What is Diabetes- A Malaysian tale for the Malaysian Layman

Diabetes is still a disease that is very much misunderstood by our community in Malaysia, despite the fact that every one in every five adults have it. This article aims to explain the disease in the most Malaysian way possible.

Now, the term diabetes is translated as "Sweet Urine" in both the Chinese and Malay Language, whereas in Tamil, It is translated as "Sugar Disease". While the terms are somewhat accurate, they do not explain the true nature of the disease.

Diabetes is essentially a disease of the hormone called Insulin.

To understand what Insulin is, first we need to know where the pancreas is in our body.

Refer to the picture of Hang Tuah Above. You see the yellow part shaped like a leaf? Yah, that's your pancreas. It is situated just behind your stomach, and below the liver.

Now your pancreas does a lot of stuff, but one of the most important hormones it produces is called insulin. Insulin, when released into our blood, goes to all parts of our body.

Insulin tells our cells, "Hey, open your doors and bring those sugars from the blood inside!".

After which your cells obeys, and bring in the sugars from the blood and use it to produce energy.

There are 2 major Types of Diabetes: Type 1 & Type 2. If you are an adult interested in the more common Type of Diabetes, skip straight to Type 2 Diabetes

Type 1 Diabetes

In a Type 1 diabetic, the pancreas CANNOT produce insulin at all (or almost none at all). That way, our cells cannot open it's doors to bring glucose (sugar) inside, leaving ALL the sugar floating around in our blood, and eventually passing out through our urine. This is the reason blood sugar and urine sugar are both high in diabetics.

But that's not the real issue. The REAL issue is, our cells now have NO fuel to produce energy! Therefore, it will start burning itself (or energy stores) to produce the much needed energy to keep us alive. When this happens, our cells release something called ketones into our blood. These ketones make our blood very acidic, and if severe, it can kill us. This is why if a Type 1 Diabetic doesn't get insulin treatment for a few consecutive days, they will probably die.

The good news here is Type 1 diabetes is not that common in Malaysia. Of all the diabetes patients in my Pharmacy, only two are Type 1 diabetics (which make up less than 1% of the total diabetes patients). Type 1 Diabetes usually affects children, and only in extremely rare cases, it can happen in adults--a condition we call LADA.

Parents of Children with Type 1 diabetes need not be too sad though, as their child can lead a very normal life, as long as they can get their insulin jabs right. A comic strip showing the life of a happy and active diabetic kid can be found here. As for why it happened to your child, experts still cannot give us a very definite answer, though most of us believe that it is either an infection or autoimmune in nature, or an infection that lead to the autoimmune destruction of the insulin producing cells.

For the rest of the 99 Plus % of diabetics, well, you're probably a Type 2 Diabetic

Type 2 Diabetes

Type 2 diabetes is the most common form of diabetes in the world. In this group of patients, the problem stems from OVEREATING, and a sedentary lifestyle. The story of a typical Malaysian Diabetic begins like this:

Once upon a time, Ali was a healthy, normal adult. Being Malaysian, Ali LOVES food. So everyday for breakfast, lunch and dinner, Ali will join his friends on the endless food hunt for the best food Malaysia has to offer, which unfortunately is usually too high in fats and carbohydrates. Examples of the food are like Nasi Lemak for breakfast, Char Koay Teow for Lunch, and Nasi Kandar for Dinner. Mind you, Ali DOES NOT like sweet food, and almost NEVER eats sweets! (because he doesn't want to become a diabetic)

Little does Ali know that the high Carbohydrate containing food that he takes (rice, noodles, bread, koay teow, Mi etc etc) will be TRANSFORMED into sugar in the intestines, and ALL this sugar will go into the bloodstream! So, Ali's poor pancreas will have to work extra hard to produce more insulin, so that our cells can take up the extra sugar in the blood. Inside our body, it is like our pancreas is shouting LOUDER to our cells:

"OPEN YOUR DOORS! Work Faster! Too much sugar is in our blood!"

Now when you shout too much at somebody, every single day, that person is probably going to grow immune to your shouting won't he. The same goes for our cells. The cells tend to respond LESS to the increased amount insulin that is being released by our pancreas. So what do we do next? Well we shout even louder.

Our pancreas will be forced to produce more and more and more insulin every day because our cells are getting more and more resistant to it's "shouting". We call this Insulin Resistance, and it is one of the main causes blood sugar is high in a Type 2 Diabetic.

All of this is happening in Ali's body, but Ali doesn't know that. Because of his career, Ali now has more money to spend on food, but less time to exercise. That also explains the big belly Ali now has. Apart from making Ali look like Baymax from Big Hero 6, the big belly has a much more sinister role to play. The fat cells inside Ali's belly secretes a chemical called adipokines, that further harms our beloved and overworked pancreas.

So Ali's pancreas is now shouting as loud as it possibly could, and adipokines are starting to attack it. But does Ali do anything to help his poor pancreas? No, of course not. Just like most Malaysians, Ali continues putting excessive food in his mouth, day in, day out.

Until one day, Ali's pancreas breaks down. He had pushed his pancreas too far and too hard, for too long. Instead of shouting at the cells to open it's doors, now it can only whisper. But the cells have grown too tolerant to the tiny amount of insulin able to be produced by the worn out pancreas. And therefore, Sugar in Ali's blood rises drastically, and Ali's urine turns sweet.

This is the day Ali becomes, a True Diabetic.

Over the next month or so, Ali will feel tired, and his body weight will drop drastically. He doesn't understand why, because he has been eating as usual. Little does he know that perhaps only 20% of the sugar in his blood will ever reach the insides of his cells to be used as fuel. With that little fuel, the energy being produced is enough to keep him alive, but not enough for Ali to function perperly. His body will also burn itself up for fuel slowly, therefore making Ali's body weight drop.

Apart from this, Ali seems to go to the toilet to urinate a lot more often than usual. This is because Ali's high blood sugar will cause water to be drawn into the bloodstream, and later into our bladder, making him pee more. And because all the water has gone into his urine, Ali also feels constantly Thirsty.

Now at this point, if Ali seeks proper medical treatment, he can bring his sugar level back to normal, and although there is no cure for diabetes right now, at least he can live a fairly normal life to a ripe old age, with the help of medication.

But Ali is a Malaysian, and after the doctor tells him he is a diabetic, Ali refuses to take any of the medication the doctor prescribes to him. The reason being, Ali chooses to believe the Lorry driver's story that if he takes Diabetes Medication, his kidneys will get damage, and then his feet will be chopped off.

Only in Malaysia the lorry driver, the uncle at the market place and the ever-so-helpful relative is more expert in diabetes than the doctors and pharmacists. Or so he thought.

So Ali embarks on an expensive journey to find the miracle cure for his diabetes. He tries all the herbs he can find, religiously boiling them each night to drink. As he tests his sugar, Ali is delighted that the the herbs could bring his sugar down SLIGHTLY. A doctor or a pharmacist would have been puzzled over why Ali chose to accept the unstudied herb that could SLIGHTLY improve his sugar levels over the common Diabetic Medicine called Metformin, which is ALSO DERIVED FROM A PLANT called the French Lilac (refer picture below).The French Lilac

Incidentally, Metformin is being sold at RM1 per strip of 10 tablets at most pharmacies, and has been proven to be safe for over 60 years. 

 

But Ali is a Malaysian, and medical evidence doesn't really make much sense to him. After trying the herb for 6 months, Ali's sugar begins to creep back up. To be fair, it probably was't the herb's fault. Diabetes is a progressive disease, and if left uncontrolled, the disease (or more accurately the rising blood sugar) will actually harm the pancreas more and more. The poor pancrease will get weaker and weaker, and insulin levels fall lower and lower. This is what we call glucose toxicity. In turn, Ali's sugar levels will increase steadily.

Now Ali is getting frustrated again and has almost given up on managing his diabetes. And this is the time where direct selling "miracle" supplements come to play. Ali's colleague, Farid has been posting benefits of the wonderful XXX Apple Stem Cell product on facebook. Farid claims that the product has cured so many diabetics, and even shows  "before and after" photos of successful patients. So Ali spends most of his savings to purchase "member priced" products at a very good price, according to Farid. Now Ali has a year's supply of XXX stem cells, and he takes it diligently to get cured.

After half a year, Ali finally accepts and realises that XXX Stem cell is NOT going to cure his diabetes. This is when he sees his friend Beng Seng Posts this revolutionary product called ZZZ Deer Placenta. It costs RM8888 for a box, but it could last you one whole year. Best thing is, it seems to be able to cure EVERY disease in the world. This is my cure Ali thinks.

So he maxes out 2 credit cards and purchases this new Miracle cure. And starts taking this as if his life depends on it. This cycle goes on for more than 5 years, and still, Ali's blood sugar has never been normal.

And all this time, Ali could have achieved perfect diabetes control with a fraction of the money he has spent had he listened to his doctor in the first place.

But what can we say? Ali is a Malaysian.

One morning, Ali woke up to find that he had problems telling time from his clock. He notices that the area in the center of his vision is blurred, and it seems that black spots are blocking his vision.

Scared, Ali decides that it is time for a real doctor's check up at the Eye Clinic. He has been diagnosed with Diabetic Retinopathy, a condition where the tiny blood vessels in the eye has leaked, and has caused damage to the most important part of the eye for seeing--the macula.

Ali didn't know, that the excess sugar in his blood does not only make his blood taste sweet. These sugars are DESTRUCTIVE. They harm all the small, tiny vessels in our body, causing damage to our eyes, kidneys, and nerves. These high levels of blood sugar also impair our body's healing ability, making our wounds heal a lot slower than normal.

So the Dr has no choice but to give laser treatment to Ali's eyes, halting further damage. But this at the same time permanently burns black spots into Ali's vision. Now Ali is beginning to feel scared. For the first time in his life, Ali asks the doctor if there is any medication he can take.

After starting on oral medication, Ali's blood sugars came down, albeit not perfectly. Now he takes his medication regularly, but never checks his blood sugar readings on his own. He will wait 6 months later, during his next doctor's appointment before he checks his sugars again. 

Big Mistake. Diabetic medication needs to be titrated (dose adjusted slowly) to fit a person's diseases, as every person needs different doses of medication.

Turns out that Ali's condition was worse than expected. And for the entire 6 months, Ali's medication had not been strong enough to get his diabetes under control. During this time, Ali's pancreas had decided to call it quits, and almost stop working completely. His sugar level rises back up to dangerous levels, and his eye condition worsens. 

During his appointment with the doctors, the doctor has no choice but to put him on insulin injections, to replace his failing pancreas. Modern insulins are manufactured to mimic HUMAN insulin, and does not have any known serious long term side effects. If Ali were to listened to his doctor and started to jab his insulin, his condition will at least not worsen.

But then again, Ali is a Malaysian.

He is worried that other people will think that he is a drug addict, and feels too ashamed to bring his injection out in public. As a result, Ali only jabs his insulin in the early morning and before bed, when he is alone in his room. He misses 2 doses of the pre-lunch and pre-dinner insulin the doctor as prescribed. And to no surprise, his blood sugars are still uncontrolled.

One day while walking around the garden, Ali accidentally kicks the edge of a wooden bench. His toe was bleeding, but it wasn't a very bad wound. Not for a normal person that is. Ali washed the wound with clean water, and bandaged the wound up with some gauze rolls. 

But alas, after 2 weeks, the wound had not healed, and the toe has become infected. Only after the toe gave out a very strong smell, Ali went to the doctor. The toe had become gangrenous. This means that a big part of the toe tissue has died, due to the initial infection and subsequent blood supply disruption. The doctors had no other choice but to tell Ali that they had to amputate his toe, as there was nothing more they could do to save the toe. 

But Ali is a Malaysian. And Malaysians never cease in looking for that miracle cure. In Ali's mind, he feels that the medicine given by the doctors to him did not do their job at all. Did he ever think that perhaps he had delayed treatment for too long? Or that he HAD NOT BEEN injecting his insulin AS DIRECTED by the doctors? Certainly not

Now it's back to square one with the search of a miracle cure that could turn his dead toe back to a live one. Again, precious time has been wasted here, and the bacteria has spread throughout the lower leg. Now Ali's life in in danger because if the bacteria spreads throughout his bloodstream, he will have a condition called septicemia, and that could kill him almost instantly.

So the only thing left for the doctors to do, is to amputate his lower leg, right under his knee. Ali is devasated. And instead of learning from his multitude of mistakes, Ali chooses to blame western medicine for losing his leg. He then goes into depression, and gives up all diabetes medication. And what comes next is a series of complications that eventually leads to Ali's death

So there you have it the story of a typical Malaysian Diabetic's sad life cycle. But don't be disheartened by it, as if Ali would just for once did as the doctor told him, the outcome would have been so so different. As a matter of fact, a huge government funded study called the UKPDS showed that if diabetic patients could lower their blood sugar levels to the normal range, these patients could reduce their risk of complications to near normal levels.

Almost as if they were a non-diabetic.

 

So to sum up what we can learn from the story above, keep in mind the following points:

  1. Type 2 diabetes happens partly because of overeating and a sedentary lifestyle.
  2. Please accept your doctor's treatment if you have been diagnosed with diabetes. None of the diabetes medication known today causes kidney failure, and none of these medication causes leg amputation either.
  3. The lorry Driver, the uncle at the market place, and the direct-selling salesmen are NOT TRAINED TO TREAT DIABETES. The "facts" they tell you are most of the time just downright ridiculous
  4. The products sold by Direct selling companies are usually NOT the problem. The problem is usually the outrageous claims by the people who sell them, which are equally untrained in managing diabetes.
  5. Diabetes complications are usually blood vessel related. If the big vessels are affected, the patient will have strokes, heart attacks etc. If the small vessels are affected, the eyes, kidney and nerves will be affected.
  6. Do not delay treatment. A well treated diabetic can lead a very normal and fulfilling life.

 By Lim Kelvin