By Salihu Lukman, PhD
Twitter Handle: @SalihuLukman

Published in Daily Trust Newspaper: December 24, 2019

Diabetes is one of the chronic diseases that can go undetected for many years. American Association of Clinical Endocrinologists (AACE) recommends the following reference ranges for interpreting HbA1c results: no diabetes: 5.6 % or less, borderline/prediabetes: 5.7 – 6.4 % (you have a higher chance of getting diabetes), diabetes: 6.5 % or higher. In Saudi Arabia, 4.3 – 6.0 % represents the normal range, it may slightly vary from one hospital to another depending on their internal normal ranges. For diabetics, the target level is usually less than 7 %. The higher the HbA1c levels, the higher the risk of having diabetes-related complications listed earlier. Based on my HbA1c result (9.6 %), I should have been declared a diabetic and start a treatment plan right away. unfortunately, that did not happen. The doctor circled the high HbA1c value on the result sheet but failed to inform me that I was diabetic based on the result. He did not even comment on the result, he only told me that my vitamin D level is fine now and that was it! My wife who is a medical doctor and I saw the results but missed the high HbA1c level because the target at the time was the vitamin D result only.

I lived almost a normal life despite this missed diabetes diagnosis for about 1.5 years until one evening in February 2015 when we went out for shopping with my wife. I felt very thirsty during shopping in a supermarket, so I bought and consumed a 2 L bottled water within less than an hour. When we came out of the supermarket, she asked me where was the bottled water which I was holding. I replied to her that I had drunk it all. She asked me about urination frequency which I replied that I had experienced an increase lately. We went straight from the supermarket to a pharmacy to buy a glucometer so she can measure my glucose level because she suspected diabetes. Remember the classic diabetic symptoms I mentioned earlier. We bought the glucometer, measured my glucose level – guess how much – about 376 mg/dL [20.9 mmol/L], super hyperglycemia! We bought Metformin (Glucophage) to bring down the sugar level but to no avail. It took the intervention of an intravenous (IV) saline water drip under observation for about 2 hours in a hospital before my blood glucose could return back to normal. About 33 % of Saudi Arabian population is diabetic, ranked 2nd in the Middle East and 7th in the world for the rate of diabetes by the World Health Organization (WHO). Every big city in the country has a Diabetic Center specifically assigned to render medical services to diabetics and hypertensives. A comorbidity is a disease or condition that coexists with a primary disease but also can stand on its own as a specific disease. For example, hypertension (high blood pressure) is a common comorbidity of TTD which implies that hypertension and diabetes often occur at the same time. Researchers have found out that up to 75 % of adults with diabetes also have hypertension and those with hypertension also usually exhibit signs of insulin resistance. Other common comorbidities of diabetes include cardiovascular disease, kidney disease, obstructive sleep apnea, and obesity. One surprising fact with hypertensives is their compensating for salt with enough seasonings (Maggi, Ajino-Moto, etc.) to taste. The main ingredient in almost all seasoning is Monosodium Glutamate (MSG) obtained by mixing sodium and glutamate. Glutamate is an amino acid that is naturally available in foods such as Parmesan cheese, tomato, mushrooms, cured meats, and soy sauce. In particular, Ajino-Moto is almost 100 % made up of MSG, hence if you run away from the sodium in Sodium Chloride (table salt) you are only substituting it with another sodium from MSG. In the end, the total work done is approaching zero. MSG had been touted to be a carcinogen and unsafe for use in foods, but emerging research on MSG made the U.S. Food and Drug Administration (FDA) state that the “FDA considers the addition of MSG to foods to be generally recognized as safe (GRAS)” that is if you are not sensitive to MSG. Why not try a potassium salt (i.e. one in which the sodium has been substituted with potassium) for a good taste?

I visited one of the Diabetic Center for proper management of my ailment. HbA1c test was conducted and the result was 10.6 % – it had moved up from 9.6 % in 2013 – the doctor declared based on the result that I was diabetic and put me on 1 g Metformin TDS (3 times daily) in addition giving me an empty designed tabular paper where I would be recording my blood glucose levels at least 4 times daily – fasting and 1 or 2 hr after each meal. I weighed 86 kg at the time of the diagnosis in 2015 – a sharp contrast from the 76 kg in 2007. The HbA1c test would be repeated every 3 months for close monitoring on how I would respond to treatment. The doctor emphasized lifestyle changes in my diet, portion size, exercise and ultimately weight loss. I asked the doctor about using artificial sweeteners instead of sugar and he replied no. He advised me to keep off sugar, high carb diets and avoid artificial sweeteners (because of their controversial safety concerns). He encouraged me to be taking high fiber diets, low fats and fruit. I complied as much as possible except for some ‘cheat’ days. My wife took up the diet challenge very seriously and gradually – the nutritionist part of her was awakened. My food portion was almost halved and high fiber meals and fruits such as beans, vegetable soup and undressed salads were introduced in addition to healthy snacks such as almonds, cashew nuts, pistachios, olives, etc. I totally refrained from drinking sweetened juice – I would use sugar-free juice or drink the fresh fruits or fruit smoothies. On my wife’s insistence, I later stopped drinking even the sugar-free juice because it is not as nutritious and fibrous as the fresh juice. In the evenings, I would either follow aerobic lessons on Youtube or take a brisk walk for about 30 – 40 min daily to burn some calories. I would still eat rice but with enough veggies and reduced portion size. My blood sugar level was under good control for one month, the doctor reduced the dosage from TDS to 1 g BID (twice daily). In addition, even though the sugar level was under control with the use of medication alone, he further recommended that I should also be using insulin injection daily at night for 6 months to give my pancreas (responsible for the production of insulin) some rest with the hope that it would pick up adequately after it had rested. He informed us that it was the new management strategy for diabetics. Insulin injection is usually administered for type 1 diabetes or for terrible cases of TTD. Despite my hatred for any injection and the daily insulin self-injection in particular, I accepted his advice and started the insulin injection. Consequent to the multi-targeted attacks (Metformin, insulin injection, dietary modifications, and exercise) on diabetes, after just 2 months of using the insulin injection, I experienced 2 episodes of hypoglycemia attacks at night after taking the insulin injection, I shed 3 kg (weighed 83 kg) and my HbA1c had dropped from 10.6 to 6.7 % – what a marvelous improvement in a short while – the doctor asked me to stop the insulin injection because of the hypoglycemia episodes and he asked me to continue with 500 mg BID.

Dr. Salihu Lukman an assistant professor at the University of Hafr Al-Batin and writes from Saudi Arabia. E-mail: slukman@uhb.edu.sa