efore we proceed to myths and facts about diabetes, we must understand some basic facts about this disease. What is Type-2 diabetes (T2DM)? Why it is important for patients to understand what diabetes is? Why is there a pressing need to detect it early? Why is long-term treatment with or without medications needed? What is impaired glucose tolerance? Above all, why as a nation it is important for us to talk about it? Lastly, why do doctors and the general public need to stay up-to-date and connected to existing evidence about its treatment?

Let’s begin with some figures about the burden of T2DM in Pakistan. According to The Lancet (May 2022), 33 million people in Pakistan have it. Furthermore, 11 million adults have impaired glucose tolerance, and there are approximately 8.9 million people who haven‘t been diagnosed yet. The numbers are alarming. The task of managing the problem is huge. Let’s split this problem into smaller and more manageable pieces and view it.

Diabetes is a condition in which the body develops a deficiency of insulin or cannot utilise the insulin produced by the pancreas hence being unable to regulate blood glucose, leading to high levels of sugars in the blood. In impaired glucose tolerance (IGT) the two hours blood glucose level after 75 grams of glucose load (approximately 8 tablespoons of glucose powder or half a glass of glucose powder) are raised, i.e. between 140 and 199 milligrams/dl. What does this mean? It means blood sugar levels are raised above normal but not high enough to be called diabetes. Risk factors for IGT include being obese or overweight, having zero to low levels of physical activity, having high blood pressure or high cholesterol, having a positive family history of T2DM etc.

Some myths related to diabetes are that it is a contagious disease, it only happens to those who are overweight or obese, it can be treated spiritually and a diabetic person can never consume sugary foods. It is crucial that we address these false notions. T2DM is not contagious and it is not possible to treat it spiritually. It is not true that only those with raised body-mass-index (BMI) develop it. With regards to the consumption of sweet stuff or carbohydrate-rich food, one has to alter it based on how controlled one’s blood sugars are. Eating in moderation helps. T2DM management requires medication in addition to lifestyle changes and weight loss.

There are various misconceptions and barriers regarding diabetes and especially insulin for the control of blood glucose, which results in non-compliance with treatment, often leading to complications of diabetes mellitus.

The most common myth regarding diabetes in our society is that increased consumption of sugar is the cause of their diabetes. This is not correct. However, lifestyle (sedentary, lack of exercise etc) and unhealthy diet are associated with diabetes.

Some people believe that diabetes can only occur in old age, which again is a misconception as it can occur in earlier years of life. Many perceive diabetes as a non-serious disorder. This is incorrect, as diabetes can result in serious complications affecting the eyes, kidneys and heart. Diabetic patients are at increased risk of stroke, raised blood pressure, cardiovascular conditions and peripheral vascular disease.

Metformin is one of the oldest and most commonly used medications for T2DM and as an add-on therapy for T1DM, particularly for those with raised BMIs. Myths related to it include: “Metformin is harmful for kidneys”. This is not entirely true. Metformin can be used in mild to moderate renal failure, however in severe renal failure eGFR <30 mL/min/1.73 m2 (eGFR is a blood test which gives an estimate of kidney’s filter function) there is a risk of accumulation of medication leading to acidosis. Another misconception related to metformin is “it is bad for the heart”; well the evidence is to the contrary. UK Prospective Diabetes Study showed improved outcomes following early use of metformin in T2DM and fewer diabetes-related complications.

With regards to another class of antidiabetic medications called sulphonylureas (SUs), glimepiride is a commonly prescribed agent. Its duration of action is up to 24 hours. It is associated with myths that it can cause ‘severe’ hypoglycaemia and weight gain. This is not entirely true according to the results of studies on adults and the paediatric population. In order to minimise the side effects of hypoglycaemia and weight gain, it is, therefore, advisable to take the dose of glimepiride and other SUs as prescribed by physicians. Careful monitoring of blood glucose and patient education regarding side effects can maximise the effectiveness of SUs.

Many diabetic patients are either reluctant to use insulin or have poor adherence. Some of them think that if they start insulin, it is the end stage of their illness, and they will be dependent on it for life. The fact is that most of the time oral hypoglycaemic agents can no longer control their blood glucose levels. Hence insulin is needed and is the next logical step in their treatment. Such transitions require appropriate evidence-based guidance and counselling through a team of primary care physicians and specialists.

Some people believe that insulin causes complications or death. This is likely related to what happened to their relatives and friends who had diabetes. This could also be one of the reasons why people are reluctant to start insulin.

These myths cause poor compliance with treatment and make it hard for patients to start searching for alternative methods that lack strong evidence. This leads to the worsening of diabetes, leading to serious complications.

To overcome these fears, those who have uncontrolled/ poorly controlled T2DM or T1DM need to be counselled and convinced that insulin is likely to delay or even prevent further deterioration and complications if started early. Addressing the worry related to disease and its management is the key.

Last but not least, diabetes requires treatment. It is a long-term condition that needs close monitoring. T2DM can go into remission through adequate evidence-based management, individualised care, patient education and shared decision-making.

Dr Hina Jawaid is an associate professor in family medicine at  University of Health Sciences, Lahore

Dr Abdul Jalil Khan is an assistant professor in family medicine at Khyber Medical University, Peshawar