monitor their blood sugar levels at home? How does it work?

It's a gadget. It comes with a lancet, which is like a very tiny needle. You prick your finger, the tip of your finger, and you squeeze out just a drop of blood onto the sensitive strip that is plugged into the machine. 

By capillary action, that blood will move into where the photospectrometry gadget is, and that will read the blood sugar level. For fasting, before the person eats in the morning, the value should be 3.5 to 6.5mmol/L. At no time should it be more than 11.1 mmol/L. Anything above that is abnormal. There are two values. 

We use milligrams per dl. We also use millimoles per litre.  If you want to convert the mmol/L to mg/dl, you multiply by 18. So, absolute level, whether you are fasting or not, once you see more than 200 mg/dl, which is 11 mmol/L, the patient is diabetic.