Sixteen-year-old Karl is seen for the first time in my optometric practice. He was referred to me for variable vision. During his examination, I saw signs that he might have diabetes, which could explain the fluctuating vision. This suspicion became a reality when his family doctor confirmed the diagnosis. Carl’s world was turned upside down.
As an optometrist, I invite you to immerse yourself in a reality that should affect us all.
What is diabetes?
Diabetes is an insidious disease. Its symptoms (thirst, need to urinate frequently, fatigue, weight loss, darker skin areas on the neck and armpits) often go unnoticed, at least in the early stages of the disease.
Diabetes affects the lives of one in 14 people in Canada (7 percent) and one in 10 in North America (10 percent).
Two types of diabetes can be diagnosed:
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Type 1, which is insulin-dependent and develops when the body cannot produce the insulin needed to metabolize the sugars we ingest that feed our tissues
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Type 2, which develops when insulin is produced but in insufficient amounts. Sometimes the insulin produced is ineffective at doing its job.
Type 1 diabetes is usually associated with the development of the disease in childhood and adolescence. Type 2, the most common, usually develops later in life, often after age 50.
A counterintuitive diagnosis, but not uncommon
From this definition, it would be logical to conclude that Karl was affected by type 1 diabetes, the course and treatment of which was well controlled by doctors. However, in his case and after the necessary tests, his doctor identified type 2 diabetes. This diagnosis is counterintuitive and poses significant challenges. The rate of onset, initial disease severity, and mechanisms of resistance or reduced insulin secretion may be different in patients who develop the disease at a younger age than in adults.
In addition, treatment options involving trial and error become more complicated due to the much longer duration of this type of disease when it begins at an early age. Both major and minor changes that affect blood vessels in a patient with type 2 diabetes can have serious consequences that are difficult to predict, since the course of treatment can last from 40 to 60 years.
However, Carl’s situation is not exceptional. More and more young people and adolescents, especially those with overweight, obesity and sedentary lifestyles, are affected by type 2. Almost 75 percent of them have parents or siblings with diabetes.
While at first glance this confirms genetics as a risk factor for the development of the disease, in this particular case it is rather a consequence of poor lifestyle, especially eating habits and lack of physical activity, which are often shared by the whole family.
Effects on vision
The fact that Carl developed type 2 diabetes earlier rather than later in life also puts him at a higher risk of developing eye complications. An article on this topic recently caught my attention. This study looked at the records of 1,362 people with diabetes living in Minnesota, ie. in North America and then extrapolated to Canada. The data was collected between 1970 and 2019, which also allows us to measure the development of the situation in recent decades.
The results are striking: young people with type 2 diabetes (compared to age-matched type 1 diabetics) are 88 times more likely to develop retinopathy (abnormal blood vessels and/or hemorrhages in the retina). In addition, the risk of this retinopathy becoming “proliferative” and therefore vision-threatening increases 230-fold. There is also a 49-fold increase in the risk of fluid accumulation in the retina (macular oedema) and a 243-fold increase in the risk of developing mature cataracts at a young age. The latter requires surgical intervention, which is more risky in young people than in age-related senile cataracts.
Vascular and metabolic complications of diabetes visible on the fundus (hemorrhages, exudates). (Langy Michaud), Fourni par l’auteur
What should we remember from this? That major problems, which often require surgical interventions to preserve vision, occur much faster in young type 2 diabetics than in those affected by type 1. Therefore, these patients should be followed more closely. Indeed, nearly one in two patients with type 2 will develop some form of retinopathy within one to eight years of diagnosis. In comparison, one in three type 1 diabetics will develop retinopathy between six and 10 years after diagnosis.
Significant consequences
Having already increased significantly over the past 10 years, the prevalence (number of cases) of type 2 diabetes in young people is predicted to quadruple by 2050. This prediction is most worrying for health professionals, but also for policy makers and managers of public health agencies. Lifetime direct medical care costs for one diabetes patient aged 25-44 were $125,000 in 2013. Since then, these costs have increased, and many more dollars must be added to cover the period between 15 and 25 years, which is not taken into account. Indeed, if 20 percent of the young population develops diabetes by 2050, millions (perhaps billions?) of health care dollars will have to be spent on their care by our governments.
The long-term quality of life of people with diabetes is also reduced. Another study, this time among young people with type 1 diabetes, shows that their disease has a negative impact on their lives. They have to spend a lot of time on their care (missing activities with their friends). And the burden of their illness on their loved ones weighs on their shoulders. The fear of hypoglycemia (lack of sugar, which can lead to coma) or the development of serious complications of the disease also affects them. Achieving autonomy is more difficult for these adolescents and their quality of life is proportional to the freedom they can or cannot exercise.
Eat well, exercise and see your optometrist
Type 1 diabetes is difficult to prevent, mainly because we don’t know all the causes of it and we don’t have to proactively screen for it. The situation is different with type 2 diabetes, which is strongly associated with an unhealthy lifestyle in young people. Eating a healthy diet, exercising regularly and fighting a sedentary lifestyle, including limiting screen time (to less than two hours a day), are good ways to avoid or delay the onset of diabetes in young people. Screen time has also been linked to insulin resistance and obesity in young people. In other words, a healthy lifestyle should be encouraged and especially shared within the family.
Healthy habits are good ways to avoid or delay the onset of diabetes in young people. (Shutterstock)
As for the eyes, regular visits to an optometrist or ophthalmologist can detect early signs of diabetic complications (symptoms are seen in up to 30 percent of patients soon after diagnosis). These healthcare professionals may also detect other oculo-visual problems resulting from the disease, such as loss of ability to focus near (accommodation), partial paralysis of certain eye muscles leading to double vision, delayed healing of surface changes on the cornea, dry eye or glaucoma. Testing should be done at the time of medical diagnosis of diabetes or in anyone with a high-risk profile (heredity, obesity, sedentary lifestyle).
Since healthy lifestyle habits are an integral part of treating the disease, it is not too late for Carl to enjoy a happier future. But it’s important not to neglect regular checkups with his doctor and frequent visits to his family optometrist.
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