The Sweet Trap of Modern Living--Diabetes

Diabetes was the fourth leading cause of death in Taiwan last year, and is a contributing cause of strokes (the number-two killer), cardiovascular disease (ranking third), and kidney dysfunction (tenth). To be more exact, diabetes is directly or indirectly involved in more than half the fatalities due to the ten leading causes of death in Taiwan.

Diabetes is a chronic illness that not only has a severe and wide-ranging impact on a sufferer's health, but also consumes enormous amounts of healthcare resources. According to National Health Insurance statistics for 1998, expenditures for the treatment of diabetics accounted for 11.5% of all health care spending, and the average disbursement for medical expenses incurred by a diabetes patient was 4.3 times that of a non-diabetes patient.

Death rate from diabetes source: DOH / graphic by Lee Su-ling

A 21st-century epidemic

According to estimates, roughly 4.3% of the total population in Taiwan has diabetes-roughly one million people. The incidence of diabetes increases with age. In 2002, the Bureau of Health Promotion commissioned the Taiwan Public Health Association to perform a survey of the incidence of the three "highs" (high blood sugar, high blood pressure, and high blood cholesterol) among Taiwanese. The study found that 7.47% of the population over 15 has diabetes. This percentage is 10% for persons over age 40, and 20% for those over 65.

Hung Chin-hui, aged 71, has a history of diabetes that spans 36 years. Looking at her slight figure-she is less than 150 centimeters tall and weighs 44 kilograms-it's difficult to imagine her as she once was, weighing 104 kilograms. "At the time, I could eat five bowls of rice at a meal," she says, extending five fingers.

After learning that she had diabetes, Hung tried both Chinese and Western treatments. As more advanced medications became available, her diabetes was increasingly brought under control. By taking drugs to lower her blood sugar, managing her diet, and exercising regularly, Hung has been able to live the past 30-plus years quite normally, despite having diabetes.

Diabetes is not solely a disease of the elderly. Increasing numbers of children and young adults are also falling victim to diabetes.

Now in the prime of life at age 20, Chang Chu-ting discovered she had diabetes through a urinalysis conducted at her school when she was in third grade. Since then she has had to live with diabetes.

Not only did she learn at a tender age to give herself insulin shots, but testing her blood sugar levels became a regular feature of her life. When she got up, before each meal, before bed, and when her mouth felt dry or she got dizzy... she would test her blood sugar levels at least five or six times every day. Wherever she went, she carried her blood sugar tester, insulin, syringes, and drinks and candy for when low blood sugar needed to be immediately increased. Having learned to live with diabetes, the vivacious Chang has only one small complaint-that it's so difficult to lose weight.

Modern diets are plagued by large amounts of sugar, salt, and oil. Even fruit, bred to maximize sweetness, represents a latent threat.

Out of sync

In traditional Chinese medicine, diabetes, along with obesity, high blood lipids, and high blood pressure, is termed a metabolic syndrome. The Chinese term translates literally as "thirst disease," referring to one of diabetes' most overt signs, while another more vernacular name is "rich man's disease."

Diabetes is a condition in which glucose cannot be utilized by the body, and is instead excreted in the urine. The reason for this "error" is related to the insulin secreted by the pancreas.

Insulin is a stimulatory hormone that promotes growth, metabolism, the formation of proteins and fats, and glucose utilization, among other functions. After a person ingests food, blood sugar levels increase, and insulin secretions also rise in response, to carry the sugar to surrounding tissues for absorption and utilization. On the other hand, when blood sugar levels fall, the pancreas secretes another hormone, glucagon, the increased concentration of which stimulates the muscles and liver to release sugar, thus maintaining an equilibrium. In diabetes this adjustment mechanism is lost, causing blood sugar levels to be excessive.

Tai Tong-yuan, formerly superintendent of National Taiwan University Hospital (NTUH) and currently director of the Division of Gerontology Research at the National Health Research Institutes, explains further that in healthy persons, pancreatic secretions are dynamic-like a boat that rises and falls with the water, secretions increase when more is eaten and decrease when less is eaten. In diabetics, not only are pancreatic secretions severely insufficient, but they lose their ability to respond dynamically to food intake, so that the patient must rely on medication to compensate.

Though the precise mechanism by which diabetes develops remains unknown, obesity, stress, genetic predisposition, and urbanized diet and lifestyle habits are risk factors.

Walking a tightrope

There are two major types of diabetes. The first is called insulin-dependent diabetes, and stems largely from a chronic autoimmune disorder that damages the beta cells of the pancreas, so that they can no longer produce insulin. The prevalence of this type of diabetes is not high, with around 1.7 to 4.5 out of every 100,000 persons affected, accounting for 2.8% of all diabetics. As it occurs most often in children, it is also called juvenile onset diabetes.

Though no one in either Wang Li-hsia's or her husband's families has diabetes, their three children are all prone to the disease. Their eldest daughter developed diabetes when she was one year and three months old, while their second daughter was stricken at age ten. Their third daughter was luckier; though she experienced an attack when she was four, she has remained diabetes-free in the ten-plus years since it was brought under control.

"After one of the children has recovered from an attack, I just collapse from exhaustion," says Wang. Because her children are affected by diabetes, she has devoted herself to helping other diabetes patients, and is currently the director of a diabetes support group at the Cardinal Tien Hospital. When her children were small, she relates, she almost never got a good night's sleep, always on edge as she monitored the children for the sweating or spasms that might signal low blood sugar, prompting her to feed them sugar to prevent them going into a coma. Drawing blood to test sugar levels was very painful, and her children's fingers were jabbed so many times that they became bruised and swollen; eventually she had to begin taking blood from their heels.

After her children began school, Wang began working as a school volunteer. Each time her daughter entered a new class, she would briefly describe diabetes to the teacher and students, hoping their understanding of the disease would enable them to offer timely assistance to her child, if it was needed. After all Wang's arduous effort, her daughter is now in her twenties, able to take care of herself. But Wang now has to deal with issues related to her daughter's romantic relationships and social activities. Just thinking that other young people can eat, drink, and be merry to their heart's content, while her daughter must stand off to one side, testing her blood sugar and giving herself insulin shots, breaks Wang's heart.

Death rate from diabetes source: DOH / graphic by Lee Su-ling

A bland life?

Type 1 diabetes does not strike only children, and 57-year-old Wang Mei-yu is proof. When she first developed the disease in her forties, the only sign was that she never seemed able to drink enough to quench her thirst. She would eat continually, but couldn't sate her hunger, yet she shed five kilograms in a single month, so that looking at herself in the mirror made her afraid. When she went a hospital for a physical examination, she learned she had diabetes.

"At first, I felt restricted. If I ate too much, my blood sugar would rise, but if I didn't eat, I would faint. Not being able to eat much of the things I liked really took a lot of the joy out of life," she says. After some time, though, she learned to accept the circumstances, and began adjusting her diet and lifestyle. Now, she gives herself five injections of insulin a day, and managing her diet is getting easier and easier, while her fainting spells have become less frequent.

Type 2 diabetes is also known as non-insulin-dependent diabetes. The causes of this type of diabetes are complex, with the main one being insulin resistance in the tissues targeted by insulin-muscle, fat, liver-leading to a loss in the hormone's efficacy. According to studies, 97% of the diabetes cases in Taiwan are of this type.

Type 2 diabetes has become more prevalent in recent years, and is affecting younger segments of the population. Tai points out that at the time Taiwan's first diabetes survey was undertaken in 1970, most victims were in the middle-aged and elderly population. However, in recent years, it has been discovered that the segment of the population afflicted by diabetes is growing broader.

A survey by Chuang Lee-ming, an internist at NTUH, found that Type 2 diabetes-which in the past had been considered a disease of adults-has in recent years surpassed Type 1 diabetes to become the predominant form of the disease in children.

In 1999, the results of urine and blood tests on children aged 6 to 18 revealed that of 343 children diagnosed with diabetes, Type 2 was found nearly six times as often as Type 1. Chuang's research demonstrates that poor diet and obesity are strongly correlated with the increase in incidence of Type 2 diabetes in children. Of the children with Type 2 diabetes, 54% of boys and 44.4% of girls were overweight. The risk of Type 2 diabetes among children whose body mass index (BMI-the ratio of body weight in kilograms to the square of height in meters), was in the top five percent, was 18.8 times higher than for children in the bottom 50%.

Modern diets are plagued by large amounts of sugar, salt, and oil. Even fruit, bred to maximize sweetness, represents a latent threat.

The price of plumpness

Although the precise causes of diabetes remain a mystery, most studies indicate that modern lifestyles and living environments, as well as hereditary factors, play a role.

Tai Tong-yuan, who been researching diabetes for more than 30 years, points out that diabetes prevalence is closely related to the level of economic development, Westernization of diet, and urbanization. Highly urbanized areas such as Hong Kong and Singapore have prevalence rates of diabetes of around 7 to 8%.

Diabetes is also closely linked to hereditary factors. Taking Type 2 diabetes as an example, if one parent has diabetes, a child has a 20% chance of also having the disease. If both parents are diabetic, their children's risk of getting the disease is 40 to 50%.

Worthy of attention is the fact that although the prevalence of diabetes is high in Western countries (close to 10%), if current trends continue the incidence among Asian peoples, due to physiological factors, will reach even higher levels. Moreover, the rate of increase in diabetes incidence is even faster than in Western countries. This is due to the so-called "thrifty gene" phenomenon.

The thrifty gene theory hypothesizes that because of harsh living conditions in Asian countries during ancient times, individuals with a genetic endowment that enabled them to more efficiently store fat as a hedge against times when food was scarce were more likely to survive the natural selection process to reproduce. Now, though the environment has improved and food is no longer difficult to obtain, the thrifty gene continues to exert its effect, with the result that the person easily accumulates body fat and becomes obese-an important risk factor for diabetes.

In the past ten years, both developed and developing countries have seen their prevalence of obesity increase to between 10 and 40%, with some countries surpassing 50%.

In recent years, the proportion of the population in Taiwan that is obese has been on the rise. According to statistics from the Department of Health, three out of every ten adults is overweight or obese.

In past times, being overweight was a sign of affluence, but today it's the source of numerous diseases. Obesity is not only an enemy of beauty, but also a menace to health. Diabetes, strokes, cardiovascular disease, high blood pressure, and kidney disease all share obesity as a risk factor. According to studies, among victims of Type 2 diabetes, 60% are either obese or overweight.

Exercise is the best way to maintain health, and this is even more true for diabetics. Maintaining a regimen of regular exercise requires determination, however.

An invisible killer

What are the signs of diabetes? How can it be detected early?

Drinking much, eating much, urinating much, weighing less-these are the signs of diabetes that people are familiar with. However, in some people diabetes does not make itself so evident. In such people, elevated blood sugar does not lead to any discomfort. Some people discover they have diabetes when they seek medical assistance for seemingly unrelated symptoms, such as numbness in the limbs, itchy skin, erectile dysfunction, or poor wound healing.

Tsai Shih-tzer, a doctor in the Department of Endocrinology and Metabolism at Veterans General Hospital Taipei, points out that although, according to estimates, there are close to 1 million diabetes sufferers in Taiwan, National Health Insurance data show that diabetes patients under medication number only 600,000 to 700,000. In other words, excepting persons whose diabetes is mild enough not to require medication, roughly 30 to 40% of all diabetes victims are not even aware that they have the condition.

Ignoring undiagnosed patients, even persons who recognize that they have diabetes do not all actively seek treatment.

Like other chronic diseases such as hypertension and heart disease, diabetes currently can be controlled, but not cured. However, if it is properly controlled and if complications are avoided, the patient can live with the disease and maintain a good quality of life.

"Diet is foremost, with exercise next in importance," says Tai Tong-yuan, explaining the principles behind the treatment of diabetes. "Restricting one's diet is the most difficult, and using medication is the easiest. But if the diet is controlled properly, and the patient exercises regularly, it's even more effective than using drugs."

For diabetes patients, exercise is a boon. Tai points out that exercise not only burns calories but it also reduces the body's resistance to insulin, allowing the hormone to exert its effects. Some people can thereby achieve the effects of medical treatment without taking any medication.

If an appropriate diet is followed and the patient gets enough exercise, but blood sugar levels still cannot be brought under control, blood sugar reducing drugs must be added to the treatment regime. If oral medications prove ineffective, the final resort is to use injected insulin to treat the diabetes.

If diabetes is not properly controlled, various complications may arise. Therefore, monitoring blood sugar levels is critical for diabetics.

No cure, only control

Diabetes is a chronic illness, and there is no danger of immediate death. However, a number of complications may result from poor long-term control over blood sugar levels. These include macrovascular disorders (cardiovascular disease), microvascular disorders (retinal and kidney disease), and nerve damage.

Forty-year-old Ku Kai-hui has undergone dialysis for more than ten years, and because of retinal damage and cataracts has had three operations. The reason for these health problems can be traced to poor control over her diabetes.

"I didn't have any of the usual signs of diabetes, and didn't experience any physical discomfort," Ku says, recalling the year when the disease first appeared. She was pregnant at the time, but the fetus died in her womb. When she subsequently received a physical examination, she unexpectedly learned that she had diabetes. Only 26 at the time, she refused to believe the news, and chose instead to avoid facing the facts. Later, when low blood sugar led to full-body shivering and incoherent speech, her family thought she was possessed by evil spirits, and sought out remedies from a divine source.

The result of delaying treatment and taking useless remedies was that complications quickly developed. After several attacks of chronic pyelitis, she was forced to undergo dialysis. "Nearly all the people I met in the dialysis room were diabetes patients," Ku says. Now, she has dialysis three times a week, and cognizant of her own experiences, urges fellow diabetes sufferers to face their illness bravely and control it properly.

In fact, the cause of death for most diabetics is not ketoacidosis (high levels of ketones in the blood) resulting directly from diabetes, but the auxiliary effects of the glycosylation of blood vessels caused by high levels of blood sugar over a long period of time. This glycosylation causes the blood vessels to become more easily ruptured and more difficult to repair, leading to complications such as heart, cerebrovascular, and kidney ailments.

Cardiovascular disease is the leading cause of death for diabetes patients (66%). Diabetes victims suffer from cardiovascular disease at a rate two to four times higher than in persons without diabetes. Additionally, diabetes patients have a 27% chance of suffering a stroke during their lifetime, a percentage that is twice as high as in the rest of the population.

Some complications, while not fatal, still have a severe impact on the patient's quality of life. Eye and foot ailments are quite common among diabetes patients, and have become the most common factor behind adult blindness and amputations.

There are studies showing that a quarter of diabetes patients have retinal ailments at the time their diabetes is diagnosed. Clogging of peripheral arteries, impaired wound healing and bacterial infections often lead to foot ailments in diabetes patients. According to a Belgian study, diabetes patients have a 15 times higher risk of needing a limb amputation than normal persons, yet 75% of such amputations can be prevented.

Modern diets are plagued by large amounts of sugar, salt, and oil. Even fruit, bred to maximize sweetness, represents a latent threat.

Patient self-management

"The earlier you accept the situation and work at controlling it, the fewer complications there will be," Tai Tong-yuan points out. Diabetes is a very difficult illness to deal with, and some people are simply not willing to accept that they have it. But it's impossible to escape the shadow of the disease, and therefore, the proportion of patients afflicted by depression can be high. Tai says that unlike the treatment of infectious diseases, where success or failure depends largely on the skill of the physician, the efficacy of diabetes treatment rests mostly with the patient. The physician can only provide suggestions, and prescribe mediations for the patient to take, but everything else depends on the patient himself.

Use of diabetes educators is one approach for helping diabetes patients learn how to control their illness.

In earlier times, because there was no one to provide guidance, some patients even thought that insulin injection solution was supposed to be drunk," relates Sugar Piyun Li, a certified diabetes educator with the Formosan Diabetes Care Foundation. Tasks like taking diabetes medications, foot care, blood sugar tests, dietary control, and the prevention of complications are extremely complex, and they can't be adequately described in a few sentences. The physician cannot possibly explain these procedures clearly in the short time allowed for outpatient visits. Therefore, the role of educators is particularly important.

Wang Yi-ching, a nurse at NTUH's Diabetes Rehabilitation Center, notes that because of our distinctive dietary culture, Chinese dishes generally contain a large number of different foods, rather than a single ingredient. Therefore, adjusting them to make them suitable for diabetics is no simple matter.

Since 1990, the Department of Health has subsidized organizations providing educators to assist diabetics. However, because the criteria for receiving subsidies are strict, no more than one-third of the diabetics in Taiwan are cared for by the more than 130 such organizations. In 1998, the Bureau of National Health Insurance began a trial with the Shared Care for Diabetes program. Health care institutions need only conform to the specified procedures, and the National Health Insurance program will provide each patient NT$1000 annually in educator fees, while also providing a two-week health education course.

Dr. Tsai Shih-tzer of Veterans' General Hospital, who is also director of the Taiwanese Association of Diabetes Educators, believes that the fact that 12% of health care resources are used by diabetics, who make up less than 5% of the general population, shows that Taiwan provides an adequate level of support to diabetics.

"Taiwan's concern with diabetes is laudable," Tsai says. In the past, medical training emphasized the care of patients with acute or severe symptoms, while it provided less hands-on training for the care of chronic diseases. The founding of the Shared Care for Diabetes program can serve as a model for other chronic disease care efforts.

Still, Taiwan's health care system is not as robust as it could be, compromising the effectiveness of chronic disease care.

"Present medical care practices are least suited for the care of chronic disease patients," Tai points out. Nearly all diabetes patients are treated in large hospitals, consuming time and money without achieving the best possible control over the disease, and this is the biggest obstacle to effective care. As an example, NTUH has 20,000 diabetes patients to care for in a year, but it has only two nurse educators and one nutritionist, clearly insufficient for the caseload.

Diabetes

Living with diabetes

"Chronic diseases must be countered at their source," says Pesus Chou, a professor at National Yangming University's Community Medicine Research Center. Once diabetes shows clinical symptoms, it is already too late to prevent, and therefore diabetes prevention must focus on avoiding risk factors. There is no other way but to eat less and exercise more.

"Enable diabetics to care for themselves, and make them understand the principle that we can only show them what to do, but that the actual doing is up to them. That's the only way diabetics can gain control over their illness," says Tsai.

Diabetes

Though the precise mechanism by which diabetes develops remains unknown, obesity, stress, genetic predisposition, and urbanized diet and lifestyle habits are risk factors.

Though the precise mechanism by which diabetes develops remains unknown, obesity, stress, genetic predisposition, and urbanized diet and lifestyle habits are risk factors.

Modern diets are plagued by large amounts of sugar, salt, and oil. Even fruit, bred to maximize sweetness, represents a latent threat.

Diabetes is the most common reason for limb amputation among adults. After getting fitted for a prosthetic device, the patient must undergo extensive rehabilitation before being able to use the artificial limb naturally.

Diabetes is the most common reason for limb amputation among adults. After getting fitted for a prosthetic device, the patient must undergo extensive rehabilitation before being able to use the artificial limb naturally.

Modern diets are plagued by large amounts of sugar, salt, and oil. Even fruit, bred to maximize sweetness, represents a latent threat.

Though the precise mechanism by which diabetes develops remains unknown, obesity, stress, genetic predisposition, and urbanized diet and lifestyle habits are risk factors.

Diabetes is the most common reason for limb amputation among adults. After getting fitted for a prosthetic device, the patient must undergo extensive rehabilitation before being able to use the artificial limb naturally.

Though the precise mechanism by which diabetes develops remains unknown, obesity, stress, genetic predisposition, and urbanized diet and lifestyle habits are risk factors.

Modern diets are plagued by large amounts of sugar, salt, and oil. Even fruit, bred to maximize sweetness, represents a latent threat.