Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, M.D.
14 November 2001

DIABETES MELLITUS – AN UNFORGIVING DISEASE

     The spectrum of diseases that humans encounter contain many that are potentially fatal and yet if treated effectively, permanent or disabling consequences are avoided.  An example would be pneumococcal pneumonia.  This very common condition strikes without any predictable warning and if left untreated is fatal in more than half of the individuals who encounter it.  Yet if a person is given antibiotics as simple as plain penicillin, the vast majority of patients recover with no permanent damage.  The lung area that was affected by the pneumococcal bacteria will appear normal after just a month or so.  Even heart attacks in which a portion of the heart muscle is permanently damaged, can be survived in 50% of the cases with no real change in the persons capability.  If a person is willing to change their lifestyle at that point and deal with the underlying risk factors causing the heart attack, many years of comfortable and productive life are still available.

    In the past year, the government of the State of South Dakota has become very interested in the topic of diabetes mellitus.  The governor has arranged for screening programs and awareness programs to alert the public about diabetes and its consequences and yet somehow the message doesn’t seem to be received by some individuals in desperate danger because of their neglect of a diabetic condition.

     A recent example illustrates the problem.  A 43 year old gentleman was brought to the hospital because he had a major infection on his foot.  He had stepped on a nail 3 weeks before but it had not been particularly painful and he felt that it would get well.  He had been diagnosed with diabetes at age 29 when his wife was pregnant with their third child.  She was being checked for diabetes in relationship to her pregnancy and he made a joke about how often he had to urinate so his blood sugar was checked too.  At age 29, his blood sugar was 350 mg%, a dramatically high level.  He was slightly overweight but was a physically active individual and he elected to “treat it with diet and exercise”.  Somehow, he didn’t get the message of how dangerous what he was doing could be.

    For three years, he carried on his normal activities as though nothing was wrong.  He made a gesture at weight loss but then regained the weight within a few months.  Then in the fall of 1990, he went elk hunting at around 9,000 feet elevation.  The physical stress of this situation along with the dehydration that can occur, lead to a pneumonia and the development of a very dangerous condition called diabetic ketoacidosis.  He was treated at a hospital in Colorado, started on insulin treatments and discharged home.  On returning to South Dakota, he felt so good in this few weeks, he just stopped the insulin feeling that he didn’t really need it.  After all, he was feeling good why should he be taking these silly shots?

    In 1994, the company that he worked with obtained a new health insurance program that strongly suggested all of the insured individuals have a periodic health check.  At that time, his blood sugar was checked and again found to be in excess of 300 mg% with him on no treatment. The insurance company was well aware of the horrible expense they were facing if this gentleman didn’t begin to care for himself better and multiple letters were sent.  Eventually, the gentleman was started on a medication and urged to check blood sugars.  He says that he did take the pill and checked his blood sugars for awhile but they seemed o.k. so he didn’t think he needed to check them anymore.  He was feeling good, so why should he worry?

    I first saw this gentleman in 1997, 10 years after his diabetic condition had begun.  A blood test called a glycosylated hemoglobin was checked and found to be 14%.  Normal value is up to around 6%.  Severe damage to the body is occurring when the value gets above 9%.  His blood sugars were averaging more than 300 mg% all of the time.  His eye exam showed that he had already begun to develop disease in the blood vessels of the eye although his vision was normal.  His urine showed a small amount of protein present and his blood pressure was slightly high.  He was started on a medication to protect his kidneys, his eyes and his blood pressure along with strong recommendations that his eating habit needed to be modified and insulin was going to be required.  His insurance program provided him with a glucometer so that he could measure his blood sugars himself and he was instructed on its use and the need to check blood sugars several times a day in a random fashion to be sure that they remain in the normal range.

     In spite of letters and phone calls that he needed to come to the clinic for followup, he said that he was feeling fine, that he didn’t need to come into the clinic, that he would call if he needed something.  He came to the clinic once a year over the next several years.  Blood tests run at that time, showed persistent elevations in the glycosylated hemoglobin.  On one occasion, he got as low as 11%, on another occasion, he had a value of 14%,  both dangerously high levels indicating  deteriorating effects from his diabetic condition.  On each occasion, he indicated that he was feeling fine and didn’t want any additional medications or tests ordered.

    So finally, he comes in for this hospitalization with a severe infection in his right foot and it is found that he has diffuse deterioration of the blood vessels to his eyes.  In addition, there is the same type of damage that has happened to his kidneys and he cannot feel the bottoms of his feet.  This loss of feeling explains why sticking the nail in his foot several weeks before had not been painful.  At the time of this hospitalization, he seems more eager to care for his diabetic condition and during the process of taking his history, the gentleman offered that his brother, who is also diabetic, had recently had a foot amputated because of a diabetic infection.  The patient at this time, wants to know if he is going to have to have his foot amputated because of this infection.

    Fortunately, the infection on his foot can be treated and the foot saved this time.  With the loss of feeling in his feet, he can not protect them in the way that a normal person does.  If he gets a cut or a blister or a thorn in his foot, he won’t feel it.  So unless he careful inspects his feet on a daily basis, he will not know that anything is wrong.  Future foot infections are predictable unless he becomes very meticulous in his foot care.  He has been instructed on that now.  He was instructed that he needs to get to the eye doctor and get laser treatments for his eyes in order to protect his vision.  He says that he can see just fine, that things are a little blurry but not bad.  He was instructed that complete blindness is a predictable event in the next two years unless, the diabetic condition is meticulously controlled and laser treatment to his eyes is done now.

    Lastly, it seems that his kidneys are loosing large amounts of protein.  This finding is a marker for a need for kidney transplant or artificial kidney treatments within the next five years.  His risk for having a heart attack in the next eight years (by age 51) is 6 chances out of 10.  He runs a 30% chance of dying by age 50.

    All of the abnormalities that are present at this time, are not reversible.  Diabetes is a very unforgiving disease and once the abnormalities develop and the degenerative changes have occurred, blood vessels don’t get well, they don’t grow back and the vision that is lost, the limbs that are lost and kidney failure that occurs doesn’t go away even when the person finally decides that the diabetic condition is worth paying attention to.  Diabetes needs to be addressed at the earliest possible time to prevent the degenerative changes and the grief that comes with loss of vision, loss of feet, and the need for artificial kidney treatments.  Those individuals who are very overweight, with slight high blood pressure and “a touch of diabetes” need to get serious in caring for their condition.  Diabetes will not forgive them for neglecting it.  Diabetes will extract an exorbitant price.  Your local clinics are well versed on how to care for diabetes and can provide education and support in preventing the progression of this dreaded disease.