John Dawson was never ill – or at least he never made time to go to the doctor. But over the years the 53-year-old Sydney public servant had piled on the weight, his fitness was failing because he didn’t exercise and by the end of his 50-hour week he was always exhausted.
A visit to his GP for a routine throat infection was to change his life. Noting Dawson weighed 106 kilos on a 1.9-metre frame and had elevated blood pressure, the doctor took a blood test that revealed Dawson was suffering from a silent, deadly disease. He had diabetes.
Diabetes is Australia’s fastest-growing chronic disease. There are more than 700,000 people with diabetes in Australia, and it is estimated that at least another half a million people are undiagnosed. One in four of us has either diabetes or impaired glucose metabolism that puts us at risk of developing the disease. Some 150 new cases of diabetes are diagnosed every day. That’s an epidemic, in which hundreds of thousands are at risk of irreversible damage to vital organs as blood sugar runs amok in their bodies.
Diabetes can lower your life expectancy by 20 per cent. It’s the biggest cause of kidney failure, the biggest cause of blindness in adults under 60 and is behind half the lower-limb amputations in Australia. It can triple your risk of heart attack – 65 to 80 per cent of people with diabetes die of coronary heart disease – and triple your risk of a stroke.
And the worrying thing is it’s getting worse. An estimated 1.7 million of us will be diabetic by 2010. Cases of diabetes have spiralled for one very big reason: obesity. It has more than doubled in 20 years in Australia, and one-fifth of the population is now obese. (A waist measurement of 102 centimetres or more for men, 88 centimetres or more for women, indicates obesity.) Obesity can bring on diabetes in predisposed people up to 15 years earlier because it increases their body’s resistance to insulin.
“We talk about diabetes being everybody’s business,” says Dr Pat Phillips, senior director of endocrinology at the Queen Elizabeth Hospital in Adelaide. “If you have not got a problem with weight and diabetes, then almost certainly a member of your family or a friend has.” But the news isn’t all bleak. Recent studies have shown that losing weight and taking more exercise can reduce the danger of developing the most common form of diabetes by 58 per cent in people at risk. And if you already have diabetes, you can still delay or reduce complications by losing weight.
Diabetes is diagnosed if the amount of glucose (sugar) in your blood is too high. Normally insulin, a hormone produced in the pancreas, enables the body to turn blood glucose into energy or to store it in cells. But if insulin production is defective, the glucose remains trapped in the blood and blood sugar starts to rise above the normal three to six millimoles per litre level, before food. In type 1 diabetes, the body produces little to no insulin. In type 2, which affects 85 to 90 per cent of sufferers, the body still generates insulin, but not enough, and cells can also become insulin-resistant.
Most of the people with type 2 diabetes are overweight, and research shows that if you gain more than 4.5 kilos between the ages of 40 and 60, you significantly increase your risk of developing type 2. The more overweight you are, the more insulin-resistant you become – you need more and more insulin to maintain blood sugar levels. At first, the diabetic’s pancreas compensates by increasing insulin production, but over the years it starts to fail, and glucose and insulin levels may swing wildly between very high and very low. High glucose levels damage small and large blood vessels, which in turn can take a terrible toll on the heart, nerves, kidneys, eyes and men’s erectile function.
Anyone at high risk of type 2 should eat less, walk more and get tested by their GP. Apart from obesity, risks include having a close relative with diabetes; being of Aboriginal, Torres Strait Islander, Melanesian, Polynesian, Middle Eastern, southern European, Chinese or Indian origin; being over 45; having high blood pressure or heart disease; or having had gestational diabetes when pregnant.
All these risk factors made Gulshan Suresh a prime candidate for diabetes. The wife of a GP in rural NSW, of Indian descent and with a mother, two brothers and sisters all diabetics, she knew she was at risk. Still, it was a shock when she was diagnosed during her second pregnancy, at the age of 32. “I didn’t think it was anything serious,” she says. Her gestational diabetes resulted in her developing full-blown type 2 in her early 40s. For years she controlled the condition by modifying her lifestyle, before having to take medication and then insulin. “It’s a lot of adjustment,” she says.
A diabetic performs a simple pinprick blood test, using a small meter to measure glucose levels. And to help control those levels, type 2s have three highly effective weapons: diet, exercise and drugs.
Type 2 diabetics can eat any type of food, but are recommended to reduce meal sizes, cut down on fat, sugar and alcohol, and eat plenty of fibre and low-GI carbohydrates. Exercise helps since it makes the body more sensitive to insulin, and overweight people with diabetes should take a brisk walk for at least 45 minutes daily. The more overweight you are, the more you have to exercise. “We are not asking people to run marathons every day – we are simply asking them to exercise,” says Dr Nic Kormas, an endocrinologist at Concord and Royal Prince Alfred hospitals in Sydney.
A pilot study Kormas conducted recently of 24 moderately to severely obese people with diabetes found weight management along with intensive supervised exercise could actually reverse their condition.
With 330 minutes on a structured, weight-bearing exercise programme every week, all of his study patients reduced their cholesterol and blood pressure to normal levels. On average, diabetes medication was halved and one in eight patients stopped their medication altogether.
John Dawson, the public servant who’d had diabetes without knowing it, was one of them. Initially he had no trouble controlling his diabetes. But a couple of years after his diagnosis, he started to work too hard again and let his regime slip. By Christmas 2003 his weight had risen to 110 kilos and his glucose levels were sky high. That’s when he decided to get serious.
After six months of attending eight exercise classes a week and watching his diet, his weight dropped to 91 kilos and his fitness improved significantly. Amazingly, he has stopped his diabetes medication, his blood pressure is normal and his glucose and cholesterol levels are both under control.
Changes in lifestyle aren’t always enough, though. Many diabetics have to take tablets such as metformin to make the insulin in the blood work better, and/or sulphonylurea to stimulate the pancreas to produce more insulin. Other drugs include acarbose, to slow the digestive process and give the blood more time to deal with the glucose, and glitazones, to increase the body’s sensitivity to insulin.
About 13 per cent of type 2s also require insulin injections. For those who need help injecting, two new types of insulin, marketed as Lantus (glargine) and Levemir (detemir), last longer and can be injected just once a day.
Although not yet listed on the Pharmaceutical Benefits Scheme (PBS), the new insulins are more predictable than conventional PBS-listed insulins and reduce extreme swings between low and high blood glucose levels. Trials are being conducted of nasal and inhaled insulin, but for now they are not available in this country.
However, other exciting developments are underway in Australia. A new class of drugs, called glitazars, will reduce blood sugar as well as blood fat levels by targeting two metabolic pathways in a once-a-day pill. Clinical trials are currently being conducted across Australia. The new drug could be available in a few years.
Even if their condition is stable, diabetics are vulnerable to heart disease. This is because they are more likely to suffer the combined problem of high blood pressure, high blood fat levels and blood clotting than someone without diabetes. So it’s vital to keep a close eye on patients’ cardiovascular systems.
“Studies suggest if you have type 2, you are looking at the same heart attack rate as someone who has just had a heart attack and doesn’t have diabetes – 20 per cent over the next seven years,” says Dr Phillips. “Heart disease is the first, second, third, fourth and fifth most important issue.”
Diabetics need to control their blood fats – with statin drugs – and blood pressure – with medications like ACE inhibitors, diuretics and beta-blockers – as well as their glucose levels. They need to have regular checks for all of these, as well as giving up smoking and possibly taking aspirin to thin their blood and reduce the risk of heart attack or stroke. As well, diabetics have to undergo regular tests for kidney function and the health of their legs, feet and eyes. The Royal Australian College of General Practitioners recommends they be seen by a doctor every three or four months.
All this can leave patients rattling from the pills they have to pop. And it’s not just the diet and exercise that’s the challenge – it’s also the cost of it all.
A recent study found diabetics without complications usually have to spend more than $5000 a year on their medications, extra insurance premiums and doctors’ visits. And when you’re having to buy pills for complications like heart disease and high cholesterol, that amount can be as high as $10,000. That’s a huge out-of-pocket expense, and things are set to get even harder now the threshold for the Medicare safety net has been raised, meaning that in a few years’ time, some people will have to spend as much as $1000 on medication each year before they start receiving government subsidies.
Diabetes Australia is now calling for government assistance averaged out as concessions on drugs over the whole year. At the moment, assistance is available only once the safety net threshold has been reached. For most, this means paying full price for the first six to eight months of each year. It is also lobbying to have more benefits for type 2s included under the National Diabetes Services Scheme that provides subsidised items such as syringes, needles, and blood and urine testing strips. At any rate, Australia will have to think hard about the costs of managing diabetes as it tries to cope with the avalanche of new cases that will hit over the next few years.
“It’s a disease that is costing this country the equivalent of five new Parliament Houses every year – $6 billion,” says Trevor Corbell, the manager of national advocacy at Diabetes Australia. “It has a dramatic effect on productivity levels in this country, and it’s a huge drain on the national budget.”
It can take a devastating personal toll, too. Richard Chua, a 65-year-old former IT specialist from Surrey Hills in Victoria, did not manage his condition when he was diagnosed 20 years ago. Now, he has had a quadruple bypass, has trouble walking due to the nerve damage in his legs, and has lost 85 per cent of his vision.
All this means he’s had to give up a $100,000 a year job and, even though he receives the disability pension, he still forks out around $2000 a year for medications. “I’ve come across many people who don’t take it seriously,” Chua says. “My message to them is you have to act now.”
For information or advice, go to Diabetes Australia’s website at www.diabetesaustralia.com.au or call 1300 136 588.
