From thestar.com.my/lifestyle
By Datuk Dr Nor Ashikin Mokhtar
Diabetes mellitus is a lifelong metabolic disease that goes far beyond high blood sugar levels.
Over time, uncontrolled diabetes gradually – and silently – causes harm to multiple organs like the kidneys, heart, eyes, nerves and vascular network.
Because of this, more recent diabetes care has substantially transformed from more specific glycaemic control to a more extensive and holistic management strategy to maintain organ function and limit complications in the long term.
Chronic hyperglycaemia (high blood sugar levels) is the mechanism behind harmful events such as chronic inflammation, oxidative stress, and gradual damage to small and large blood vessels.
The accumulation of these events eventually gives rise to serious complications such as diabetic nephropathy (kidney disease), cardiovascular diseases, neuropathy (nerve disease) and retinopathy (retinal disease).
Understanding this, therapeutic tactics in modern times target not only the rise of blood sugar, but also the events that lead to organ damage.
As result of this, there are improvements to organ protection from pharmacological progress over the last several decades.
Drugs that protect
In recent years, there have been many classes of anti-diabetic drugs known to have anti- diabetic effects far beyond the reduction of glucose levels.
SGLT2 (sodium-glucose cotransporter 2) inhibitors, including empagliflozin and canagliflozin, work via urinary glucose excretion through the kidneys.
Significantly, big clinical trials have demonstrated that these agents notably slow the development of diabetic nephropathy, reduce rates of heart failure hospitalisation, and mitigate cardiovascular death.
Their mechanisms seem to work via haemodynamics, decreased intraglomerular pressure and inflammation pathway modulation.
GLP-1 (glucagon-like peptide 1) receptor agonists, including liraglutide and semaglutide, act like endogenous incretin hormones that modulate glucose metabolism.
They increase glucose-dependent release of insulin, inhibit glucagon secretion and delay gastric emptying.
Not only do they promote good glycaemic control, but they are also agents that lead to effective weight loss and reduced rates of major adverse cardiovascular events, such as heart attack and stroke.
Their anti-inflammatory and vascular benefits, as well as anti-atherosclerotic properties, further contribute to cardiovascular protection.
Despite all these advances though, metformin remains the keystone of type 2 diabetes treatment.
Through this means of improved insulin sensitivity and impaired hepatic glucose synthesis, it achieves satisfactory initial control with a predictable safety record.
Increasing new evidence also indicates that it carries modest cardiovascular and metabolic benefits; further supporting it as a fundamental medication for diabetes.
Lifestyle interventions
Though drug treatment is vital, lifestyle changes are still the basic building block for ensuring sustainable care for diabetics and the protection of their cells.
There is an emphasis on medical nutrition therapy.
Whole foods, high fibre vegetables, lean protein and low glycaemic index (GI) carbohydrates in diets promote stable glucose and enhanced metabolic responses.
Reducing processed foods, refined carbohydrates and sugar-sweetened beverage consumption is an important intervention in lowering glycaemic variability and cardiometabolic risk.
Sufficient hydration is equally important, but frequently neglected.
Adequate fluid consumption promotes renal function, excretes glucose more effectively and supports metabolic homeostasis.
Dehydration can worsen hyperglycaemia and maintain a circle of osmotic diuresis and subsequent loss of fluid.
Regular physical activity promotes insulin sensitivity, cardiovascular fitness and weight loss.
Moderate volume aerobic exercise and resistance training provide great benefits, especially at moderate load.
Outside of mental health, exercise is good for mood, sleep and quality of life.
Weight optimisation is especially crucial in those with type 2 diabetes.
Visceral adiposity in particular, induces insulin resistance and elevates cardiovascular risk.
Even slight weight loss will result in a large enhancement in glycaemic control, blood pressure and lipid profiles.
Emerging therapies
The diabetes care sector is developing at an increasing pace.
Next-generation insulin treatments as a whole are expected to mimic more closely physiological insulin secretion.
This includes ultra-rapid acting compounds, once-weekly basal insulins and investigational glucose-responsive “smart” insulins intended to lower risk of hypoglycaemia, while increasing both convenience and adherence.
There is also a growing interest in targeting inflammation as a therapeutic strategy.
Low-grade chronic inflammation is a major source of insulin resistance and vascular complications.
Both known and novel agents, such as IL-1ß antagonists, are being investigated for their ability to affect diabetes progression.
In the future, gene-based therapies could potentially offer game-changing new approaches by altering the molecular determinants of diabetes.
Although still in its infancy, this field of study is indicative of a larger move towards precision medicine.
At the same time, digital health technologies are transforming patient care.
Continuous glucose monitoring (CGM) systems, smart insulin delivery devices and integrated digital platforms lead to more precise, personalised management.
These help patients and clinicians make real-time adjustments to therapy and also enhance outcomes by generating their data in real time.
Protecting the whole
Diabetes management has entered a new era.
No longer is the focus only on glycaemic control, it encompasses wide-ranging organ protection and the preservation of long-term health.
To ensure effective care, a comprehensive plan now needs to integrate pharmacotherapy, lifestyle programmes and advanced new technology.
Through recognising the multifactorial characteristics associated with the disease (metabolic, inflammatory, vascular etc), doctors can further mitigate the complications.
With early intervention, ongoing follow-up and involvement, people living with diabetes are able to achieve improved outcomes and quality of life.
At the end of the day, the objective of this process is no longer to manage the blood sugar, but to protect the whole body.
Datuk Dr Nor Ashikin Mokhtar is a consultant obstetrician and gynaecologist, and a functional medicine practitioner. For further information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
