Unfortunately diabetes is a very common disease in our society. It was recently estimated that there were over a million diabetics in Australia with about 87% of those being Type 2 diabetics and 10% Type 1 diabetics. There are probably another 700,000 Australians who have diabetes and don’t know that they have the disease, and for every known diabetic there are three who have pre-diabetes of which half will eventually proceed to full blown diabetes at some stage.

Another worrying fact is that indigenous Australians are two to three times more likely to develop this condition and, when they do, it is generally at a younger age. The estimated cost to our community is somewhere in the order of $10 billion dollars. Type 1 Diabetes refers to diabetes requiring insulin injections right from the beginning as the body is unable to produce any of the hormone insulin to keep the blood sugar or glucose level down. Type 2 Diabetics, which I will concentrate on, can initially produce insulin and hence the treatment doesn’t initially require insulin, but it may be needed later after diet, exercise and the various medications have failed.

The male to female ratio is slightly higher for males at 5:4, mainly due to the higher incidence of midlife obesity in males. That excess beer-gut or ‘roof over the tool shed’ is a sure-fire sign of impending diabetes. I call it the D sign – D for diabetes. Stand side on to a mirror and if you look like the letter D because your gut is sticking out then you are probably prone to developing diabetes. I also thought up the Double D sign which also increases your risk of diabetes. Double D stands for the Disappearing Dick. When starkers, put your chin on your chest, look down and if you can’t see your dick you are Double D positive and more at risk of developing diabetes. But no cheating with this one as I can see a few of you blokes playing with yourselves to bring your old fella into view. If it still doesn’t come into view with this then you are officially DED – Disappearing Erect Dick positive and in a lot of strife! Amidst this doom and gloom there is the wonderful figure that 60% of Type 2 Diabetes can be prevented … by lifestyle change!

If you develop diabetes, the sugar or glucose level in the blood is high and that sugar or glucose is not readily usable by the body. It is trapped in the blood stream. It can’t be used as fuel because of problems with the hormone Insulin which comes from your pancreas which is near your stomach. Insulin is required to lower the levels of sugar in the blood but it is either absent or not working properly. The main role of the pancreas is to squeeze out dissolving juices into the bowel after a meal is eaten to digest mainly proteins, but also fats and carbohydrates. Its other role is to produce the hormone Insulin. The main role of Insulin is to tackle and round up the floating glucose molecules in your blood stream and push them into the body’s cells, mainly muscle cells, so it can be used by the cell as a source of energy.

Glucose is the purest form of carbohydrates or ‘sugars’ and is the main fuel used by the body’s cells for energy, and it comes into our diet in a lot of different forms. It is easily recognisable as sugar in the sugar bowl or the sweetness of a soft drink. But it is also present in a more complex, tied-up form in foods such as rice, pasta cereals, and starchy vegetables. It is also part of lactose in milk and fructose, or fruit sugar. When foods containing glucose molecules are digested, the food is broken down into its individual glucose molecules, they are absorbed from the bowel and then they are released into the blood stream. This surge of glucose into the blood stream causes Insulin to be released by your pancreas to herd the glucose molecules into the cells to be used as energy. If this doesn’t happen then the glucose or sugar molecules build up in your blood stream causing the symptoms of diabetes and then the damage to the affected organs such as eyes, heart, kidneys, nerves as well as the blood circulation in general.

The main symptoms are:
– Tiredness;
– Excessive thirst; and
– Passing excessive amounts of urine.

If you are over-weight, thirsty and peeing a lot, get to your doctor ASAP! Other symptoms are:
– Weight loss;
– Blurred vision;
– Recurrent infections;
– Slowly healing wounds; and
– Recurrent cramps.

What are the complications of diabetes?
It mainly affects the blood vessels accelerating blockages in them and also the nervous system, particularly numbing nerves and reducing sensation. Thus, heart attacks and strokes occur more often and earlier in diabetics. The eyes are particularly affected by what is called diabetic retinopathy and blindness may eventually occur. The kidneys are often affected leading to kidney failure. The blood has difficulty getting through the narrowing arteries and hence Erectile Disorder may start and the blood supply to the feet and toes shuts down leading to ulcers, infections and eventually amputations. Overall, it is a pretty nasty disease to have.

How is it diagnosed?
Thank heavens I don’t have to do what ancient doctors had to do – taste the patient’s urine to see if it tasted sweet!

A simple blood test will generally tell you if your blood glucose or sugar level is high. Sugar may show up in a urine test but it is not reliable. The blood test specimen may either be fasting, that is, you haven’t eaten or drunk anything other than water in the previous 8-15 hours, or a random one with no reference to when you last ate.

The cut off levels for diagnosis vary depending on whether it is a fasting or a random blood sample.
– Diabetes is unlikely if your blood sugar level is less than 5.5, either fasting or random.
– Diabetes is likely (but not 100%) if your blood sugar is over 7 fasting or over 11 random.

In between is the grey zone – perhaps an error and needs repeating, or perhaps early or pre-diabetes. The way this region is sorted out is a test called a Glucose Tolerance Test. This test takes about two hours to do. After fasting overnight, a standard amount of glucose is given and regular blood tests are done. With diabetes, the blood glucose level goes higher and stays elevated longer. Often with this test it can be equivocal and a diagnosis of “impaired glucose tolerance” is made. It means you don’t have full blown diabetes… yet!

Management of diabetes
The basis of properly managing Diabetes is a ‘team approach’. With wide ranging ramifications, input is required in varying degrees from doctors (GP, Endocrinologist), diabetes educators, dieticians, podiatrists (feet), optometrist or ophthalmologists (eyes), pharmacist (medication), exercise physiologist, and dentists.

When a bloke is diagnosed with Type 2 Diabetes, lifestyle modification is the cornerstone of initial management and should be maintained for life. Weight reduction is paramount and smoking is vigorously discouraged. If you smoke you are a #%&@*#@ idiot!! Smoking will accelerate all the vascular (heart attacks, stroke and peripheral vascular disease) complications of diabetes. Clinical parameters such as cholesterol level and blood pressure need to be maintained within the normal range. Diet and exercise need to be spot on.

Diet
Let’s keep it pretty simple and general. There is no diabetic specific diet anymore and it is not simply a matter of cutting out sugar in the diet as previously stated. In fact a little bit of sugar is fine. Funny enough, it just needs to be a healthy diet in quality and in quantity, one which controls your weight.
– Reduce your serving size and marry it to your level of exercise/activity.
– Don’t skip breakfast and eat regularly, particularly if you are on insulin or medication.
– Occasional treats are OK – think of those foods as ‘sometimes’ foods.
– Lean to low fat eating and beware of hidden fats in cakes, biscuits and pastries.
– Limit takeaway food – you don’t have control of what is in it.
– Eat more fresh food and less processed food particularly, sugary foods.
– Eat cereals but choose those low in sugar and fat.
– Eat fruit and vegetables.
– Eat lean meat and skinless chicken.
– Eat low fat dairy products.
– Eat beans and lentils.
– Eat more fish.
– Eat nuts but in moderation.
– Moderate your alcohol intake and have alcohol free days.
– Drink water and avoid soft drinks.
– Choose a higher fibre alternative e.g. wholegrain bread over white bread.
– Reduce salt in your diet to assist with your blood pressure.

Exercise
Diabetics are really not any different to the run of the mill bloke who wants to exercise for health. They may be a bit more overweight perhaps which may limit their exercise ability initially.

Firstly it is important to get a heart and general check-up if you are starting exercise for the first time in a while. Your cholesterol level should be known as well as your blood pressure. Your history, including family history, along with your physical examination may require you to have an exercise stress test of some kind. It is better to be safe than sorry. This will generally be done on a tread mill with you attached to an ECG machine. If you are given the all clear by your doctor then away you go, but follow these important principles:
– Start slow, but then go. Don’t try to do too much too early. Settle into it and then step up the intensity gradually.
– Do something you like or have liked in the past. Do – don’t try, just do!
– Aim to do something every day or at least six out of seven days per week.
– Preferably cross train and do a variety of different exercises – walk, jog, run, bike, swim or gym. This will help if you develop an injury.
– Do a session of stretching, yoga or Pilates.
– Improve balance with Tai-Chi.
– Train with a friend or group for motivation.
– Preferably train in the morning but whenever you can if that is not possible.
– Continue your training regime through the winter when it can get very difficult to keep going.
– Look for opportunities for incidental exercise e.g. taking the stairs rather than a lift, the furthest car park rather than the closest.
– Any chest pain whilst exercising needs to be checked out before you exercise again.

I think that exercise is your most powerful tool to prevent or manage diabetes. A diet is a restrictive therapy and hence has an upper and lower limit. You can’t eat too much, but you can’t eat too little either (starvation). Exercise begins at nothing but then the sky is your limit – it is unrestricted except for the number of hours in a day and your fitness and capacity to do it. This will increase the more you do so the sky really is your limit.

Drugs
The decision to start drugs is up to your doctor to decide. He or she will base this largely on blood tests that show how good your control is. It will not be based on one reading but many readings over time. The main blood test used to test diabetes control is called the Haemoglobin A1C (Pronounced a-one-see). It gives a reading which looks at the average control of your blood sugar levels over the previous three months. Hopefully you will also have been taught how to test your own BSL (Blood Sugar Level) by finger prick test and have a diary of BSL levels to look at. Unless lifestyle changes bring about very significant reductions in your sugar levels and weight, you will probably be on medication for life. One drug is generally started and then others added to improve control if need be. You may end up on two to three different pills eventually and then insulin injections may be brought in. The time-line for this is generally over several years but it can be quite rapid if the insulin producing factories shut up shop.

Then there is Insulin! Most people are fearful of needles and the thought of injecting yourself everyday fills most people with horror. However, it is pleasantly surprising how most people cope with giving themselves injections. With proper tutoring, especially by a diabetes educator, this perceived difficult procedure can be made quite mundane. Perhaps one day, a tablet form of insulin will be developed but, until then, insulin therapy via a needle is the only option.

That’s Diabetes in a nut shell. I deal with this in more detail in my new book, Blokes’ Health 2 but this will give you some understanding of this very important disease.

Stay happy and healthy.
Dr Bernie Crimmins