Managing Diabetes with Ph. Gina Koay (Part 1)

    4:26AM Jun 8, 2021

    Speakers:

    Jeffrey Leong

    Gina Koay

    Keywords:

    diabetes

    glucose

    pancreas

    check

    gina

    insulin

    sugar

    cell

    body

    blood glucose

    amputated

    symptoms

    people

    type

    means

    feet

    pharmacist

    pharmacy

    question

    diabetic

    Hi, good morning everyone. It's great to have the Web Series once again. So today it's very exciting. I just want to have a quick introduction of myself, my name is Jeffrey I'm part of the Homage team that is in charge of the northern part of Malaysia and I'm based in Penang. So [Hokkien greeting] Right and today with us we have a lady with us. Her name is Miss Gina Koay and she is from City Wellness Pharmacy, and let me just give a quick introduction on Gina who she is and where she's from, so that we all know like who we are hearing from today. And so Gina Koay is a registered, and practising pharmacist in Malaysia for, for the past 20 years, and she is the founder of City Wellness Pharmacy in Penang since 2007 and Gina also obtained a Bachelor of Pharmacy degree from Curtin University in Australia. Back in 2001, and later she also obtained a graduate certificate in evidence based. Complementary Medicine in University of Queensland back in 2003. And she's also an integrative nutrition health coach Wow, and she grad- that's where she graduated from Institute of Integrative Nutrition, New York, in 2016. Wow you have a lot in your belt. Gina. Currently Gina is also the chairman of Malaysian's Pharmacy Society of Penang. She's also the industry and community advisory panel. In short iCAP for USM University Science Malaysia, so let's put our hands together welcome Gina.

    Hi, good morning Jeffrey, everyone. Yeah, thank you Homage for the invitation today to share about the management of diabetes in terms of medication, and lifestyle changes from a perspective of a community pharmacist, so I'm actually a current practitioner. Still, a community pharmacists in my own pharmacy in Penang, so I'm glad to be sharing some of my experience and maybe some stories, You know, we try to you know have more interaction during this session so that our viewers can understand, you know what is diabetes so I know that we everyone is anxious about the lockdown coming up FMCO right, so I know COVID, COVID cases is increasing. I know COVID is always a hot topic. But today we wanted to share, you know diabetes management I know that a lot of people aren't able to go to hospital you know and all that. You can do it at home, you know, so I hope to share some tips today yeah.

    Yeah I think diabetes is also one of the topic where because nowadays we have a COVID right and then we kind of like always overlook the other diseases, which is equally lethal as well. So as far as I know. Diabetes is very much related to obesity and I think Malaysia's one of the most obese country. For the past many, many years. So, so that's where we want to really visit this topic again on how, what is diabetes, and then, and, and how does it affect us in this case so I mean firstly I want to really ask you, right Gina right so when. Usually when, when we talk about diabetes, right. So I think about 'potong kaki', you know, or my leg is gonna be chopped off from that. So, generally, is that a right thing to think this way?

    Yes. Diabetes is always, other than mental health illness or diabetes is also a taboo lah you know like everyone was so scared, you know, the moment you say, Oh, you do want to check out sugar they'll say no other ones. What if I check my sugar level just rise, and I have diabetes I cannot accept that because they probably have heard many stories about, you know, their own family members or any friends get amputated, you know, the amputation is the thing that gets people in your mind.

    Yes, so it's like, it's not like cut your nail, your nail will grow back and once you cut your leg off your leg won't go back this is really hard to be mindful of, I think, Gina you have some, some, some visuals to share with us on that, that that will help us to better visualise what we are trying to story today.

    Let me share my screen now. Yes, yes. Can you see my screen now?

    Yes, it's processing on the way. Yes, we can see a your screen.

    Okay, so, so this is something. The first page on my presentation. We will do a more interactive, one right.

    Yes. So, questions and all.

    Yes so this is a managing diabetes and lifestyle changes, sharing, from the perspective of a community pharmacists as Jeffrey introduction, kind introduction just now. Yes, have been a practising pharmacist for the past 10 years, so I'm still one. So I have very passionate about of my job, you know, as a community pharmacist, I would say my profession, and diabetes is actually in my heart I have many many clients who have diabetes and and always talk about, you know, how do you manage it, because diabetes may come in and look for you one day you know but, you know, just the spread not like you know because diabetes can be managed. So, I'm sure just now we mentioned about what is diabetes in your mind, right, and some be may be thinking of it like insulin jab. Okay, people will be so worried. Diabetes means insulin. Insulin means that, "oh no you know you're gonna jab me for the rest of my life, I don't want this kind of lifestyle, I don't want, this kind of thing. So, how about this? Diabetes means, I have to swallow a lot of pills. So I don't want to swallow pills because I'm the person who against swallowing any pills. No, I will, I will wait and see, you know, so that I may not get uh, get diabetes. Maybe I just had some, some very sweet things yesterday you know because MCO, I just had a lot of sweet things, but upon checking and checking later we'll share on the checking part, but diabetes is coming. You see, there are many ways of checking well, right, right. Thirdly is amputation or without, leg, I think this is the the-the thing that come into people's mind that Oh, diabetes means, I'll get my leg amputated, I don't want to get into that even. Right,

    Correct. Gina when we talk about diabetes them, very often we hear about ohh, there is actually Type 1 and Type 2. So, so maybe we can just visit this this topic about so what is really a Type 1 diabetes that often we're talking about.

    Okay, I think when when people talk about diabetes. People may not aware what is Type 1 and Type 2. In fact, there are two types of diabetes in.. we will be talking about. All right. The first one is definitely Type 1 diabetes, and you probably have heard about it. Okay, some of your family members and all that we have already Type 1 diabetes and to tell you the truth, diabetes Type 1 normally can happen in children like children, may get it more often. Or this is just a statistic share lah. Yeah, recently I also encountered one of my friends son who is only about two or three years old. Suddenly, has this problem of a lot of urine, urinated. You know? The diapers is always full, and it's kind of smelly, and the person who showed this to me is also a pharmacist, and she just got a clue, like, how come you know my diapers is always wet and it's always full, you see, and she just took that diabetes monitoring machine, and just prick on the other hand, of the son or the finger of the sonn, and guess what they know what upon check is like more than 10 is very very high and to get to get the shock of her life and she she went to diagnosis as a doctor and confirm the Type 1 diabetes. So she was devastated. So why is it a Type 1 diabetes. In fact, Type 1 diabetes is nothing we can control is because our immune cells destroy our beta cells in the pancreas. This is very technical. Basically, pancreas is one of your organs in your body. And, unfortunately, our body, self attack, you know, has already gone to the stage where you don't know who is good guy who's bad guy in a body.

    Correct. So it's not an external factors were already the child had too much ice cream too much chocolate then cause this Type 1 so Type 1 is not caused by external factors.

    No, no, not at all. So, in fact these immune cells basically just attacked itself and attacked the beta cell, so beta cell is actually the one okay the beta cell in the pancreas that is actually producing the insulin. So the insulin is a hormone produced by the pancreas and actually kind of metabolise, the glucose and all that in the body. So, if this one is already been shut off, you can't, can't do anything in order diabetes glucose ever in your body will be always, you know on the higher mode, because whatever ice cream or whatever food that you consume, it will just remain in your body but not being sent to your cell level.

    Wow, Okay, sounds, sounds really scary, but maybe we can then compare it with two so how about Type 2 in this case?

    Okay, Type 1, Type 1 is auto immune. Okay, so Type 2. Okay, this slide is actually a busy slide. I got it from a reference okay, it's actually compare Type 1 and Type 2 altogether. Type 2 is, it's more basically that our bodies is unable to respond to insulin, and overtime production is decreases, so it's actually insulin resistant case. So means that the pancreas is not yet, you know, being attacked fully, but slowly degenerating. So that's how the Type 2 come in and normally Type 2 will say is a mature age diabetes, where you will come slowly upon maybe 40 years, 50 years and even 60 years old. Around that time, but that the risk is there. So, Type 1 difference between Type 1 and Type 2 is like this. So Type 1 is normally a younger age, Type 2 is actually at more mature age, and Type 1 is actually the pancreas is gone. Okay, Type 2 is slowly degenerating.

    Okay then one question right you know can you get Type 1 and Type 2 at the same time?

    No, I haven't heard of it.

    Yeah, because the Type 1 one the pancreas is already gone, so you need to be using insulin for life, and checking your blood sugar for life also.

    Right, right.

    Okay, so Type 2, it's more like you know, of course today our topic is more on to Type 2. And we have you know, we talk about you know healthy diet, regular exercise and all that to prevent the onset of the Type 2 diabetes. So there are many risk factors, we can talk about later, you know, to prevent this, can, can some may actually asked me, Can diabetes be prevented? Yes, it definitely can.

    I think definitely you just shed a light at the end of the tunnel where, where, you know, we can actually prevent Type 2 diabetes so it's not the end of the world when you get diagnosed so there is something that we can do to in fact, probably slow down or even, even reverse, if I may say that. Alright, so, yeah, so, so,

    I think I hope that we, I explained the main key thing that I don't want to go on too technical, but the main Type 1 and Type 2 hopefully already handle here. So we go on to the next one, you wanted to address this topic today what is diabetes Type 2, you know, diabetes, means the high sugar level a lot of people say Oh, does it mean that my sugar level is very high, and cannot digest yes means that it is a condition where, which the body does not properly process food for use as energy. Imagine this, This slide I show two bright photos that I think a lot of people would like them a lot of people have this sweet tooth problem. You see, anything that's sweet. No like sugar like cakes and or anything we fondant, anything. Very nice. I think children will also like it. Now, we actually start giving sugar when our child is this young, you know like feed them ice scream, feed them Smarties, feed them whatever you know thing that you can think of, and that's actually the sugar that once you eat it, because you have to get your body to work harder to process off the glucose, you know that you consume, and glucose when you eat it you feel very happy because they actually give these happy moments. That's how some, some company may say oh you, you take these ice cream you know or you take this drink, you feel happy because, glucose actually satisfies the need, you know

    Right, so when children they throw tantrums right then, then the parents "Come papa give you ice cream, or papa will give you chocolate, make them happy to make them stop throwing tantrums, right, so that's, that's not good at all. Yeah. So parents, don't do that

    So yeah, being a parent myself, I also do that. But, uh. No cannot do that all the time, you know, so, you know, it's just a part of our, our society like you know to actually give a sugar first, so the more sugar you give, Okay, the more, the harder the person you know as a whole, because the pancreas has to work harder, slowly, because you already cultivated that happy, you know, no sugar, don't you know, not happy. So that's how this sweeth tooth you know come by this term . So, unfortunately Type 2 diabetes is a matured age diabetes. Imagine your pancreas when born is at 100% efficiency. As we grow older, the efficiency drops. So when you test your sugar level, it will show you, if a person has got a poor pancreas function, the sugar doesn't get metabolised, and you will show let's say, we talk about the figure later it will be higher than normal. All right, I'll go on to the next slide, you see the carbohydrates, when consumed. Okay, is broken down into glucose. So carbohydrate you can think of your noodle, your rice. Even your Apple. Apple is actually fructose, and then maybe pasta, or any sweet stuff, you know, your, your ice cream, your chocolate, anything that you put in your mouth. And then once you consume digests, and then you go into your bloodstream. This is how it work. And then after it goes into your bloodstream, the blood glucose increases the insulin will start to come already, start to do the work, the pancreas is doing the work. So the insulin will actually bind to the cell and the insulin, unlock the cell and the glucose sensor into your body system to be used for energy. So that's how the whole process works inside our bodies. Every moment, every second, the moment you eat something. Okay, so that's that's how it's become like that, then this is another chart, it's more technical, but this is more into like science or maybe when you study science you will tell you, you know, the glucose, insulin going into that you have this receptor, and once the receptor is on the insulin, you know the glucose will go through that. So, if, if the Type 2 diabetes come by. This does not happen. The first the first diagram on the top to show this is a healthy one. So the Type 2 come in, you see more glucose is outside the cell. That's how one of the symptoms of diabetes is. Suddenly you see the person lose weight losing weight, why because the glucose is not entering your cell. It's not feeding your cell, is not entering your bloodstream, you know, it is in your bloodstream, but it doesn't enter into your cell. So the cell is actually always hungry because there's no insulin to come by and work, you know, to respond to insulin properly. So, very common one of the symptom of being a diabetes, you can see the person suddenly lose weight a lot, because the body is hungry, it doesn't mean that all your glucose is a lot means you don't have to eat, but in fact, this is a situation where the pancreas is not functioning well already.

    So sound very hard right. Yep. Okay.

    It's a bit technical but it's basically just an abnormal situation, the body, the food that you eat, doesn't get into your cell. The cell is the smallest unit of your body. So when the cell is not fed properly, then you, your body system is in on haywire mode.

    So that's that's very, that's very good information down there. Like, when, when we taking su-, it's interesting to find out that okay if someone is, is kind of like having a symptom of of a diabetic, right, that means the one on one, You mentioned that they could be losing weight because their cell is not able to absorb the glucose that is there. As a result, they lose weight right, so in this case - my question is that then the blood sugar will probably be high because the glucose is remaining at the bloodstream, is that right, yes.

    Yes, correct. Doesn't go into the cell.

    Then it is good to also get an idea of how much sugar is contained in our blood, at this point of time, right, so can we actually measure that how can we do that,

    Yes, definitely yes. Go to the next one, how can I measure my blood glucose at home, and what are the ordinary signs to look out for. The next question. So I think you probably have heard about blood sugar machine, monitoring system I call it. There are many brands in the market in a pharmacy setting or even you go to hospitals, a doctor may give you one also in a government hospital setting. And then, This is how it looked like. And the moment you prick your finger on the diagram on the right. Of course you need a lancing device that you've prick your finger and the strip will actually absorb the sugar into the machine and it will show a figure. So anytime of the day, let's say let's say, I would say to, two mode - one is on fasting mode means that you fast for 10 hours, then the moment you prick your finger, and then you will see the sugar level. If is less than 6.1 means you're healthy, don't have any diabetes problem. But if it is more than 6.1 to seven, you may have insulin resistance. Right.

    This is 10 hours of fasting?

    Yes correct normally I'll say 10 hours but some people may say I need to fast longer but 10 hours is fine. The moment you finish the last bite of your food, and let's say, seven o'clock you finish your food, at the moment, eight o'clock to the next morning, maybe about six o'clock you can check already.

    Right, right.

    Okay. So, it is after this 10 hours about fasting and is 6.1 or below then you are you're safe. Okay. If above that, then you have to be very careful. Right. Another mode you can check is two hours after your food for example you wake up first thing in the morning you check 10 hours fasting, and you may drag until eight o'clock, six o'clock you check your blood glucose eight o'clock, just before your breakfast. You can check one time, and after your breakfast, eight o'clock. You know, 8:30 you finish your food 8:30 to 10:30. 1030 You check, and supposedly it shouldn't be more than 7.8.

    So this is to see how well our body absorbs the sugar in the cell,

    If your pancreas is working. If the insulin is working properly. The beta cell is working properly. So if it is working properly, then your sugar level should be lower, means that your sugar that you consume already gone into your cell, it doesn't remain in your bloodstream.

    Right, so if it's a lot of the sugar still in the bloodstream that means then this blood sugar test will, will show that it's above eight, or something like that. Right.

    Okay, okay,

    Insulin resistance is for pre diabetic case or maybe like seven, eight, was very high, or serious diabetes cases may go very high that more than 10, even one time check 20, 30. I think I've heard a storyy like emergency case I-can go up to 60. It's very very critical already. So, so you see here as I mentioned, on my screen, I say, health check your blood sugar test seven times a day. So actually it's a bit too many times I think at the end of the day your finger will probably feel very hurtful. But if a person has diabetes, and not control well this is how I will advise my patient to do it - seven times daily.

    So Gina would you recommend people with sweet tooth right, to actually get one of these to actually check at home because those who-

    Yes, why not.

    Yes, it's just a precaution, precautionary because, right, because we probably wouldn't know that actually we are diabetic or pre diabetic. Before we even check it. So, is there any other testing for example, if let's say you were to go to hospital or different, different medical centres right. Do they use this to check or is there any other tests, that's available?

    Okay. I finished this slides and I mentioned that seven times daily right, you can go to just now, seven. Fasting, when you wake up seven times. Seven times means that fasting upon waking, and then just before your breakfast one time after your breakfast on time, just before lunch, one time, after your lunch, one time, just before dinner, one time, and after your dinner one time. So that's total seven times, seven times. So that's how far, so how that's, that's been monitored. Okay, So your question back to your question, what are the other tests that you can check. In fact, HBA1C is the one that normally in a hospital setting. You can check or lab testing, and in fact that pharmacy level we do have a machine which can check this. So HBA1C is checked, It's a method to check your blood sugar level, average blood sugar level for the three months. The logic behind this, is this. So what is HBA1C? Just now I mentioned red blood cell right, our body the glucose actually attached to our haemoglobin, So it means the glucose, our sugar and our red blood cells, so called 'abang - adik', a good friend. So, when the blood red blood cell, see the blood glucose, it will actually attach together, and the red blood cell actually recycle every 90 days. So this marker HBA1C actually come by to check these glycosylated haemoglobin, glyclated. Sorry, glyclated haemoglobin, so it's developed when the haemoglobin a protein within red blood cell carries, that carries oxygen throughout your body, joins with glucose in the blood, become glycaleted. So by, by measuring glycated haemoglobin HBA1C means average blood sugar for the past three months, we will actually give you a idea of how your sugar level is being monitored. So normally this is being measured in percentage wise, So, it should be less than 6%.

    I see. So so the thing that the take home figure over here is, whenever we do this test, we should be mindful that it should be below 6%.

    Correct.

    Got it, got it, got it. So let's let's zoom out a little bit right on like so usually we talk about Type 2 Diabetes right. So what are the symptoms that we should be paying attention, in this case?

    So, next topic we're gonna talk about is why the diabetes symptoms. So I think I mentioned about sudden weight loss. So if you are unintentionally losing weight, means that you are not like restricting your diet, which going for exercise on the, on the weight loss programme but suddenly just weight loss. Then people say, "wah suddenly weight loss good!". "Oh, I don't think so!". Upon checking, first thing you have to get into your mind is to check your blood sugar level, let's say, upon checking is more than 6.1 means that you either pre diabetic or even more worse. We'll have to see the figures. So that's the common one. Go back to you see this there are 10 symptoms here. The one on the top left is always tired. No matter how many hours of sleep also, being very tired. Okay, and frequent urination. Just now I quote an example of Type 1 diabetes, of the child always, you know, with wet diapers. Very commonly for adults also the same and intentionally you'll always have to go toilet for some reason. And the third one is sudden weight loss. The fourth one is wound that won't heal. A lot of times I when I have a client, they will come in and say, my wound heal very fast, I don't need think I have diabetes, because the moment they have a wound, you know, somewhere in odd place, especially on the feet and all I ask them the first question I asked them, Do you have diabetes? No no no I don't have my wound heal very fast. Yes, in many ways, it means that if you heal fast, your diabetes is lower, but no harm checking if you have a wound that doesn't heal. And then the fifth one is actually sexual problems, male or female may not have. They wouldn't have interest in sexual in sexual wise and sexual

    This would be a serious problem.

    Already serious, maybe ED will be the problem or dysfunction and all that, that's another topic, then you go down. Okay, always hungry, or food is always, no matter how much I eat, I always hungry, you know, that one.

    Why why is always hungry- being a symptom for diabetes?

    Because, because your cell doesn't get the food, whatever food that you eat away.

    So you have already had this desire to eat more, but the more you eat, your cell wouldn't absorb.

    Yes, yes. Oh, you're always hungry. Okay, okay, then blurry vision because diabetes has a lot, got a lot of complication, means that you are actually gone into the eye, you know, the eye has gone, the blood cell, sorry the blood glucose, doesn't go into the cell, and actually affect one of the organs, and eye is one of them. Okay, that's how some they have the symptoms of blurry vision not because you have shot shortsightedness or long-sightedness. No it does doesn't go away even though you were specs and all that, yeah.

    This is good information. Yeah.

    And then the next one is actually numb or tingling hands or feet is it's very common because it will affect the circulation of your lower body. Okay, another one is always thirsty. One of the symptoms, always thirsty, and always go into the toilet or urination. The final one is actually vaginal infection.

    Okay,

    So these are the top 10 symptoms.

    These symptoms are usually affecting, is there a particular age group that we are talking about like, or maybe a particular body type. Are we are we probably should we be more aware when we are approaching middle age, or even elderly, or should we be more aware, if you're overweight, so that's that's that this affects everybody or just a particular group of people?

    Of course, if the person is overweight is definitely one of the risk factor and overweight and, of course, nowadays, diabetes may not only attack those who are senior in age only, as I mentioned about 40 years old, commonly is 40 years old and above then you have to be very careful. So, a lower age group, the Type 1 diabetes may be a risk factor all right I mean maybe one of the factors, and those that really you see them always on Coke doesn't drink any normal water it doesn't drink any of this common mineral water or anything like that, always on Coke, or any drink. They say that the water is tasteless, though they like something that you know has some sugar in the drink so that they do drink. Be careful, you're always feeding glucose into your body system only. So the bloodstream is always full of glucose. I have, I had people who, who are very young age. Sometimes I see them, they come in and test, then I'll ask them the same question. Oh, are you a diabetic, they said no, but I have history of diabetes, then I will say oh okay so upon checking and they are like, let's say 5.1 or whatever on passing. They're very happy. Then I'll ask them again, why you want to check why you want to bother to even check at your age, let's say they are working class like 20 to 30 started working, but I say around 30 years old. So, because my family history has got diabetes. I have a sweet tooth they will tell me that I just want to be very cautious so they may come once or twice a month so just to check just to make sure. Yeah, I think. so it's good that we have these kind of awareness so that even though they have diabetes, they know how to prevent it, because before it gets worse.

    Right. Okay, okay. Yeah, okay.

    So, I'll go to the next slide.

    This is the question I asked,

    Yeah. Diabetes only affects the elderly or individuals who are overweight so prevalance of diabetes, according to our National Health and Morbidity Survey. This is 2015 figure I am quoting, actually target all people who are more than 18 years old, non diabetes already 8.3% and non diabetes, 1.2%, and total diabetes, it's actually 17.5% So, I would say that you know, according to the survey, they actually take 18 years and above, to do the survey. So I would say that it doesn't mean that you are 18 that you are safe. Of course this is just a very safe figure. I feel that, it's not, it's not checking everyone, checking those that have very high risk factor or have certain times, a certain level of health literacy or awareness. They wanted to know, you know, their body system. Alright, so that's how the figure come about. But this is a very high figure and I think it may be high now, because it's 2015. Yeah, you know sometimes it's double. So what are the causes, just now I mentioned overweight is overweight, definitely is definitely one of the controllable risk factor, lack of physical exercise, bad eating habits, uncontrollable risk factors such as family history, as I mentioned about family history. Anyone age more than 45 or anyone receive polycystic ovary syndrome, these are some of the risk factor. So just bear in mind that if your parents has diabetes, then you should be very, very be careful.

    So I think over here I think we can kind of like focus on the controllable risk factors where we can play a part in reducing the risk of diabetes where if I think we are overweight, then we know what to do, in terms of having a healthier diet, exercise more and have a good exercise plan, so that we can control the risk, and then uncontrollable risk, I think we can't do anything about it, but the good news is that we can control the risks by really having a good lifestyle, in a sense. Right. So that brings me to that next question now what, what if right, if I have if What if I have diabetic and I'm pre diabetic, so. So what what are the consequences of diabetes?

    Okay, just now I mentioned about the eye factor and all that right there are many consequences of diabetes. You see here there are like 10 already- eight or 10 already. So complication or consequences of diabetes, these are such that it will affects the organs organs. First one is actually the eye. You see the diabetic retinopathy cataracts, glaucoma, and then you will affect your heart also that's how you get a heart attack, and they'll affect your lower body, they'll lower in from the feet or around the feet area, lower body. So, peripheral artery disease, and they have numbing, you know peripheral neuropathy. And you can see diabetic foot is also listed, on your feet, and also your diabetic nephropathy is actually your kidneys.

    It affects top to toe.

    Yes correct everything, every organ disease because it's the whole bloodstream what, yeah, yeah, the glucose level is actually in your bloodstream so that's how diabetes may lead to and other issues. So, those that already have diabetes, normally we will advise them on how to manage. Otherwise, is usually very common- strokes. Okay. All right, so just now I mentioned about diabetes food, you know, share on diabetic food and also another one on the eye, because these are the two common ones. So I think just now we mentioned about amputation, the first slide. Now, why gone to bat because for diabetes cases they wouldn't feel anything on your feet, and they may have corn, calluses, they may accidentally step on something. I do have a patient who asked me, that was something but they are not aware, Yeah, they don't have any pain, you know, they don't even feel that it's painful. That's is the worst part, so they don't feel even that painful and let's say they have corn or calluses, means they form very hard skin and all that on beneath the foot, and they don't ever feel it. Until one day someone just, or maybe he or her caregiver saw the foot become like that. The the photo on the left. I think it's bit too later. And then on the photo on the right is already like, you know, the cells and all that are already, I think, cannot do already - all black in colour, and that being amputated. So, that's the worst part because to have this, the blood sugar level may be easily 20 and above. I have cases where they are 20 and above and still they say they won't want to control their food, is still very easy-going, the don't care attitude, I'll die faster, you know, diabetes, it's an, it's a chronic disease, etc. And it doesn't mean that you want to die tomorrow, then you will die tomorrow and it just torturing so that's how management of diabetes is very important that you don't want to go until that stage, and when it amputations starts right, then the family the caregiver will be thinking like, should I amputate, or should I just leave it like that. Yeah, it's very drastic, you know, when you do amputation. Today you have your feet nicely there, but it's all black. Tomorrow you wont to have your feet, ready and you will be thinking how do I walk, you know your life, life will be different from there. So I really urge you, don't go to this stage, because it's very heartbreaking, especially in terms of caregiver, the family members are more heartbreaking than the patient. Because. Because the thing is that diabetes management is about self care is about yourselves, it is not about other people, your caregiver is someone to take care of you. But if you as a caregiver doesn't really even take care then, who else together. So, diabetes foot when going into this stage, definitely. You need podiatrist, a specialist, you know, to really assess the foot because you may have ulcer somewhere and all that, and that's where the wound dressing and all that will come in. It's actually continuous it won't stop for wound dressing wound management. There's another issue. If this one doesn't get addressed properly I've seen cases where maggots will come, even worse, Because it's being amputated, that you will want to amputate and the whole cell is like already in that state, the cell is that, what, what other what other creatures will come definitely maggots. So, that's horrible right yeah I have, I have this experience of one's one caregiver, actually told me that all I need to buy certain very potent chemical. I said what why you why you need such potent chemical, I mean yes I can help to arrange that. But why do you need that, Then they suddenly share that, the doctor asked me to get it because my mother has really got maggot in the wound, does that oh my god and we see the worst part or so, oh my god, serious? Can work or not? So this is a bit of story to share. So the next one is diabetic retinopathy, you see the blood glucose is all over your body. So, eye is a delicate organ in your body that can be affected drastically. Okay.

    That's how, If you will notice certain advertisement or certain product in the market they will target on diabetes, diabetic retinopathy is what you see here. The Soundflower has got black patches and patches and all that, even though you wear your spectacles you may fall without your spectacles nowadays you have to wear face shield so more, so you will see black patches all around it and I say, How come is that that because it's actually blocking the view already. Your blood vessels or is already been damaged by the excess blood glucose in your body.

    Right.

    So, that's how before you get that worse, you should actually take precaution to go back to diabetes management, the glucose level is a key.

    Alright, so that brings us to like so, while something the consequences is really bad and severe. So what are the- how do we treat diabetes, in this case?