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How to improve quality of life in people living with diabetes

One out of every five adults in Kuwait has diabetes. As it does not cause any pain or discomfort, it is often ignored till dangerous complications develop. Diabetes reduces quality of life in Physical, emotional and social dimensions.

However with proper care diabetes can be managed well and many of the complications prevented. Thus people with diabetes also can enjoy good quality of life.

What are the common ways related to the physical aspects of the disease that affect quality of life?

On the physical aspects the quality of life can be impaired in several ways. Diabetes affects most organs of the body. “If you know diabetes well, you know most of Medicine" is a common dictum.

Symptoms related to the disease: Tiredness, excessive thirst, urination, hunger, frequent infections, delayed wound healing, problems related to excess weight etc may occur with the onset of the disease itself.

Impairment of QOL due to the complications of diabetes.

Most of the vital organs of the body are affected by diabetes. It affects the heart and blood vessels, kidneys, eyes, skin, legs, brain and nerves mainly.

Another factor which reduces QOL is the side effect of medicines used in the treatment of diabetes. This can be in the form of hypoglycemia (abnormally low blood sugar), weight gain, swelling of legs, breathlessness, chronic cough, increased fractures etc.

What is the relationship between emotions and diabetes?

When diagnosed to have diabetes, most people undergo stress, fueled by fears and myths about diabetes.

Anxiety and Depression are products of the stress. These emotional problems impair quality of life.

Many people do not like to accept that they have an emotional problem or depression. It is more comforting to put everything on diabetes. If one has a ‘masked’ depression, he/she may not feel depressed or sad. If depression is not recognized and treated, it can result in using high doses of medicines or insulin in an attempt to control the blood sugars leading to higher medicine related side effects and diabetes related complications.
Some of the ways in which depression may appear are:
1. Loss of pleasure
The activities you used to enjoy before, eg. seeing a movie, do not give the same amount of happiness.
2. Change in sleep patterns
There can be trouble falling asleep, or you wake often during the night, or want to sleep more than usual.
3. Early to rise
You wake up earlier than usual and cannot go back to sleep.
4. Change in appetite
You eat more food or less than before and put on or lose weight.
5. Trouble concentrating
You can't watch a TV program or read a book because other thoughts or feelings disturb you.
6. Loss of energy
You feel tired all the time.
7. Nervousness
You always feel so anxious you can't sit still.
8. Guilt
You feel you "never do anything right" and worry that you are a burden to others.
9. Morning sadness
You feel worse in the morning than the rest of the day.
10. Suicidal thoughts`- This requires the urgent attention of a psychiatrist.

Most people with diabetes accept that they need to look after themselves through proper diet, exercise, medications and stress relieving measures as required.

Some patients can however carry a good thing too far and become obsessed with diet and exercise or develop phobias related to the possible complications like nephropathy (kidney damage) or neuropathy (nerve damage) which may develop after years of illness.

How does diabetes impair quality of social life?

Social life can be impaired by self or family set restrictions. A person may skip a birthday party because he feels he cannot eat the birthday cake which he is expected to eat at the party. He may not visit friends and acquaintances as he is afraid to drink a coffee or tea they may offer.

The family may act as ' diabetes policeman' denying the person some simple, harmless culinary pleasures.

What are the major complications of diabetes that affect quality of life?

Diabetes is the main cause of kidney failure and in Kuwait most of the patients requiring dialysis have diabetes. It is also the main cause of blindness. The commonest cause of non traumatic amputations of limbs is diabetes. Diabetes increases the incidence of heart attack and heart failure several fold. Paralysis and damage to nerves are another major complication of diabetes. The damage to the nerves and blood vessels lead to problems of dizziness, weakness, numbness, sexual inadequacy etc.

Involvement of blood vessels, nerves and joints of the feet can lead to non healing ulcers, gangrene and amputations.

Is it possible to prevent the complications of diabetes?

Most of the complications can be minimized with good control of blood sugar, blood pressure, cholesterol, other fats and weight along with exercise, avoidance smoking and excessive alcohol consumption. Aspirin in low dose may be used if there are no contraindications like acidity, asthma or bleeding tendencies. GLA, Omega 3 fatty acids and other antioxidants are also advised.

Good emotional health is also helpful.

How can we detect the onset of complications early?

The complications of diabetes are preventable but difficult to treat after they develop. These creep upon the person without causing the victim any discomfort. This gives diabetes the notorious name of a "silent Killer". If detected early, the complications can be prevented to a large extent. Some of the tests that help are

1. HbA1c which is related to the 3 month average blood sugar. Reduction in HbA1c by 1% decreases overall complications by 21%.

2. Urine microalbumin. This detects the onset of diabetic kidney disease. If detected early, there are medicines and other measures to reduce the progress to kidney failure

3. ECG - Coronary heart disease may be silent. Resting ECG which should be done at diagnosis and repeated yearly. A 24 hour ambulatory ECG would pick up changes related to our daily activities before the changes occur on resting ECG. 24 hr ECG also helps to detect early cardiac autonomic neuropathy. Treadmill and nuclear studies and Echocardiogram etc may be required.

4. Eye examinations help to detect retinopathy, Glaucoma and cataract.

5. Foot examination for A) blood flow - AB index , photoplethysmography for capillary perfusion. B) Monofilament and Biothesiometry to detect early neuropathy

What can we do to improve quality of life if complications have set in already?

Complications of diabetes impair quality of life but better late than never, as proper care can prevent the deterioration of QOL and help is at hand to improve QOL. General care applicable to all people are good control of blood sugar without producing hypos which are dangerous, good control of blood pressure, aggressive control of fats, control of weight and emotions. Specific care related to the organ which are affected.

A. Heart and blood vessels

Coronary heart disease requires medicines to reduce the load on the heart and to improve blood flow and metabolism. Where medicines are not enough to control symptoms or when there is impending danger of a heart attack, other interventions like angioplasty and stent insertion to make the coronary blood flow better or bypass surgery to give additional channels for blood flow.

For heart failure -Food restrictions to reduce salt and fluids, medicines to reduce the load, reduce the fluid overload and to improve the strength of the heart. There are surgical methods and use of special equipments to support the heart. Heart transplant is also an option when other measures prove ineffective.

For dangerous abnormal rhythms there are medicines and if these are ineffective, devices like pace makers, defibrillators etc would help.

Angioplasty and stenting or bypass may be used to improve blood flow to the limbs and some vital organs.

B. Kidneys

If kidney involvement is detected early through microalbumin test, medicines are available to reduce the progression of renal damage. Diet modification with protein restriction is indicated. Since kidneys play important role in blood formation and activation of vitamin D, medicines like erythropoietin, 1,25 vitamin D and Calcium may be required to improve anemia, bone pain etc. Other symptomatic treatments would also be required. When kidney functions become very low and quality of life becomes impaired due to symptoms, dialysis and renal transplant may be required to improve the quality of life and longevity.

C. Eyes

Diabetes is one of the commonest causes of blindness. Diabetic retinopathy remains silent and vision can be lost suddenly. It is important to get the eyes examined by an eye doctor. Laser treatment may be required to prevent bleeding and blindness. Medicines may be injected into the eyes to prevent bleeding. Bleeding and other complications like retinal tear and detachment may require immediate sight saving surgery.

Another cause of blindness is cataract which occurs earlier and more frequently in diabetics. The surgery to remove the cataract and insertion of an artificial lens is one of the measures that produce a very remarkable change in the quality of life.

Less common causes like glaucoma are more in diabetics. It causes pain and decrease in vision and is treatable with medicines and surgery.

D. Feet.

Decreased blood flow, damage to nerves, joints and skin lead to numbness, pain, weakness, discoloration, infection, non healing ulcers, gangrene and other complications affect quality of life. Medicines, proper footwear using micro-cellular rubber and surgical procedures help to improve quality of life. For those unfortunate to lose a limb, prosthetics improve quality of life.

E. Nerves and Brain

Peripheral neuropathy is common. It produces numbness, abnormal pain sensation, weakness or joint damage and occurs mainly in the legs and hands. These are treated with medicines, vitamins, antioxidants, certain local applications and other measures like special footwear and devices.

Autonomic neuropathy can produce distressing symptoms like giddiness, fall, bowel and bladder symptoms which can impair quality of life very much. Medicines have to be used judiciously for treating this and may be helpful. If autonomic neuropathy produces severe fall in BP on standing with giddiness, pressure stockings, salt and salt retaining medicines help to reduce the symptoms.

The brain may be involved through strokes which are easier to prevent than treat. Symptoms like giddiness; transient weakness etc should be treated actively. Medical treatment, physiotherapy and sometimes surgical procedures help.

Hypoglycemia especially in the elderly can impair quality of life and produce loss of consciousness and even deaths and is a medical emergency which should be prevented through proper diet and choice of medicines. Very high blood sugars especially in conjunction with stroke or infection can also produce central nervous system dysfunction and coma. Diabetics have higher risk of meningitis from extension of ear and sinus infections which should be treated aggressively.

F. Sexual

Impairment of sexual function is something that most patients suffer in silence and it is estimated that 50% of male diabetics above 50 years have impotence of variable degree.

Medicines are available to improve this but have to be taken only with the doctor's consent. Do not be misled by advertisements .The doctor should be informed of all the medicines the person takes for the various problems.

If medicines are not effective, prosthetics are available which may be discussed with an andrologist.

Sexual problems also occur in women and the gynecologist may prescribe medicines or local applicants.

Conclusion

Diabetes reduces quality oflife in many ways. The best way to have good quality of life for many years to come is to take care of diabetes from the beginning itself. Proper diet, exercise and stress management along with proper medicines and regular monitoring, decrease the incidence of complications. Early detection and appropriate measures can delay the worsening of complications. Timely and proper management of complications help in preventing loss of quality of life for many years to come.

So act now to avoid complications and loss of quality of life later.