Diabetes is a chronic condition characterized by high blood glucose (hyperglycaemia). There are different types of diabetes, including type 1 diabetes, type 2 diabetes, monogenic diabetes, gestational diabetes, and other types of diabetes. Each different type of diabetes will require different treatment plans.
Type 1 diabetes is an autoimmune condition where the body produces abnormal antibodies that damage insulin-producing cells in the pancreas. This leads to insulin deficiency and high blood glucose. People with type 1 diabetes will require insulin injections to replace their own natural insulin.
Type 2 diabetes is a multifactorial condition that results from lifestyle, genetic, hormonal, and age-related factors. This is the most common type of diabetes and is generally treated with oral medications. However, some people with type 2 diabetes may require insulin or other injectable treatment if they cannot achieve adequate control with oral medications alone.
Monogenic diabetes is caused by mutations in a single gene that is involved in glucose metabolism. This results in high blood glucose and may require different treatments depending on the types of genetic mutation.
Gestational diabetes is diabetes that occurs during pregnancy. However, many people may have undiagnosed type 2 diabetes before their pregnancy, and it is important to differentiate between these two conditions as the treatment and pregnancy outcomes can be very different.
An excess of glucose in your blood can lead to other health complications in the long run. This is why diabetic patients have to take steps to manage their disease and stay healthy.
What are the affects of diabetes on your health?
When the blood glucose level in the body is very high, people with diabetes will experience an increased thirst, hunger, frequency of urination, weight loss, and lethargy. Untreated, this leads to dehydration and occasionally diabetes emergencies such as diabetic ketoacidosis (DKA) or hyperglycaemic hyperosmolar state (HHS).
On the other hand, many people with diabetes do not experience any symptoms when their blood glucose is elevated but not high enough to cause dehydration. These people are often diagnosed during blood tests. However, even without any symptoms, diabetes can still cause long-term adverse effects on health. The commonly seen complications of diabetes include heart attack, stroke, blindness, kidney failure, liver failure, and lower limb amputations. Other long-term complications also include an increased risk of cancer, sexual dysfunction, skin-related conditions, bone fractures, mental health-related complications, and many more.
During pregnancy, diabetes can increase the risk of miscarriage, fetal malformation, and complicated childbirth. During an intercurrent illness such as COVID-19 infection or surgery, diabetes increases the risk of hospitalizations, prolongs the duration of hospitalizations, increases the risks of surgical complications, and increases the risk of death due to the illness or surgery.
Testing & diagnosis
There are several ways to screen for diabetes. The most used method is by measuring plasma glucose level from the venous blood. This can be done either after an overnight fast, or at any random time, even after a meal.
An increasingly common method to screen for diabetes is by using the HbA1c test. The HbA1c test is not affected by fasting states, meals, or intercurrent illnesses, and can be done at any time of the day.
A single reading of high plasma glucose or high HbA1c level will require a repeat test to establish the diagnosis of diabetes in the absence of an established diabetes complication. In the presence of diabetes symptoms, overtly high glucose or HbA1c levels, or established diabetes complication, a single test is sufficient to confirm the diagnosis.
Oral glucose tolerance test (OGTT)
Oral glucose tolerance test (OGTT) is now less commonly used as a diabetes screening test in non-pregnant adults. However, in some people whose HbA1c test may not be reliable (for example during pregnancy or anaemia), OGTT may still be needed to diagnose diabetes.
Who should be tested for diabetes?
You should get tested for diabetes immediately if:
• You have symptoms of diabetes (increased thirst, increased urination, lethargy, or unintentional weight loss), or
• You are diagnosed with any complication of diabetes, or
• You are pregnant
You should get tested every year if:
• You were previously diagnosed with pre-diabetes
You should get tested every 3 years if:
• You are more than 35 years old, or
• You were previously diagnosed with gestational diabetes, or
• You are living with HIV
In the absence of the above, you should get tested every 3 years if you have BMI > 23 kg/m2, or a waist circumference more than 80cm (women) or 90cm (men) with:
• An existing cardiovascular disease, or
• A family member with diabetes, or
• High blood pressure or high cholesterol, or
• A birth weight of > 4kg, or
• A history of maternal diabetes during pregnancy, or
• Sedentary and inactive lifestyle, or
• Existing hormonal disorders are known to cause diabetes, or
• Concomitant medications are known to cause diabetes
In summary, you should get tested for diabetes if you are 35 years old or older, even in the absence of other risk factors. In the presence of risk factors for diabetes, testing should start even earlier.
Pre-diabetes is a transition state from normal glucose level to abnormal glucose level. It is diagnosed using glucose levels from the venous blood, HbA1c test, or the oral glucose tolerance test (OGTT). People with pre-diabetes are at high risk of developing type 2 diabetes and should be tested regularly every year.
The progression of pre-diabetes to type 2 diabetes can be prevented with lifestyle modifications, including diet, exercise, weight loss, and occasionally using medications. If you are diagnosed with pre-diabetes, please discuss with your diabetes team the most suitable way to prevent the progression of diabetes.
Diabetes Care Team
The diabetes care team consists of your:
- Diabetes nurse educator
- Mental health specialist
- Other specialists that look after specific diabetes complications
Treatment of diabetes, when provided by the diabetes care team, has been shown to be more effective as compared to when treatment is provided without a dedicated team.
Diabetes Treatment & Monitoring
Treatment of diabetes will vary depending on the types of diabetes and other coexisting medical conditions. For example, people with type 1 diabetes will require insulin treatment, whereas people with type 2 diabetes will require oral medications with or without injectable treatments depending on their needs.
Regardless of the type of diabetes, there are three core areas that will be covered in your diabetes treatment plan:
- Multifactorial intervention: Treatment that lowers HbA1c, blood pressure, cholesterol levels, smoking cessation and body weight management have been shown to reduce the risk of diabetes complications. Medications that have been directly shown to reduce the risks of diabetes complications are generally preferred.
- Complications screening: Some diabetes complications, such as eye, kidney, liver, and nerve complications can be diagnosed, prevented, and treated early with screening tests that include regular eye examinations, kidney and liver function tests, urine albumin tests, and foot examinations.
- Diabetes self-management: People with diabetes who make better day-to-day decisions on their food choices, exercises, sleep, stress management, medications, and blood glucose monitoring will have a lower risk of high blood glucose (hyperglycaemia), low blood glucose (hypoglycaemia), and hospitalizations. The diabetes care team will provide continuous education and support for people with diabetes to overcome the daily challenges of living with diabetes
How do I monitor my diabetes treatment?
The most important test used to monitor diabetes treatment is the HbA1c test. This is a test that measures the average glucose control over the past three months.
HbA1c test should be performed at least every 3 months in people whose glucose levels are not yet controlled, and at least every 6 months in people who have achieved treatment goals.
In people who are using insulin, home blood glucose tests are also recommended to adjust insulin doses and to monitor for hypoglycaemia.
People with type 1 diabetes and some people with type 2 diabetes may also be offered a continuous glucose sensor to monitor their home blood glucose.
Blood pressure should be measured during every clinic visit, but home blood pressure measurements have been shown to be more accurate at predicting the risks of complications and adjusting blood pressure-lowering treatments. Similarly, body weight should also be examined during every clinic visit.
People with diabetes may experience weight loss or weight gain due to the effects of lifestyle modifications, medications, or poorly controlled diabetes itself, and the diabetes care team will address these concerns accordingly.
Other tests that will be done on a regular basis include cholesterol level, kidney and liver function tests, as well as urine albumin test. These tests will be done at least once a year, or more frequently if the results are abnormal.
On top of the usual examinations and lab tests, your general well-being is also important.
Therefore, the diabetes care team will also assess your physical well-being, coping mechanisms, lifestyle changes, and mental health on a regular basis throughout your follow-up.
Is insulin treatment dangerous?
Insulin treatment can potentially cause hypoglycaemia, but insulin treatment is also crucial for people with type 1 diabetes, people with type 2 diabetes who are not controlled with other medications, and pregnant mothers with diabetes.
The most important step to mitigate the risk of hypoglycaemia in people who are treated with insulin is by monitoring glucose levels at home regularly.
People with type 1 diabetes may also be offered insulin pumps, or automated insulin delivery systems to help with their insulin treatment.
If you require insulin treatment, your diabetes care team will advise you about the most appropriate way to monitor your glucose levels at home.