People with type 2 diabetes are at risk of a number of complications from the disease such as nerve damage, kidney disease and vision disorders. So it’s no surprise that clinicians devote a lot of time in consultations looking for early warning signs of these complications.
But for many patients grappling with diabetes, the here and now is often far more important. Patient concerns such as loss of strength and mobility, which make it difficult for them to get around the house independently, to go walking or to climb stairs, are far more likely to cause anxiety than the potential for future complications.
These immediate concerns, however, don’t tend to elicit the same attention from physicians – particularly when it comes to older patients, whose increasingly frailty may be viewed with a certain inevitability.
To be fair, there hasn’t been a large body of scientific evidence to date to warrant much attention. But researchers are now attempting to determine whether diabetes exacts another burden, in addition to the known complications of the condition.
Perhaps most importantly, researchers are now attempting to determine which parts of type 2 diabetes are strongly linked to physical dysfunction.
At a broader level, this prompts some interesting questions about what health professionals can learn by listening more closely to their patients. It’s not a novel approach by any means, and one only has to look to history for many examples.
Sir William Osler, a physician and pathologist described as one of the founding fathers of modern medicine, revolutionised medical teaching in the late 19th century by urging young physicians to listen to their patients instead of relying on textbooks alone. “Care more particularly for the individual patient than for the special features of the disease,” he said.
In line with this philosophy, it may well turn out that one avenue of scientific exploration to help better understand type 2 diabetes has been right under our nose all this time. Maybe understanding frailty will finally make us sit up and take notice of what our patients have been telling us.
Through the introduction of a muscle strength and physical functioning test in the third round of the Australian Diabetes and Obesity and Lifestyle (AusDiab) study, we hope to learn more about the burden and impact of frailty in a wide range of conditions including diabetes.
While a great deal more research is needed in this area, overseas studies are already drawing important links. In 2003, researchers from the United States found that people with diabetes were more likely to have a physical limitation than those without diabetes. In this study, tasks involving mobility or lower extremity function, such as stooping, standing, walking, pushing and climbing, tended to be the most problematic for people with diabetes.
The implications of such findings on a health system facing an ageing population and a rapidly increasing burden of type 2 diabetes are enormous. But, more importantly, the impact on an individual’s quality of life is likely to be profound.
At present, we incorporate a range of health professionals in the management of people with type 2 diabetes, including dietitians, ophthalmologists and renal specialists. But scientific research might one day demonstrate that the biggest burden facing people with type 2 diabetes is physical functioning and frailty and that there is a need for specific interventions.
Such interventions might involve the introduction of strength training sessions or the addition of exercise physiologists in the diabetes management team. While it is premature to speculate too much, it’s clear that if we can understand more about the underlying disease, it’s likely to influence prevention and management strategies.
Physical activity researchers are also exploring hypotheses about links between advancing age and declining muscle mass or frailty, which is exacerbated by inactivity.
The links between inactivity and the development of chronic disease are increasingly being documented, but more research is needed to understand if there are links between the degenerative loss of skeletal muscle mass associated with ageing known as sarcopenia, inactivity and type 2 diabetes.
Researchers who undertook the third US National Health and Nutrition examination survey in 2011, for instance, hypothesised that low muscle mass may be an early predictor of diabetes susceptibility. But there is a long way to go before we understand if and how diabetes might be linked to physical dysfunction and to conditions such as sarcopenia.
So why has it taken so long to focus on frailty? It is said that the hardest thing about research is to come up with a good question, and lots of questions seem so obvious afterwards.
For too long, we have assumed that frailty is an inevitable consequence of ageing and haven’t paid enough attention to this very troubling issue. As Sir William Osler said, we can learn a lot from listening closely to our patients, which in turn can help us to ask the right questions.
Hopefully one day, we can also provide our patients with some answers to issues, such as declining mobility, that really matter to them.
This is an edited version of an article that appears in the latest issue of Perspectives, an opinion-led journal published by Baker IDI Heart and Diabetes Institute.