Question 1
WHAT IS DIABETES MELLITUS?
This is a life long disease that is characterized by abnormally high blood sugar.

Question 2
What is blood sugar?
This is a substance called glucose which your body needs for energy. The cells of your body need this substance which is found in the food that you eat. There is a normal level for glucose to be in your blood; not too high not too low.

Question 3
Why are we so concerned about this disease?
Diabetes can cause blindness, kidney failure, impotence, stroke, heart attack, loss of limbs and nerve damage (leading to numbness or pain).

Question 4
What are the symptoms of diabetes mellitus?
It is important to know that there may be no symptoms for the first four to seven years of this disease, even though it is causing damage to your organs. The symptoms that are most common are

1. tiredness
2. loss of weight
3. polyuria [passing a large volume of urine frequently]
4. polydipsia [severe thirst with drinking of lots of fluid e.g.  water]
5. itching
6. recurrent yeast infections in vagina or on penis
7. difficult to heal wounds
8. blurred vision
9. dry mouth
10. drowsiness

Question 5
Are there different types of diabetes mellitus?
Yes: There are three main types that I think would apply to you. TYPE 1, TYPE 2 and GESTATIONAL DIABETES.

Type 1 diabetes tends to occur in the younger age groups. This disease needs insulin diet and exercise for treatment. These patients may develop diabetic ketoacidosis. Type 1 use to be called insulin dependent diabetes in the past.

Type 2 disease tends to occur in the older age groups, especially if they are overweight or have a family history [other members of the family having same disease ] of this disease. Treatment of type 2 involves diet exercise tablets and/ or insulin.
Gestational diabetes is the form that only occurs in pregnancy. This patient would not have had the disease before and it would disappear within six weeks of delivery. These patients are however prone to or at risk of developing type 2 disease in the future.

Question 6
What is insulin?
Lets go back to basics. Some of the food we eat is broken down to glucose in the gastrointestinal tract and absorbed into the blood. Glucose [blood sugar] stimulates the pancreatic gland to produce the hormone insulin. Insulin causes the cells and tissue of the body to use the glucose for energy. Insulin also reduces the amount of glucose produced by the liver and fat tissue.  Glucose is the fuel of our body. Insulin regulates the amount of sugar that is in our blood.

Question 7
Who is at risk of developing diabetes?
The patients who are at risk of developing this disease

1. are obese
2. have had gestational diabetes in the past
3. live a sedentary lifestyle [do not exercise ,drive to work, use the elevator sit at desk ]
4. overeat
5. eat a diet containing abundance of  high glycaemic index  food
6. have family history of diabetes

Question 8
What is glycaemic index?
This is a way of describing a food by its ability to raise your blood sugar. So the higher the glycaemic index the more likely the food would raise your blood glucose after eating it.

Question 9
Can this disease be cured?
No, but it can be controlled. You have this disease for the rest of your life.

Question 10
Can I have a touch of diabetes?
No, you are either diabetic or not like you are either pregnant or not.

Question 11
How is this diabetes treated?
The treatment always involves diet and exercise. Type 1 disease also requires insulin and this cannot be substituted by tablets [oral hypoglycaemic medication]. Type 2 disease may require medication and this may take the form of oral hypoglcaemic tablets and or insulin.

Question 12
Does being on insulin mean that my diabetes is worse than someone who is not on insulin?
No; the name of the game is controlling the sugar level and preventing the complications of diabetes. If you have complications then I consider you worse off than someone who does not have any.

Question 13
Why would someone with Type 2 disease need insulin?
Type 2 disease is a progressive disease such that as time goes on you need more medication to control the blood sugar. A time arrives when oral hypoglycaemic medications [tablets] are not enough and insulin is needed. But remember the blood sugar needs to be controlled all the time by any means reasonably necessary.

Question 14
What is insulin resistance?
This is when the insulin in your body is not functioning well. This means that the insulin is not working at the potency you would expect for the amount of insulin that is present. The pancreas therefore produces more insulin to compensate for this diminished potency. This increased secretion therefore leads to hyperinsulinaemia [high amount of insulin in the blood], which we believe maybe the cause of other problems like hypertension and vessel damage.

Question 15
What are the conditions associated with insulin resistance?
Some conditions are:

1. type 2 diabetes
2. hypertension
3. dyslipidaemia
4. atherosclerosis [formation of cholesterol plaques on inside of vessel wall]
5. central obesity [critically overweight with fat mainly on abdominal area ]
6. hyperuricemia
7. decreased fibrinolytic activity [decreased ability to break up clots ]
8. Acanthosis nigricans [darkening of skin around neck and armpits ]
9. Impaired glucose tolerance
10. Polycystic ovary disease [obesity, numerous cysts on ovary, infertility]

Question 16
What is impaired glucose tolerance?
This is a condition or state where your blood sugar is above normal but not high enough for a diagnosis of diabetes. Ten out of 100 patients with this condition would develop type 2 diabetes every year.  The main complication of this condition is type 2 diabetes, but atherosclerosis (hardening of arteries), cardiovascular (heart disease) and cerebrovascular (stroke) disease are other possible complications.

Question 17
Can impaired glucose tolerance be treated?
Yes, and I strongly believe that it should be treated because it can lead to complications and in practice I see no need to differentiate from diabetes except for my initial treatment protocol.

Question 18
How is impaired glucose tolerance treated?
Treatment is by diet, exercise and weight loss. A weight loss of only ten pounds is usually sufficient.
This treatment is to delay or prevent the onset of type 2 diabetes and other complications. If the desired blood sugar levels are not attained with the above measures, then drugs should be added.
These drugs are mainly to reduce insulin resistance.

Question 19
How is the diagnosis of diabetes made?
The diagnosis of diabetes is made from symptoms, signs and blood tests.
If the fasting blood sugar is above 6.8 mmol/ l or 2hour post prandial [2hrs after you eat] is greater than 11 mmol/ l on two occasions, the diagnosis is made. An oral glucose tolerance test can be done to make the diagnosis.

Question 20
Is the urine dipstick test useful in screening for diabetes?
No, the blood sugar can be elevated and yet there is no sugar in the urine. There can be sugar in the urine and the blood sugar level is normal.

Question 21
What is the fasting blood sugar?
The fasting blood test is done when you fast [or have nothing to eat or drink] from 10 pm the previous night and the blood sugar checked first thing in the morning around 6-8 am. 

Question 22
What is the oral glucose tolerance test (OGTT)?
OGTT is a blood sugar test done over 2-3 hrs; where the blood sugar is tested fasting; then a specific amount of glucose is taken orally [by mouth] and the blood sugar is checked every half hour.

Question 23
What is the glycoscylated haemoglobin test [HbA1c]?
The glycoscylated haemoglobin [HbA1c] level in the blood gives a good idea on how well the blood sugar was controlled over the last 3months. You cannot therefore fool your doctor and only take your medication or follow your diet when you are coming to see the doctor. The lower the Hba1c the less likely are you to have complications of diabetes.

Question 24
Are the glucometer results as good as the laboratory test results?
Yes, glucometers are hand- held devices that can give you a blood sugar reading result in 30 seconds or less. They are as accurate as the lab test. Every diabetic must own or have access to a glucometer [hand- held machine]. It is the only way to keep a tight monitor on your blood sugar.

Question 25
How often should I check my blood sugar?
Often; you should check your blood sugar at least 3 times per day in the beginning until your blood sugar is well controlled. If money or cost is a problem, then after control you might be able to diminish the frequency of testing to three times per week or a level stipulated by your health practitioner.

Question 26
How can I obtain a glucometer?
Glucometers are now inexpensive and in fact sometimes can be obtained free. I suggest that you obtain your glucometer locally and, if a relative is adamant in sending one from overseas or out of state, then ensure that the device and the strips are common to your area. This to ensure that training, strips, batteries and exchange for the glucometer can be easily obtained. Ask your doctor how to obtain a free glucometer.

Question 27
Are there any glucometers which are better than the others?
No, they are basically the same. But one might be more appropriate for you. Some devices have large memories, can track your progress and advise on action. Some devices are simple and only involve few steps to results. Some devices need less blood and therefore blood can be obtained from other areas other than finger tips.

Question 28
What are the complications of diabetes?
The complications are numerous, but there are some that are more common:

1. blindness
2. toe and leg amputations
3. kidney failure
4. impotence
5. hypertension
6. stroke
7. heart disease
8. increased susceptibility to infections
9. delay in healing of wounds
10. coma and death.

Question 29
What is a risk factor?
A risk factor is something that increases your chance of having another disease or condition; something that places you at risk.

Question 30
What is endothelial dysfunction?
This is a malfunction of the cells lining the inside of the blood vessels (endothelium). It is believed by some experts that this endothelial problem is the starting point for some diseases like atherosclerosis (cholesterol plaque formation), coronary vessel disease (Angina, Heart attack) and stroke.

Question 31 
What cause blindness in diabetes?
Poor control of diabetes and /or hypertension result in new vessels being formed on the retina (back of the eye). These new vessels rupture easily and cause bleeding in the eye, resulting in blindness. Cataracts (or opacity in the eye lens) can also cause blindness in diabetics.

Question 32
Can the eye disease seen in diabetes be prevented or treated?
Yes, the eye disease (diabetic retinopathy) can be prevented or retarded by good blood sugar and blood pressure control and also by the use of special blood pressure medications. At present some stages of diabetic retinopathy are treated by laser treatment to the retina. Cataract removal with lens replacement is also commonly done. There is no cure for diabetic retinopathy, treatment is only to stop or retard progression of eye disease.

Question 33
When and how often should a diabetic see the opthalmologist?
Every diabetic should see the opthalmolgist (eye doctor) if available. Type 1 diabetics within 3 months of being diagnosed and type 2 immediately. Follow-up with the opthalmologist should be once per year or sooner if the eye doctor recommends.

Question 34
Does diabetes affect the kidneys?
Yes it might; poor control of diabetes and /or hypertension can result in kidney damage (diabetic nephropathy).  This damage causes kidney failure; diabetic nephropathy is a common cause of end stage kidney failure worldwide. The diabetes and hypertension affects the small vessels in the kidney, leading to kidney failure.

Question 35
What are symptoms of kidney disease?
Early kidney disease has no symptoms. There might be no symptoms for the first 7 years of the disease. The symptoms of late disease might be swelling of the feet and legs, nausea, vomiting, tiredness, weakness, tremors, twitching, pale frosty skin and shortness of breath.

Question 36
Are there any tests to detect early diabetic kidney disease (diabetic nephropathy)?
Yes, the first sign of diabetic nephropathy is small amount of protein in urine (microalbuminuria) and this can be tested for. This test can be done at your doctor’s office or at home.

Question 37
Can diabetic nephropathy be prevented and or treated?
Fortunately great progress has been made in this field. We can  reduce the chance of having this disease by good control of your diabetes and blood pressure .There are some drugs  that protect the kidney from diabetes and reduce the speed at which the kidney damage gets worse. A special diet also reduces the rate of kidney decline when there is established kidney disease. There are specific targets for blood sugar, blood pressure, blood cholesterol and glycosalated haemoglobin levels that must be met.

Question 38 
What is cholesterol?
Cholesterol is a fat found in the blood. It comes from meat and shell foods in our diet. Our liver also produces cholesterol; some people inherit conditions that make their liver produce too much cholesterol. There is good cholesterol = high density lipoprotein (HDL) and bad cholesterol =low density lipoprotein (LDL). A high level of bad cholesterol puts you at risk of developing atherosclerosis, heart disease and strokes.

Question 39
What is a myocardial infarction?
This is the same as a heart attack. The vessels of the myocardium (heart muscle) get blocked by atheroma plaques (cholesterol plaques) and clots. The heart muscle cells die from lack of blood (infarction).

Question 40
Does diabetes predispose you to heart problems?
Yes, heart problems are one the most common cause of death and poor health in the diabetic patient. Diabetes is usually associated with high cholesterol, high triglyceride, hypertension and obesity; all risk factors for heart disease. Diabetes on its own causes endothelial dysfunction, which can lead to large vessel disease (macrovascular disease) and small vessel disease (microvascular). Macrovascular disease leads to myocardial infarction and strokes. Microvascular disease causes eye and kidney disease.

Question 41
What is a stroke?
A stroke is an event that takes place in the brain that leads to brain damage. This damage can lead to confusion loss of or slurred speech, paralysis or weakness of the limbs and death. The blood vessel causing the stroke can either be blocked or ruptured. Blockage causes an infarction; stroke and rupture cause an haemorrhagic stroke.

Question 42
What is diabetic neuropathy?
This is nerve damage caused by diabetes. Several nerves can be affected, including the nerves that control swallowing and bowel movements. The nerves that are responsible for sensation in the feet can also be affected if there is poor control of diabetes. Loss of sensation plays an important part in loss of limb in diabetes.

Question 43
What causes poor healing in diabetes?
The small vessels in the tissues are affected, causing poor blood supply.  This results in less nutrients and oxygen getting to the wound or area that needs healing.

Question 44
Why are diabetics at risk for lower limb and toe loss?
Loss of sensation allows small bruises and cuts to go unrecognised. This coupled with poor healing, leads to difficult- to- treat infections.

Question 45
What can be done to prevent amputation?
Good foot care and good diabetes control. Every diabetic should see a foot care specialist for care, advice and treatment of nails or callouses .There is general advice that every diabetic should follow:  

1. examine your feet every day for cuts and bruises and, if found, inform your care provider immediately
2. wear comfortable shoes, shop for your shoes in the afternoon when your feet might be a bit swollen
3. always wear shoes or slippers outside
4. check your shoes or slippers every day for nails ,tacks or foreign objects wash your feet every day and pat dry thoroughly

-    it is good to wear socks or shoe inserts that soak up sweat

1. do not have pedicures done, but have your nails trimmed on a regular basis.

Question 46
Can diabetes cause anemia?
Yes. This is possible because diabetes can cause kidney failure and kidney failure cause anemia. It is important to correct the anemia to remain healthy and if possible slow down the worsening of the kidney failure.

Question 47
What should I do before getting pregnant?
You should seek preconception counseling from your doctor. Your doctor would review your medication and make changes to ensure safety for the fetus. Some medications must not be used in pregnancy or while breastfeeding. Insulin is still the drug of choice in the pregnant diabetic, even though you were on oral medications before.

Question 48
How is diabetes treated?
All types of diabetes are treated with diet, exercise, cardiovascular and stroke risk reduction steps. To this treatment regime, insulin is added in the type 1 diabetics; tablets and /or insulin may be needed in the type 2 diabetics.

Question 49
Is exercise important even though my blood sugar is well controlled?
Yes. Even though exercise is used to help control blood sugar this is not its only use. In my opinion, the major importance of exercise is in reducing cardiovascular risk .Exercise helps control weight increases good cholesterol, reduces blood pressure increases endorphins (happy hormone) and reduces insulin resistance. It also helps peripheral circulation and boosts your immune system.

Question 50 
What should I do before exercising?
You should see your doctor who would evaluate your cardiovascular system to ensure it is safe. Your doctor would also advise you on whither weight bearing exercises are safe for your feet. The doctor would also prescribe the amount of exercise and frequency. But in general I advise my patients

1. to wear comfortable shoes with sweat absorbant socks
2. to exercise with a partner ,wear a medical alert bracelet
3. to ensure to drink fluids to prevent from becoming dehydrated
4. to warm up and cool down
5. for the first two weeks, to  check blood sugar before and after exercise to see the effects of exercise on blood sugar
6. if blood sugar is  less than 5 mmol/l then eat or drink something  containing carbohydrate for the type 1 patient before exercising ; also for type 1, do not exercise that day if your blood sugar is 20 or greater ; or if blood sugar is 14 and these are moderate ketones in the urine
7. brisk walking is good enough ,but aim to walk for 30 to 60 min  4 times per week
8. carry a candy with you in case of hypoglycemia (low blood sugar)
9. always check your feet after exercise for blisters, cuts and bruises.

 Question 51
Can sex be considered as exercise?
Yes. Sex is significant exercise. Twice per week has the potential to keep you fit and bestow the benefits of exercise on diabetes management.  It can lower your blood sugar, so take the usual precautions of preventing hypoglycemia with exercise.

Question 52
Can my household chores be considered as exercise?
Yes. Household chores and gardening, done briskly, are considered as light exercise and have benefits. These are specially recommended in people who are unable to do weight-bearing exercise.

Question 53 
What is impotence?
Impotence or erectile dysfunction is the inability of a man to create or maintain a penile erection sufficient to have penetrative sex.

Question 54
Are diabetics more prone to impotence?
Yes. Men who have diabetes for more than 10 years are prone to have erectile dysfunction (impotence). In fact, half of all men with diabetes for more than 10 years would have some degree of impotence.

Question 55
Can impotence be prevented?
Yes .Good diabetes control and management from early on can prevent impotence. Good management includes blood pressure and cholesterol control; since these are also risk factors for impotence. Cessation of smoking is also important in preventing and treating impotence.

Question 56  
How is impotence treated?
Quite difficultly, as it is easier to prevent than treat. Treatment involves careful assessment to detect nonorganic or psychological causes which can be treated by psychiatrist. Blood sugar, blood pressure and blood cholesterol levels are controlled. There are mechanical and medication methods of treating impotence but now medications are far more often used with the invention of new drugs. Some of these medications cannot be used with other drugs or if the patient has significant heart disease. However impotence today is more successfully treated with less effort than 10 years ago. It must be treated by a doctor and not a neighborhood friend.

Question 57
 If I am risk of developing diabetes can it be prevented?
Firstly, being at risk does not necessarily mean that you would win 100% certainty develop diabetes. But you have a high chance of developing the disease.  This chance can be reduced significantly by adopting some of the following measures:

1. losing weight {if overweight} to your ideal weight
2. exercising on a regular basis
3. modifying your diet to be balanced and contain a reduction of high glycaemic index foods
4. actively treat glucose intolerance
5. use of specific proven drugs to treat glucose intolerance along with lifestyle modification
6. if hypertensive , to use antihypertensive drugs that are not diabetogenic and use drugs which have some evidence for delaying onset of diabetes
7. check every 2 years for glucose intolerance and / or diabetes

to do a glucose tolerance test or (2 hour post prandial test) and glycosalated haemoglobin .