The Silent Assassin: diabetes


Frank Booth, RGN (Retired)

Background information

Is this why it is a ‘silent’ killer, a potentially debilitating illness that creeps up on you and takes its toll before you realise what is happening?

The silent assassin

Diabetes is perhaps the single most important silent killers of our generation, but despite many applying their minds and skills, still remains without a cure.  So we have to live with it; but what do we (the diabetic patient) know? As a diabetic myself, I am surprised (and indeed concerned) how little I know; my diabetes doesn’t really bother me, it’s just something that I have had for years. It doesn’t hurt, I can’t see it, and apart from the fact that I can’t eat everything that I may want to, it doesn’t impact on my life. At least, it didn’t until recently. Is this why it is a ‘silent’ killer, a potentially debilitating illness that creeps up on you and takes its toll before you realise what is happening? By which time it is too late to reverse it.

This article will give you some insight into what we have known about diabetes, along with personal reflection that suggests that what is written in the books is not always true for the individual. If you are to learn anything from reading this two-part article, it should be that not everything is as it seems and that sometimes your patients do know something about their bodies. They may not be able to proffer the right words or the technical terminology but please hear what they have to say. The text book is not always right for every person!

History of diabetes

According to Diabetes UK, an Egyptian papyrus mentions a rare disease that causes the patient to lose weight rapidly and urinate frequently. This is thought to be the first reference to the disease, approximately 1550 BC [1]. Diabetes was given its name by the Greek Physician Aretaeus (30-90 AD). Later, Galen (131-201 AD) noted the rarity of this condition and theorised that it was an affliction of the kidneys. After this, diabetes is rarely mentioned. Indeed, it seems to have been a mystery or incredibly rare during the Middle Ages.

Diabetes is a chronic disorder of glucose metabolism and is a major cause of heart disease and premature death. The number of people with diabetes is rising worldwide; between 35–40% of people in Europe will develop diabetes over their lifetime [2].

General Aetiology/Causes

In 2011, it was estimated that around 366 million people have diabetes worldwide, with this number predicted to grow to 552 million by 2030. In the UK, more than 1 in 20 people are thought to have either diagnosed or undiagnosed diabetes; approximately 90% of those have type 2 diabetes, the remaining 10% type 1 diabetes [2]. There are commonly said to be two types of diabetes, type 1 and type 2. More recently speculation suggests a new type 3 but this has not been nationally approved as yet but is said to be linked to Alzheimer’s disease [3].

In general, diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. Hyperglycaemia, or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body's systems, especially the nerves and blood vessels.

Type 1 diabetes

Type 1 diabetes (previously known as insulin-dependent, juvenile or childhood-onset) is characterised by deficient insulin production, and therefore requires daily administration of insulin. The cause of type 1 diabetes is not known and it is not preventable with current knowledge. Symptoms include excessive excretion of urine (polyuria), thirst (polydipsia), constant hunger, weight loss, vision changes and fatigue. These symptoms may occur suddenly.

Type 2 diabetes

Type 2 diabetes (formerly called non-insulin-dependent or adult/late-onset) results from the body’s ineffective use of insulin. It has been suggested that type 2 diabetes originates from an interaction between genetic and lifestyle behaviour factors such as physical activity and diet. The European Prospective Investigation into Cancer and Nutrition (EPIC) study included 350,000 participants across 10 European countries, and investigated the relationships between diet, nutritional status, lifestyle and environmental factors, and how these discoveries may help to prevent the development of diabetes [4].

Symptoms may be similar to those of type 1 diabetes, but are often less marked and as a result, the disease may be diagnosed several years after onset, once complications have already arisen. Until recently, this type of diabetes was seen only in adults but it is now also occurring in children.

Gestational diabetes

Gestational diabetes is hyperglycaemia with onset or first recognition during pregnancy [2] , with symptoms similar to type 2 diabetes. Gestational diabetes is most often diagnosed through prenatal screening rather than reported symptoms.

Type 3 diabetes?

There appears to be evidence linking insulin resistance to a disorder of the brain [3]. The research suggests that a protein present in the brain of people with dementia binds to the tips of nerve endings; this makes them resistant to insulin, crucial to the brain's ability to learn, and store and recall memories. Researchers postulate that when the brain prevents insulin from acting properly, the ensuing chemical imbalance could trigger Alzheimer's disease [3]. They believe think the link is so strong that they have named Alzheimer's disease "type 3 diabetes"[3].

We also need to be aware that impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG) are intermediate conditions in the transition between normality and diabetes. People with IGT or IFG are at high risk of progressing to type 2 diabetes, and thus require monitoring.

Common consequences of diabetes

Over time, diabetes can damage the heart, blood vessels, eyes, kidneys, and nerves. It:

  • increases the risk of heart disease and stroke; 50% of people with diabetes die of cardiovascular disease
  • reduces blood flow and causes foot neuropathy (nerve damage), thereby increasing the risk of foot ulceration and infection, and/or possibly amputation
  • damages the small blood vessels in the retina leading to diabetic retinopathy; globally, one percent of blindness can be attributed to diabetes
  • causes of kidney failure
  • doubles mortality risk


According to the World Health Organisation (WHO) [5],

  • 347 million people worldwide have diabetes; the number affected has almost doubled in the past 20 years
  • in 2004, an estimated 3.4 million people died from consequences of high fasting blood sugar
  • more than 80% of diabetes deaths occur in low- and middle-income countries
  • diabetes will be the 7th leading cause of death in 2030
  • healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use can prevent or delay the onset of Type 2 diabetes

So now we have an idea about the history and basic common key facts and it is clear that in at least the last two centuries this is a disease that has not yet been able to be beaten.

At the moment it is incurable but can always be managed better. Part two will outline management approaches in greater depth and provide some personal reflection of living with diabetes.