The condition is on the rise, but we're not very good at spotting it. Sylvia Thompson reports on efforts to do a better job
The silent killer, as diabetes is sometimes called, is believed to be the fourth biggest cause of death in Ireland. Complications due to undetected or inadequately controlled diabetes cause about a quarter of heart attacks; diabetes is also the leading cause of blindness in the working population and the leading cause of kidney failure in the general population.
These shocking figures highlight the importance of identifying everybody with diabetes. Yet we know perhaps only half of them; the total number of people with diabetes is close to 200,000, or 5 per cent of the population. Tracing them, then managing their condition before complications develop, could be the key to tackling the disorder.
But it's a complex task, not least because many people with diabetes can stay symptomless for years.
It is often only when complications develop that they first arrive at their GP's surgery or hospital's accident-and-emergency unit to have their condition discovered.
Once diagnosed, diabetics face a lifetime of monitoring their blood glucose levels. They also need regular medical checks to keep track of their cholesterol level, blood pressure and glucose level in their red blood cells. Ideally, diabetics should also visit an ophthalmologist and a podiatrist each year, to check for sight loss or treat poor circulation in the feet before more serious conditions develop.
Last year, the Diabetes Federation of Ireland set out the care that diabetics will need in the future. Diabetes care currently costs €350 million a year, more than €200 million of which is spent treating the costly complications of the disease: kidney failure, heart disease, sight loss, gangrenous feet. It believes the money would be better spent on preventing or delaying the complications' onset.
"The emphasis needs to be on early diagnosis and access to treatment," says Anna Clarke, the federation's health promotion officer. "The services in Ireland for diabetes are grossly inadequate, and although in Dublin there is better access to specialists, living in the capital is no better for patients in terms of waiting time for appointments.
"There has been a slight improvement in services - the appointment of two endocrinologists and some appointments of diabetes nurses - since we published our report last year, but the number of patients diagnosed has increased to negate the improved services. We need a major input of money and manpower both at primary-care [GP\] and secondary-care \ levels."
The report, which was compiled for the federation by the Diabetes Service Development Group, stresses the importance of co-ordinating services between GPs, other community-based health professionals, such as dieticians and podiatrists, and hospital outpatient clinics.
One pilot scheme that aims to manage patients more efficiently is the Diabetes Shared Care Project at two Dublin hospitals, St James's and the Adelaide & Meath. "Diabetes is among the most data-intensive of any disease, with the number of healthcare professionals involved in patient care far greater than in most other conditions," says Patrick Jordan, its project manager.
As the project gives doctors and other health professionals on-screen patient records, including details of laboratory-test results, prescribed medication and clinic visits, they can more easily identify risk factors and reduce the likelihood that patients will develop complications.
"We also aim to give patients access to their records online, so that they can enter their home blood-glucose-monitoring results. This will provide the hospital with data [to monitor the patients' condition\] and allow the patients to view their readings over time, giving them a better understanding of how well they are managing the condition."
Gerard Boran, a chemical pathologist and the project's leading physician at the Adelaide & Meath, adds: "Such a system will include blood-glucose-test results from GPs in the community, which will allow us to place alerts on patients in a pre-diabetes state. Studies have shown that if diabetes is caught early enough, up to 58 per cent of cases can be treated with lifestyle interventions alone" - that is, changes to diet and exercise.
Anna Clarke says the Diabetes Federation of Ireland would like to see a national register of diabetes patients, so they can be recalled more easily, services streamlined and future resources planned. "The majority of patients with diabetes are not receiving a standard of care that is internationally recommended, which is directly due to cancelled appointments and delays in accessing the services."
As far back as 1989, the Department of Health and Children, together with more than 50 other countries, signed an international declaration agreeing to reduce new blindness due to diabetes by at least a third, reduce the number of diabetics entering end-stage kidney failure by at least a third, reduce the rate of limb amputations for diabetic gangrene by half and drastically reduce the number of diabetics with coronary heart disease. Fourteen years later, Ireland has shown very little progress on any of the targets.
The Diabetes Federation of Ireland is hosting a diabetes health awareness day at the RDS, Dublin, on Sunday from noon to 6 p.m. It will include free diabetes screenings, with dieticians, ophthalmologists, podiatrists and diabetes nurses available to answer questions. The federation's helpline is 1850-909909. Its website is www.diabetes.ie. World Diabetes Day is on Friday (see www.idf.org)
What is it? Diabetes is a chronic disorder caused when the pancreas is bad at producing insulin, a hormone that regulates glucose in the blood. Type 1 diabetes, which is usually diagnosed in childhood, occurs when little or no insulin is produced. Type 2 diabetes occurs when the pancreas produces too little insulin or can't properly use insulin due to a build-up of fat tissues. Obesity and lack of exercise are the chief causes of the huge jump in type 2 diabetes in the Western world. Type 2 diabetes accounts for 90 per cent of diabetes patients, who can go undiagnosed for up to seven years.
What are the symptoms? Diabetes prompts an unquenchable thirst, a frequent desire to pass urine, extreme tiredness, genital itching and blurred vision. It is diagnosed by a blood test.
What is the treatment? Type 1 diabetes responds to frequent self-administered injections of insulin. Type 2 diabetes is treated with drug therapy, dietary changes and regular exercise. If detected early, it can be controlled through regular exercise and dietary changes alone.
Is it preventable? Yes and no. Because it has a genetic component, diabetes can't be prevented by a healthy diet and regular exercise alone. Even people with family histories of type 2 diabetes can prevent complications, however, by living healthily, keeping an eye on their blood glucose levels and taking prescribed drugs. The life-threatening nature of diabetes results from complications such as kidney failure, heart attack and stroke rather than from the condition itself.Ann, who is 68, was diagnosed with type 2 diabetes two years ago. She had put her tiredness down to her underactive thyroid gland, but her GP found she had diabetes after a blood test. She started to take tablets, adjusted her diet and exercised more. "I hated vegetables and never ate much fruit. Now I eat lots of vegetables and I walk every day," she says. She has painful hands and feet, but her biggest concern is that her blood-glucose level is showing no sign of falling despite her lifestyle changes and drug therapy.
Helen O'Reilly, a diabetes nurse at the Adelaide & Meath Hospital's diabetes day centre, says Ann's next step may be to inject herself with insulin, as the oral medication isn't sufficient. "Many patients are afraid of taking insulin, but in fact it comes in a pen which you prick into the fatty part of your leg or tummy. The process doesn't even hurt as much as the finger-prick test diabetes patients do several times a day to check their blood glucose levels," saysO'Reilly.
Charlie, who is 39, was diagnosed with diabetes 10 years ago, after his father, who was also diabetic, checked his blood glucose levels. "Initially I was in denial, and for years I remained somewhat blasé about it, because I didn't have any symptoms. But about two years ago I realised this is serious and not to be messed with. Since then I have cut down on alcohol, and 10 months ago I gave up cigarettes. After I gave up cigarettes I put on one and a half stone, which threw my blood sugar levels into complete disarray.
"So I took up cycling to lose the weight. So far I've been lucky, but my dad died at the age of 57 of a massive coronary. I have two younger brothers who are also diabetic, one of whom is not looking after himself. The thing about diabetes is that you have to take it seriously."