Diabetes

I'm on endocrinology at the moment, drifting between wards of acute patients to clinics filled with chronic ones. The first thing that sets the diabetes clinics apart for me is walking into the reception/waiting area. It's new and shiny and clean with the fresh smell of paint. Clean architectural lines and lots of natural light from the floor to ceiling windows. It has sparse chairs scattered along the walls, as they are mostly dominated by long white and blue leather benches. They're comfy to sit on, and as I perused an old issue of New Idea while waiting for a consultant I mused that they also fit the clean lines of the new building.

It wasn't until the clinic started to fill up that I realised that they were not just an architectural statement, a nod to hypermodernism - but that these long wide couches were deliberate and needed. Quite simply, the chairs with arms were not big enough for 90% of the patients who walked through the door. The doctors' rooms hold similar traces - the chairs for patients are easily wide enough for me to curl up with my feet to the side and lounge on, they are also heavily reinforced.

The endocrinology clinics are very interesting. Strange, rare diseases affecting primarily the tiny organ in the middle of your head about the size of a large pea called the pituitary. MRI scans show minute shading differences while careful pathology tests reinforce suspicions. But these clinics are not the majority of my term, the majority is the diabetes.

I sit in the room, next to the doctors who have seen it all before, in my first clinic full of the unquashable enthusiasm and optimism of a medical student. The lady who shuffles in slowly before gratefully sinking into the oversized chair in front of me looks uncomfortable and in pain. It was 11 degrees outside when I came in, but she is sweating, it beading frostily on her brow from the effort it has taken to get from the waiting room to this office some 20 metres away. She shifts a little in her seat, lifting her pannis and settling it more comfortably over her legs. They are splayed apart, both the pannis and the breadth of her thighs make it impossible for her knees to meet.

She clasps her hands together tightly, resting them on her pendulous breasts which are held up by the cushion of abdominal adipose tissue. If she was to stop clasping them they would spring apart, the spilling out of her abdomen prevents her from even resting her arms on the armrests, as modified as they are. She squints a little as the doctor asks her questions, her eyesight having rapidly deteriorated in the last 2 years from diabetic retinopathy. She complains of headaches when she tries to read, so she doesn't do it any more. She looks very tired, around her eyes deeply wrinkled and the bags beneath almost violently purple. She suffers sleep apnoea, caused by the weight of tissue around her neck collapsing her airway as she sleeps. All night long she cycles between hypoxia, as the airways are occluded, to waking, gasping for breath before falling asleep again. She does this maybe 12 times an hour, and she only sleeps for 6 hours a night. She is always tired.

She cannot feel her feet, diabetic neuropathy set in some years ago, and her feet are tortured. She cannot feel the ground, or when she kicked the bedpost, so she has had broken bones in her feet. She has had a previous charcot foot, where the bones keep being broken but unable to feel the damage she walked around on them until the heat and swelling caused her to seek medical attention. There is no arch to her foot, all of the normal contours gone. It is a fleshy protuberance that she somehow manages to balance on, the normal anatomy deranged.

Her other foot looks somewhat normal until we look at the sole. A deep ulcer has formed over the ball of her foot and she cannot feel a thing. We debride the sloughing, smelly tissue with scalpels that she can't feel, packing and padding the wound before calling up to the hospital to have her admitted - she needs IV antibiotics and we need to exclude osteomyelitis - we could see the bone in the base of her ulcer.

Examining her for a systems review is very difficult. Her heart is almost impossible to hear beneath its cushion of fat, even when we lift her breast to find a yeast infection underneath. The poor healing and the sugary exudate of diabetics makes this a common finding and the smell is overpowering. I mouth breathe through the examination, hoping not to embarrass her, but unable to ignore the pungency of her skin. The respiratory exam similarly difficult, the abdominal exam impossible. As I push my hands deeply into her flesh I give up searching for organs, I cannot get deeply enough to feel them. Thankfully however her bowel habit is regular and unchanged, so there is no major index of suspicion. She also has 2 yearly colonoscopies, the twin risks of family history and obesity playing heavily against her.

She is in need of bilateral knee replacements, but although she has been placed on the list, the consultant and I both know that she is unlikely to get them. Her morbid obesity makes her an extreme anaesthetic risk, so she continues to hobble a little in pain. The public hospital system is reluctant to spend $100k on replacing knees that will not be long used. Her foot ulcers have also prompted her to have a vascular surgical review, as due to her extensive peripheral vascular disease her ulcers are not healing. These surgeons are also unwilling to operate. They show me pictures of the circulation to her feet and it is almost nothing. If they cannot get this infection in her foot under control she will have an amputation. Her dwindling mobility is reducing almost daily. Soon she is likely to be confined to a wheel chair.

The most awful part of all of this? This lady is barely 50. She could be my mother, my Aunt, a colleague. She isn't on the end of a long and full life that has gradually slowed down past 70. She has been living a painful, uncomfortable and medicalised life for the past 20 years, though the marked deterioration began at about 44. I have seen her identical twin, both male and female every day for the last 2 weeks. Those who for years treated their obesity as nothing more than a nuisance, or an insurmountable hurdle, and their diabetes as merely a little sugar issue. They blushed a little as their chiding GPs mentioned their HBA1c, and insisted they stuck to their low GI diet most of the time, as I glance at the large bottle of full strength Coca Cola in their bags.

Some I met in GP-land, angrily reacting if any mention was made of their weight. Insisting that they had tried EVERYTHING and that we could not possibly understand how hard it was. Others not angry but insistent that they were fit and healthy even if they were overweight and that they exercised every day and that waist circumference and BMI were bullshit.

And the overwhelming feeling I have is of sadness. That lives are played out to a symphony of pain and disability, shunned from society with social engagements merely a combination of specialist visits at the hospital every month, or in some cases every week. They know every detail of their management plans, the names of each doctor who looks after each failing system. They are inured to the gravity of each complaint, as they began to stack up it became easier to treat them all as a separate intellectual entity. Otherwise the depression and hopelessness of it all would consume them.

It has been a confronting few weeks, deeply impressing on me how important it is that I deal with lifestyle issues now. I have always eaten healthfully. I like fruit better than chocolate, and saturated fat gives me the squits. But I am not immune from comfort eating and it is very easy to serve yourself a meal that has twice the recommended caloric specifications. Exercise is the very last thing I feel like after spending 9 hours at work and 2 hours commuting every day, and so strong is the pull in the cold evenings of my comfy couch, with my quilt pulled up over my knees as I munch on a delectable home made apple crumble drizzled with cream.

But as I flashed forward into the future, I imagined gaining 3kg per year for the next 15 years. A familiar story for many of the patients I have chatted to. Many started slightly heavier than me in their teens, always with a bit of "puppy fat" but never obese, and it just kept coming and coming. In 15 years I will be 41, and I could, in this hypothetical but easy to imagine scenario weigh 115kg at 40. Without even thinking about it. The cruel cycle being that with every kilogram gained the more effort exercise took on their bodies.

I think of how much more effort it takes when I am carrying the girls up the stairs every day and think about how gradually, it would just become more than I could handle, such that I avoided situations where incidental exercise would be necessary. Until there came a point where even if I wanted to, walking up stairs would be impossible.

I've started riding to work, I figured I'm moderately fit anyway with all my gymming so it would be a good way to ensure an hour of cardiac exercise every day with the added benefit of not having to change buses/trains. And it was hard. Goddamned painful. It's only 8km to work, and admittedly very hilly, but it is not that far really, I can do it in 45 minutes. But the pain on that first morning - it tore at my lungs. I got maybe a km from home and debated turning around and catching a bus, or even better driving because I did not feel good.

When I got home last night, sweaty and breathless, I thought about the fact that before that ride I would have told people that I was of average/acceptable fitness, and that as I conform to a healthy BMI and waist circumference that my lifestyle was fine. Perhaps I even felt a little detached from the patients I saw, wondering loftily how they could possibly have ever got to this state. And now I know, because even I, with all the knowledge and stubborn discipline in me could easily get there. It's not laziness, but denial is strong. There denial in the community is overwhelming.

I sat in the food court today, the smallest person in an area of maybe 40 people but one. I looked down at my rounded belly, my inflated arms and the way that my buttocks spilled out on the chair and thought guiltily of how little attention I have paid to keeping it healthy and disease free, resting on the laurels of good genes and youth. I was grateful that I had chosen a salad sandwich, but I looked around in despair at all these people, so many of them easily twice my weight, eating the chips and gravy that perfumed the air. Watched them drink their soft drinks and thought to myself that something is seriously wrong.

We're so far in denial that it's now just an accepted thing that we're fat and unhealthy and unfit. We're ignorant and think of diabetes as "just a sugar problem" and that size is just a media tool to make women feel guilty enough to buy miracle cures. It's so easy to cure, but at the same time it isn't. And we should know better.