Published January 5, 2020
Dr Olayiwola Bello is a family physician and the Chief Medical Director of SUBOL Hospital, Lagos. He talks to ALEXANDER OKERE about the management and treatment of diabetes as well as the conditions that could lead to amputation
What is diabetes?
Diabetes mellitus is a condition where there is lack of insulin in the body. This manifests with the blood sugar level being consistently high. This is as a result of inadequate insulin in the body or the ineffective nature of existing insulin.
What are the types of diabetes?
There are two types: the juvenile onset or insulin dependent type and the other one is called the adult onset or non-insulin dependent. The second one, which we call Type 2 diabetes, is the most common one. In fact, about 70 or 80 per cent of the cases of diabetes in this country are the Type 2 diabetes. It cuts across different states but I think Lagos State records about six to eight per cent prevalence rate now and I think the national average is about eight to nine per cent.
What is worrisome about the incidence of diabetes is that what is recorded is the tip of the iceberg because there are people out there who have diabetes but are unaware, and even their doctors don’t know about it. It means that what we have (documented) is less than what is out there.
What are the early signs of the disease?
In children, the common signs are that they start drinking water and urinating excessively. That is the classical presentation common in children. But the unfortunate thing about diabetes in adults is that it is often not symptomatic. Adults may just complain of weakness of the body and find that their blood sugar is very high after a blood test. Sometimes, when a pregnant woman is delivered of a large baby, the woman could be suspected to have diabetes. So, it is important to screen them.
Also, there could be recurrent boils and after treating with antibiotics, the boils go and later return. If someone has a relation that is diabetic, we always watch out for them because it is common in families.
How can diabetes be properly diagnosed?
It is quite easy to diagnose. Once you check your blood sugar level in the morning before you eat, if the level is above 126 mg per decilitre, you have diabetes without any question. But if it is less than 110, then you don’t have diabetes. However, you would have to be screened because there could just be what is called pre-diabetes; if you are between 110 and 126, we will not label you. We may even subject you to further tests to confirm that you have diabetes. But if the blood sugar level is above 126 and you have not eaten anything in the last eight to 12 hours overnight, then it is diabetes?
Apart from children, pregnant women and adults, what other category of people are most likely to develop Type 2 diabetes?
Obesity is another precursor; people who are obese have insulin resistance, so they are easy candidates for the development of diabetes. The development of diabetes doesn’t come as a result of the consumption of sugary beverages. There is no age limit, when it comes to diabetes. Once you are an adult and you have the genetic disposition, you can have it.
What are the health problems that result from the disease?
We are always concerned about early diagnosis which gives a chance in the prevention of target organ damage. There are certain organs of the body that are vulnerable. If you have diabetes, your retina (the eye) is at risk. The brain is at risk of stroke. The heart is at risk of heart failure. The kidney is at risk, there is the risk of kidney failure and, importantly, the legs are at risk. There is what is called the diabetic foot and it is a common cause of amputation in Nigeria and around the world.
If you go to (the National Orthopaedic Hospital,) Igbobi today, and you go the ward where amputation is done, you will find out that two out of three people who have had amputations had diabetes; only one may be as a result of road traffic accident or industrial accident. That tells you that one of the common complications of diabetes is the diabetic foot and it often leads to amputation.
Is amputation preventable?
It is preventable with good treatment. All the complications are preventable with good treatment.
Amputation is one of the worries of diabetic patients and their loved ones. Is amputation avoidable when a patient sustains an injury or a wound in the lower limbs?
What we emphasise is that anybody diagnosed with diabetes must listen to their health care provider because diabetic foot care is very important. You must prevent wound or injury because diabetes has an effect on two major things in the body: the nerves and the blood vessels that carry blood to the legs. Diabetes damages these two parts of the body. It damages the nerves such that when you put your leg on fire, nail or needle, you may not even be aware because you cannot perceive pain again. That is how injury occurs without the knowledge of the injured diabetic patient.
Also, if the blood supply to the affected part is compromised, then the wound or injury is not likely to heal. But once you control your blood sugar level well, your chances of damaging the blood vessels are reduced to prevent leg ulcers. But the truth is that when leg ulcer occurs, if it is adequately and promptly treated and the blood sugar is under tight control, the damage suffered by the veins, arteries and nerves is reduced, unless there is a major blockage of the blood vessels. Foot care is important to prevent wounds and amputation ultimately.
When is amputation inevitable?
A vascular surgeon could do a reconstruction that will allow blood to flow to the affect area. We have vascular surgeons but they are very few in Nigeria and the cost of a vascular surgery is high. But if a major vessel has been blocked and there is no way the blockage can be circumvented, then there will be no other option but to amputate. When a doctor, who has done due diligence, comes to the conclusion that amputation is the best option, if that is not done, the patient may lose their life. Loss of life is what we want to prevent. One can live without a leg, though efforts should be made to prevent amputation as much as possible. When the blood vessels are blocked, they make amputation inevitable.
What are the treatment options for diabetes?
There are various drugs for the treatment of diabetes mellitus. I must also point out that there are certain conditions where such drugs may not work. In such conditions, insulin will have to be injected. For instance, during pregnancy, it is not safe to use some of the drugs, so pregnant women have to be given insulin injection and if there are certain infections, the drugs won’t work. But by and large, tablets are administered for most cases. However, one tablet may not be able to give the patients adequate control of their blood sugar level; there are various drug combination that can be used and are effective.
What are the healthy habits Nigerians can adopt to prevent or manage diabetes?
Patients are advised to monitor their blood sugar at home and visit hospitals at regular intervals for doctors to do other investigations to make sure the patients are on course. Once diagnosis of diabetes is done, the first thing we talk about is lifestyle modification and that starts with your diet. We advise diabetic persons to avoid alcohol, cigarettes and take a lot of fruit and vegetables. In fact, with dietary control, people with mild diabetes mellitus can get good control of their blood sugar level. But people that fall into that category are very small. Exercise also helps in controlling the blood sugar. When your physical activities are low, your blood sugar level tends to be high.
Are bitter herbs helpful in the prevention of diabetes?
I don’t believe they are, as an orthodox practitioner. But that is not to say that there are certain leaves that people use that can control blood sugar and not prevent diabetes. Preventing diabetes is different from blood sugar control but such leaves act as tablets or injections. Also, bitter leaves are capable of reducing blood sugar level.