1.2 Discovering the risks
The incidence of diabetes is dramatically increasing both nationally and worldwide. This is of great concern because of the debilitating day-to-day effects of the condition if it is not controlled, but in particular, because of the long-term damage that diabetes causes to blood vessels and nerves in the body.
In the short term, people with poorly controlled diabetes can suffer any or all (or, in fact, none) of the following complications:
tiredness and lethargy;
depression and change of mood;
passing large amounts of urine frequently (a condition known as polyuria);
loss of weight;
Sometimes, as with Mrs Begum, there are no obvious signs or symptoms of the condition. This can make it difficult to see the diabetes as serious and so taking tablets regularly or attending clinics for diabetes checks may not be seen as important.
However, the possible long-term complications (irrespective of any short-term complications) include:
coronary heart disease (CHD), which includes angina and heart attacks;
cerebrovascular disease (strokes);
nephropathy (damage to the kidney which can lead to kidney failure);
peripheral vascular disease (which can lead to gangrene of the feet);
retinopathy (damage to the blood vessels in the retina at the back of the eye);
autonomic neuropathy (damage to nerves which can lead to erectile dysfunction (i.e. impotence), chronic diarrhoea, and other problems)
peripheral neuropathy (damage to nerves to the extremities, causing painful or numb feet).
Much of the focus of diabetes management is based on the early detection of these complications and their prompt treatment. However, just as important is the detection of factors in the person with diabetes that increase their risk of developing such damage. By correcting these risk factors, the chance of developing diabetes complications can be avoided, delayed, or the complications reduced in severity. The checks for these risk factors are included in the diabetes annual review.
What are the risk factors? High blood glucose (hyperglycaemia) does cause the short-term complications described above, and contributes to some of the long-term damage, particularly to nerves and small blood vessels. As the blood vessels involved are small, these are called microvascular complications. Retinopathy is an example of a microvascular complication. However, high blood glucose is not the only cause of diabetes damage. High blood pressure (hypertension; see Section 5) and abnormal blood fat levels (dyslipidaemia; see Section 4) are also major contributing factors particularly in the development of complications such as CHD and cerebrovascular disease. These are known as large blood vessel diseases or macrovascular complications because of the blood vessels affected.
What other factors increase the risk of heart attacks and strokes in the general population?
You probably thought of smoking, lack of physical activity, being overweight, excessive alcohol intake, an unhealthy diet consisting of high fat, high sugar, high salt, and a lack of fibre.
These factors are all important when considering the risk someone with diabetes has of developing diabetes complications. Other risks may be less obvious and include a difficult social situation, low income level, poor learning ability, a lack of knowledge in self-management of diabetes, old age, mental health problems and stress.
However, that is not to say that every person with diabetes will develop complications if they have high blood pressure, poor long-term blood glucose control and high cholesterol levels. People often cite the person they know who has had long-term high blood glucose but has never developed eye disease (retinopathy), for example. However, many medical studies over the years tell us that there is a greater likelihood of developing diabetes complications if the condition is not well controlled. A complete picture of these factors is therefore crucial to assess the person: to guide medication choice, to identify education needs, to offer other interventions such as advice on giving up smoking, but most importantly, to give the person with diabetes a clear and honest view of their risk so they can make choices about how they manage the condition.