For the next few weeks we will be looking at complications of diabetes that are associated with micro-vascular damage – that is damage to small blood vessels, like in the eye, the kidneys and nerves.  These result in diabetic retinopathy in the eye, diabetic renal disease and diabetic peripheral neuropathy.  More about each of these as we discuss them individually.

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Diabetic retinopathy is the most common cause of blindness in most western countries.  In some of the less developed countries conditions like cataracts, and chronic eye infections are more likely to result in blindness.  But as the incidence of diabetes increases around the world, diabetic retinopathy obviously will also increase, outstripping the health resources to monitor and manage patients with this condition.  According to authors K J Hofman, C Cook, N Levitt in an article in the South African Medical Journal, entitled “Preventing diabetic blindness: A priority in South Africa written back in 2014, “Currently approximately 2 million South Africans live with type 2 diabetes, with a projected 115 000 new cases per year. It is of concern that about 55% of people with diabetes are likely to suffer from diabetic retinopathy. Diabetes is the third leading cause of blindness in SA, with retinopathy and cataracts accounting for 8 000 new cases of vision impairment every year. In a 2010 survey in Cape Town, diabetic retinopathy was responsible for 8% of blindness and 11% of severe visual impairment.”

Of note is the following quotation:  “The fact that timely treatment of diabetic retinopathy can reduce the risk of visual impairment by 90% implies a need for screening and early detection.”

Unfortunately a large portion of patients with diabetes seldom are screened regularly for diabetic retinopathy.

This can be done by an interested GP, by an optometrist, or by an ophthalmologist, the latter who also will effect management of the condition.

Types of Diabetic Retinopathy

The American Optometric Association gives this information.

Retinopathy is classified into two types:

1. Non-proliferative diabetic retinopathy (NPDR) is the early stage of the disease in which symptoms will be mild or nonexistent. In NPDR, the blood vessels in the retina are weakened. Tiny bulges in the blood vessels, called microaneurysms, may leak fluid into the retina. This leakage may lead to swelling of the macula (the central major point of vision).

2. Proliferative diabetic retinopathy (PDR) is the more advanced form of the disease. At this stage, circulation problems deprive the retina of oxygen. As a result new, fragile blood vessels can begin to grow in the retina and into the vitreous, the gel-like fluid that fills the back of the eye. The new blood vessels may leak blood into the vitreous, clouding vision.

It is thought that proper management of diabetes with medications can reduce the rate of progress of diabetic retinopathy, but unfortunately, even careful, tight control of blood sugars, seems not to stop the progression of the disease.

What causes the damage to the small vessels?

Studies suggest that it is primarily the high levels of blood sugar that cause damage to the endothelial lining of the small blood vessels.  This causes small micro-aneurysms which are like little balloons in the blood vessels.  These become clogged with blood clots and result in decreased oxygenation of the retina.  New blood vessels then grow into these areas, but these new blood vessels are fragile and can easily pop.

Treatments for diabetic retinopathy

Apart from proper control of the diabetes with exercise and medical control, treatments offered include laser cautery of the affected retina and intra-occular injections of medication that reduce excessive blood vessel regrowth.

What other options are available to reverse diabetic retinopathy?  Most doctors are happy with slowing down the progress, but there is increasing evidence that with significant lifestyle modifications, much of the condition, especially in the earlier stages can actually be reversed.

Way back in 1939, Dr Walter Kempner showed that one could reverse chronic diseases through the so-called rice diet which consisted of rice and fruit, which was 90% carbs  Already at that stage, they noticed dramatic reversal of quite severe retinopathy in 30% of diabetic patients with retinopathy.  Although this diet needs careful medical supervision as it is not considered complete, he was perhaps the father of scientifically studied plant-based dietary intervention for chronic lifestyle diseases.

Here is a fascinating article by Dr Michael Greger on lifestyle medicine and reversal of diabetic retinopathy through lifestyle changes – most particularly eating a whole-food, plant-based diet, which is low in fats and salts, and eliminates animal products.  This same approach has been proven to reverse diabetes, pre-diabetes and most other lifestyle diseases as well – such as heart disease, arthritic pain, fatty liver disease, auto-immune diseases, and even many early cancers.

Here is a fairly comprehensive review article on the benefits of a plant-based diet in the management of diabetes and its complications.

If you want to read a really dramatic story about reversal of diabetes, severe retinopathy, and end stage lung disease on a plant-based diet, check out this article.

What are the take-home messages for the prevention and management of diabetic retinopathy?

• Prevention is better than cure. Eating a healthy diet, low on fats and processed foods is far better than the standard Western diet so many people are indulging in to prevent diabetes in the first place.
• If you do have diabetes, go for yearly eye tests.
• The best intervention is a low-fat whole-food, plant-based diet.

Next week we will look at diabetic kidney disease – the biggest cause of kidney failure in South Africa.

To life and health,

Dave Glass

David Glass graduated from UCT in 1975. He spent the next 12 years working at a mission hospital in Lesotho, where much of his work involved health education and interventions to improve health, aside from the normal busy clinical work of an under-resourced mission hospital.

He returned to UCT in 1990 to specialise in obstetrics/gynaecology and then moved to the South Coast where he had the privilege of, amongst other things, ushering 7000 babies into the world. He no longer delivers babies but is still very clinically active in gynaecology.

An old passion, preventive health care, has now replaced the obstetrics side of his work. He is eager to share insights he has gathered over the years on how to prevent and reverse so many of the modern scourges of lifestyle – obesity, diabetes, ischaemic heart disease, high blood pressure, arthritis, common cancers, etc.

He is a family man, with a supportive wife, and two grown children, and four beautiful grandchildren. His hobbies include walking, cycling, vegetable gardening, bird-watching, travelling and writing. He is active in community health outreach and deeply involved in church activities. He enjoys teaching and sharing information.

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