Catching Diabetes Before It’s Too Late

“Diabetes doesn’t make you feel sick. You don’t feel like you’re going to die, you know? You don’t feel like you need medical help,” says Yeoh Phek Chin, a 47-year-old type 2 diabetic patient. “Until something drastic happens.”

KUALA LUMPUR, Dec 14 – “I had a wound that started as a mosquito bite. I would scratch it and it didn’t heal. It got worse and worse until it became a really big, deep wound and it got infected,” says Yeoh Phek Chin, recalling the wound on her leg 12 years ago.

It was only when Yeoh consulted her family doctor that she knew what was happening with the wound. “The doctor said it was a very obvious diabetic wound and it’s diabetes that was out of control.”

Like many Malaysians who are unaware that they have diabetes, Yeoh, now a 47-year-old administration assistant, became aware of her condition only when she had a non-healing wound, despite having a family history of the disease.

“I didn’t seek treatment until the wound happened. I had no choice, right? Otherwise, I wouldn’t see a doctor because I don’t habitually do a medical test every year, prior to this [diagnosis],” Yeoh told CodeBlue in an interview.

In hindsight, Yeoh said she had been exhibiting a number of diabetes symptoms, prior to her Type 2 diabetes diagnosis.

“I never realised it because of the things we do in our daily lives. You know, like I used to be very parched all the time. That thirst is one of the first signs of diabetes,” said Yeoh, who used to work at local independent book shop, Silverfish Books.

“I used to do a lot of physical labour in the book shop and all that. So, I just assumed it was because I was tired. I was sweating a lot and all that. And therefore, I want to drink a lot. And those days are hot, and I’m one of those people who don’t like heat, you know?

“I just assumed I wanted to drink a lot of cold drinks because of that,” Yeoh said.

Yeoh’s diabetic wound would eventually heal more than a month after her diagnosis. Her treatment included wound dressings, oral antibiotics, and antibiotic jabs.

Yeoh’s father was a diabetic patient also. However, her late father was not as fortunate. “It started as a sore on his sole, and that was before we knew anything about diabetes. We just knew that he had a wound and he wouldn’t heal right,” Yeoh said of her father’s diabetic condition.

He was ultimately diagnosed with diabetes in 1999 at a “very late stage”, which led to the amputation of his left leg.

“He had kidney failure and all that already. So, they put him on peritoneal dialysis. Peritoneal dialysis is not the one that’s through the blood, it’s actually a solution that goes into the stomach. It replaces the function of the kidney. The solution had to be drawn out every four hours.

“The treatment was very expensive. At that time, it was already very expensive. Whatever savings he had was spent on the treatment for those few last days,” Yeoh said. “But by then, we already knew, the doctor told us he doesn’t have very much time. It was very bad by then.”

Yeoh’s father passed away in 2001.

Over the past 12 years since Yeoh being diagnosed as diabetic patient, Yeoh said she has spent nearly RM30,000 on medications and diabetes-related treatments, including glucometer purchases and upgrades, meter strips, and lancets – a cutting instrument with a double-edged blade and a pointed end for making small incisions or drainage punctures.

Given her type 2 diabetes condition, Yeoh was prescribed an antihyperglycemic drug that she can purchase at the pharmacy to lower blood glucose concentrations.

Apart from the daily medication, Yeoh has also made some lifestyle changes by eating more vegetables, cutting carbohydrates from her diet, and going for routine walks.

“I think education on health is very important, as well as starting young. You don’t think about it when you’re young. When you’re a young person, you are always healthy. You know, and when something goes wrong, you recover very quickly. So, you really take your health for granted.”

“Diabetes doesn’t make you feel sick. You don’t feel like you’re going to die, you know? You don’t feel like you need any medical help,” Yeoh said. “Until something drastic happens.”

Type 2 diabetes is the most common form of diabetes that causes the level of sugar in the blood to become too high. It can cause symptoms like excessive thirst, needing to pee a lot and tiredness. Type 2 diabetes means that a person’s cells don’t respond normally to insulin.

For comparison, type 1 diabetes is a chronic condition where a person’s pancreas doesn’t make insulin or makes very little insulin. Type 1 diabetes was once called insulin-dependent or juvenile diabetes as it usually develops in children, teens, and young adults, although it can happen at any age. Insulin is injected or jabbed daily to keep blood glucose levels under control.

About 18.3 per cent or 3.9 million of Malaysia’s adult population above the age of 18 have diabetes, which is equivalent to one in five adults. About half are unaware of their condition, according to the Ministry of Health’s (MOH) National Health and Morbidity Survey (NHMS) 2019.

The prevalence of diabetes has risen over the years from 11.2 per cent in 2011 to 13.4 per cent in 2015 and 18.3 per cent in 2019.

The NHMS 2019 survey also found that the majority (about 68.2 per cent) of those with known diabetes sought treatment at MOH health clinics, followed by MOH hospitals at 15 per cent, private clinics at 12.1 per cent, and private hospitals at 2.8 per cent.

A separate report by the MOH and the World Health Organization (WHO) released in August this year showed that annual direct health care costs from diabetes in Malaysia total about RM4.4 billion, more than triple or 227 per cent higher than cancer (RM1.3 billion) and 11 per cent higher than cardiovascular disease (RM3.9 billion).

In terms of disease awareness, the Malaysian Diabetes Index (MDI) found that over half of its 2,539 respondents (52 per cent) said they do not know that diabetes cannot be cured, while 51 per cent think that diabetes is not difficult to manage. One in three respondents (37 per cent) with diabetes do not know what abnormal blood sugar level readings are.

In 2020, the National Institutes of Health (NIH) reported that seven in 10, or 70 per cent, of people who succumbed to Covid-19 in Malaysia, as of October 11, 2020, had diabetes. At the time, the official Covid-19 death tally stood at 157, with 15,567 infections recorded.

According to MOH’s KKMNow site, as of October 11 this year, Malaysia’s cumulative Covid-19 mortalities amounted to more than 36,000. Per capita, Malaysia has the highest Covid-19 death rate in the Asean region at 1,084 deaths per million people, 88 per cent higher than Indonesia at second highest with 578 fatalities per million.

Diabetes Prevailing Among Children

Prof Dr Muhammad Yazid Jalaludin, senior consultant paediatrician and paediatric endocrinologist at University of Malaya Specialist Centre. Picture courtesy of University of Malaya Specialist Centre.

Prof Dr Muhammad Yazid Jalaludin, a consultant paediatric endocrinologist at the University Malaya Medical Centre (UMMC), attributed the prevalence of diabetes in Malaysia to late identification, misdiagnosis, lack of awareness, and lack of financial assistance as most necessities for diabetes management is not covered by insurance.

“Fortunately, insulins are free in government hospitals but other necessities, including blood glucose monitoring are from their own pocket and not covered by insurance companies,” Dr Muhammad Yazid told CodeBlue when contacted. “Blood glucose monitoring is expensive.”

He said in the case of children, a child would need at least three times a day meal bolus insulin and once or twice basal insulin, plus a minimum of four to five blood sugar checks daily.

On the misdiagnosis of diabetes in children, type 1 diabetes, a study by Meenal Mavinkurve et al published in 2021 revealed that over a third (38.7 per cent) of 119 confirmed childhood type 1 diabetes cases identified at UMMC between 2010 and 2019 were misdiagnosed.

According to the study, the most common erroneous diagnoses made in children presenting with type 1 diabetes were respiratory at 36.9 per cent, gastrointestinal (34.8 per cent) and infectious illnesses (10.9 per cent).

Other studies have similarly reported that infective conditions are a common misdiagnosis in children with type 1 diabetes and this may be attributed to health care professionals having greater exposure to common childhood illnesses rather than type 1 diabetes.

A lack of familiarity among health care professionals with the symptoms of childhood type 1 diabetes can lead to incorrect diagnoses such as asthma, pneumonia and gastroenteritis, in which presenting symptoms are similar to type 1 diabetes.

The most commonly reported symptoms in the misdiagnosed cases were polyuria (45.7 per cent), polydipsia (43.5 per cent), weight loss (32.6 per cent) and vomiting (32.6 per cent), which the study’s authors described as “classic symptoms” of diabetes. Polyuria refers to excessive urination volume, while polydipsia is the medical term for excessive thirst.

The study showed that there was a significantly higher rate of misdiagnosis in children under the age of five compared to those children aged above 10.

Dr Muhammad Yazid also said type 2 diabetes among children in Malaysia is prevailing, as seen in the last five years. Type 2 diabetes has become a concern in children and young people as a result of increasing prevalence of obesity.

An MOH study in 2020 revealed an increase in overweight and obesity, affecting more than half the adult population in Malaysia, compared to 2019.

An estimated 54.2 per cent of the Malaysian adult population is overweight or obese, an increase of 4 percentage points from the findings of the NHMS in 2019. Among children, experts estimate that one in five children in Malaysia is overweight.

A 2013 study by Poh BK et al from Universiti Kebangsaan Malaysia found that 9.8 per cent and 11.8 per cent of Malaysian children aged six months to 12 years were overweight and obese respectively, totalling 21.6 per cent.

Malaysia’s child obesity rate surpassed Thailand (7.8 per cent), Vietnam (five per cent), and Indonesia (3.5 per cent).

“What is needed for type 2 diabetes, policies on childhood obesity prevention are very important and necessary. For type 1 diabetes, policies on free insulin and blood glucose monitoring need to be addressed,” Dr Muhammad Yazid said.

For type 1 diabetes, he said care should be made more affordable, especially with the use of newer insulin and gadgets like the intermittently scanned glucose monitoring (iGMS), continuous glucose monitoring (CGM) and insulin pump.

For type 2 diabetes, Dr Muhammad Yazid said more effort is needed to educate health care professionals and the public on the danger of obesity, even during childhood.

Cultivating Good Eating Habits From Young

Like any human behaviour, dietary patterns can be shaped at an early age and these habits and preferences can become difficult to change as a person gets older.

In Malaysia, the consumption of sugary drinks has increased dramatically over the past decade as incomes rise, according to the United Nations Children’s Fund (Unicef).

More than a third (36 per cent) of students have sugary drinks at least once a day, and the average daily sugar intake for adolescents has increased from seven teaspoons in 2012 to 10 teaspoons in 2017 – more than the recommended limit for adults.

On average, Malaysians consume around three kilograms of sugar per year in the form of sugary drinks. Yeoh pointed out, however, that healthy dietary options are often a privilege.

“A lot of times, things that are affordable are always very carbohydrate-heavy. The drinks that are affordable are very sugar laden, or habitually, sugar laden. So, it’s really for you to choose not to have something with sugar in it,” Yeoh said.

“That’s very difficult because you know that from young, we already cultivate that palate – that taste for something sweet. Like even in milk.

“The school programme I’m working on now, they have started giving milk to students that is just plain milk. But before that, they used to get flavoured milk. So even milk is flavoured, and they’re telling you, this is good for health.

“This is milk, right. But there’ll be some chocolate flavour, strawberry flavour, and they are all sweet. I think it’s a difficult thing,” she added.

Yeoh said working in a school programme, she realised while people in middle-income groups may have enough wages to avoid consuming sugary or unhealthy foods, people in lower-income groups “almost have no choice” due to affordability.

“It’s a very uphill battle as it already is,” Yeoh said. “So, then you cultivate that kind of palate, you know, as you grow up, you are not used to eating vegetables.”

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