Web of Life

November 14 is celebrated all over as World Diabetes Day. In India it is the birthday of Jawaharlal Nehru, and it is labelled there as Children's day. It is also the birthday of Frederick Banting who first conceived the idea which led to the discovery of insulin. This may be a coincidence, but for many medical professionals like me, it makes us doubly aware that our focus should be on children who are potential candidates for developing diabetes, which is being now labeled as the "mega disease" of the future.

In 2001, the World Health Organization (WHO) estimated that more than 177 million adults have diabetes, an increase over the 2000 estimate of 151 million. This does not take into account children who are becoming fat or sedentary, and are potential candidates for this disease in early adulthood. The theme for the World Diabetes Day 2004 is thus appropriately "Fight Obesity Prevent Diabetes".

Being an orthopaedic surgeon, my interests in the fight against diabetes mainly focus on three problems: nerve and blood vessel damage over the long term, leading to the much dreaded complication of Diabetic foot, with ulcers and infections, which may sometimes even lead to amputations! I do think the theme for next year (2005), Diabetes and Foot Care is very appropriate. However, since I have written extensively on the Diabetic Foot in recent columns, I will focus on two other aspects: how diabetic neuropathy affects the extremities, and how the effect of diabetes on your kidneys could modify drug use for pain prevention (this was the theme for 2003 - Diabetes could cost you your kidneys: Act Now!)

World Diabetes Day, organized by the International Diabetes Federation is a global awareness campaign for diabetics. Introduced in 1991, it is a response to global concern over the escalating incidence of diabetes. "World Diabetes Day is the primary global diabetes awareness campaign, and therefore the ideal occasion to inform the general public about the strong link between overweight, obesity and diabetes," says Prof Pierre Lefèbvre, IDF President. Prof Martin Silink, IDF President-Elect, further explains the potential problems-"Several complex and interrelated factors are at work for the rise in diabetes prevalence: an ageing population, the lack of physical activity and unhealthy eating habits due to urbanization combine to produce large numbers of people with type 2 diabetes. All over the world traditional lifestyles and dietary patterns are giving way to a sedentary lifestyle and a high-fat diet. Increasing obesity is a significant risk factor for diabetes"

The message that is being transmitted with this campaign is a simple one: lifestyle changes such as eating a healthy diet and being physically active are effective in delaying and, in many cases, preventing the onset of diabetes, and reducing the risk of developing complications in people with diabetes. It is estimated that at least half of all cases of type 2 diabetes could be prevented if weight gain in adults could be avoided.

Diabetic nerve damage ( known as Diabetic Neuropathy) has been known to cause numbness leading to the common problem of insensate feet and their complications; however, many patients are not aware that this can also result in pain in the legs and feet in the initial stages, and overtime be replaced with numbness, as nerve damage becomes nerve cell death. Pain is often attributed to many other causes and the correct diagnosis may be delayed; patients should realize that this pain is a "scream" from the nerve cells, and is caused by the double damage resulting from too high a blood sugar content as well as deprivation of blood supply to the nerves due to obstructions occurring in the blood vessels themselves. Nerve damage in other areas of the body can result in such things as incomplete emptying of the bladder, incontinence, or sexual dysfunction, and in the stomach/ gut lead to abdominal discomfort, nausea, vomiting or bloating. Damage to nerves that regulate blood flow and blood pressure can result in significant blood pressure drops when sitting or standing, causing a person to feel light-headed or even faint.

The doctors need to exclude other causes of neuropathy confirming the diagnosis. Certain nerve and muscle tests should be done early, and when the picture is clear, treatment should focus on strict blood sugar control and prevention of complications in the limbs.

Many medications are available to relieve the pain of neuropathy. Routine pain killers maybe of no benefit; the simple ones, like Paracetamol etc. may be safer, as other analgesics, if used over a long period of time have the potential to damage the kidneys, which are already being influenced and damaged by the Diabetic disease process. So drug use in diabetics has to be very carefully monitored, and both the patient and the physician should take care of this aspect. Surprisingly, certain antidepressants are helpful and take the edge off the pain of neuropathy. This doesn't mean that you are depressed! Rather, it seems that the medications block the pain. If taken at night, they help reduce the pain. Antidepressants can take several weeks to become effective, so patients should try them for a month before deciding about their effects. Today, one of the most commonly used and effective medications to help with the pain caused by neuropathy is called Neurontin, which has relatively few side effects.

A topical cream (capsaicin) is now available and helps relieve neuropathy pain, by blocking nerve signals, especially when pain is localized. Patients should avoid taking narcotic painkillers for neuropathy, as they do not work very well for neuropathy, and will lead to addiction.

Newer medical research is focusing on fatty acids as Alpha Lipoic and Gamma linolenic acid, as well as nerve growth factors. The data is preliminary, and the work is experimental at best.