Much of the diabetes burden can be prevented by making lifestyle changes. The complications of diabetes are of significance also in terms of socioeconomic costs.
Diabetes is a chronic disease which occurs when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. This leads to an increased concentration of glucose in the blood, known as hyperglycaemia.
Type I Diabetes Mellitus earlier known as Insulin Dependent Diabetes Mellitus, childhood onset or juvenile diabetes Mellitus, is characterised by a lack of insulin production. Type II Diabetes Mellitus earlier known as Non-Insulin Dependent Diabetes Mellitus or adult onset diabetes is caused by ineffective use of insulin by the body. Gestational Diabetes Mellitus is hyperglycaemia that is recognised during pregnancy, it can lead to serious health risk for both mother and child.
Diabetes is a growing challenge in India with estimated 8.7 per cent diabetic population in the age group of 20 to 70 years. The rising prevalence of diabetes and other non communicable disease is driven by a combination of factors like sedentary lifestyle, rapid urbanisation, increasing life expectancy, unhealthy diet, consumption of tobacco and alcohol and sudden increase in per capita income and increased consumption of processed foods.
Obesity is the most important risk factors responsible for diabetes. Much of the diabetes burden can be prevented or delayed by making lifestyle changes favouring a healthy diet and regular physical activity.
According to the Indian Heart Association, India is projected to be home to 109 million individuals with diabetes by 2035. The number of Indians with diabetes is likely to be doubled in the next decade. Diabetes was India’s seventh biggest cause of early or premature death in 2016, according to the data shown by Institute of Health, Matrix and Evolution. According to the same report around 47.3 per cent of India’s 70 million diabetics are undiagnosed.
There is a general perception that diabetes is a disease of the rich and affluent society, however, data has shown that there is evidence of an epidemiological transition with the prevalence of diabetes being higher in low socio economic group of urban areas of more economically developed states.
According to a research by Indian Council of Medical Research (ICMR), Asians have a 2-4 times higher risk of acquiring type II diabetes than Europeans. Studies have shown that diabetes in Asians develops a decade earlier than in Europeans, at lower weight and those with pre-diabetes progress to diabetes at a faster rate.
Being an orthopaedic surgeon, now I will focus on the related orthopaedic complications. The pathology behind the orthopaedic complications can be mainly attributed to neuropathy and angiopathy. Nerve damage (neuropathy) is a complication of diabetes that leads to a loss of sensation in the feet. Decreased sensations can lead to a wound as small as the size of a pinhead which can progress to a serious infection in a matter of days as they often go unnoticed. Diabetes also damages the blood vessels (angiopathy), decreasing the blood flow to the feet. Orthopaedic complication of diabetes include: foot ulcer, gangrene of toes, plantar fasciitis, tendonitis, avascular necrosis of femoral head, Charcot arthropathy, diabetic foot in the lower limbs and frozen shoulder, carpal tunnel syndrome and Dupuyptren’s contracture in the upper limbs.
In the upper extremity carpal tunnel syndrome and frozen shoulder are the most common problems. In such patients the pain increases during night time. Carpel tunnel syndrome is due to compression of nerve at the level of the wrist. If the patients are hypothyroid then there is an additional risk of it. Diabetic patients are also more prone to frozen shoulder. Diabetes also causes premature osteoarthritis, delayed bone healing and increased chances of infection after open injury or any surgical intervention. It is also associated with poor wound healing because of narrowing of the arteries and damage to the nerve.
Poor circulation weakens bone, and can cause disintegration of the bones and joints in the foot and ankle. As a result, people with diabetes are at a high risk for breaking bones in the feet.
When a diabetic patient fractures a bone in the foot, he or she may not realise it because of the pre-existing nerve damage which causes loss of sensation and lack of pain. Hence, patients continue to walk on an injured foot which results in more severe fractures and joint dislocations. Sharp edges of a fractured bone within the foot can point downward toward the sole, increasing the risk of chronic foot sores from the abnormal pressure.
The easiest measures to lower the risk of diabetes is to keep your blood sugar level under 100 mg/dl, HBA1C below 5.7 per cent and blood pressure below 130/90 mmhg.
The chances of lowering the risk factors can be enhanced by brisk-walking, running, swimming or playing sports. In our country, swimming or community recreation centre facilities are not available widely.
We can follow the principle of doing any recreational activity that makes you sweat and breathe harder for at least one hour a day for seven days a week. This will significantly reduce the chances of diabetes in the future. There is common slogan “wider the waist line, shorter the life line.” Keep a healthy weight with waist size below 90 cm for men and 80 cm for women.
For general screening, the approximate weight can be calculated with a simple formula of height in centimetres minus 100. The remaining number in kilogramme is roughly the approximate weight.
The other standardised formula is Body Mass Index (BMI) which can be calculated as:- weight in kg divided by height in metre square multiplied by 100. It is interpreted as underweight <18.5, normal weight 18.5 – 24.9, overweight 25-29.9, obese class I 30-34.9, obese class II 35-39.9, obese class III > 40.
Other simple measures used to lower the risk are to use the stairs rather than the lift, stop smoking and reduce your alcohol consumption, do your daily household work. It could be cleaning your utensils, room or clothes and arranging your wardrobe or bed.
These complications are of significant clinical concern in terms of morbidity, mortality and socioeconomic costs. The yearly cost to treat diabetes is estimated to be Rs 27,400 per capita, which if constant would reach an annual Rs 1.95 lakh crore over six times the 2018 health budget by 2025, according to a report by a global consulting firm.
(The author is an orthopaedic and joint replacement surgeon based in Dehradun)
Monday, 14 January 2019 | Dr Gaurav Sanjay | Dehradun–