Hiding in plain sight

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It is well-known that diabetes can affect the eyes, kidneys, feet, heart and circulation. However, there are other complications of diabetes that are much less recognised. But these emerging complications should be on your radar. So, what are they and how can you reduce your risk?

This article was written by our very own Dr Joanna Gong and Della Wang with Diabetic Living magazine.

When most people think of diabetes, they think of glucose meters, insulin and complications, such as heart and eye disease. But, for many people living with diabetes, it’s the lesser-known complications — from cancer to cognitive impairment — that disrupt daily life. We examine the overlooked challenges faced by people with diabetes. They were always there, hidden in plain sight.

Let’s start with what we know

Diabetes complications are traditionally divided into macrovascular and microvascular complications. Macrovascular complications are caused by damage to the large blood vessels, and include heart disease, stroke and peripheral arterial disease affecting the feet and legs. Microvascular complications (from damage to the small blood vessels) include eye disease, kidney disease, and various forms of nerve damage. The most common form of nerve damage is peripheral neuropathy, where people living with diabetes experience numbness and pain, typically in the feet.

Over the last few decades, the outcomes for people with macrovascular and microvascular complications of diabetes have significantly improved. This is largely due to improvements in the management of cardiovascular risk factors and the diseases themselves.

This reduction in the vascular complications of diabetes has revealed other diabetes complications. These include various cancers, infection, liver disease, cognitive impairment and mental health conditions. Further, ongoing research continues to identify new diabetes complications, most recently anaemia. Being aware of these emerging complications of diabetes can help us to prevent them or start treatment earlier to avoid ill health.

Traditional and non-traditional diabetes complications

Cancer

People living with diabetes are at an increased risk of cancer. In fact, in some regions of the world, cancer has overtaken heart disease as the leading cause of death in people with diabetes. The main cancers implicated are liver cancer, pancreatic cancer, bowel cancer, breast cancer, ovarian cancer and endometrial cancer. Interestingly, diabetes may be protective against prostate cancer.

There are a few reasons why people with diabetes are at an increased risk for cancer. Firstly, high blood glucose levels can alter and damage DNA. Secondly, overweight and obesity are more common in people with diabetes and are linked to some cancers. Finally, certain cancers have insulin receptors, and increased insulin levels in people with diabetes can promote the growth of these cancers.

Cancer risk can be reduced through maintaining a healthy lifestyle, smoking cessation and regular health check-ups.

For bowel and breast cancer, there are also established screening programs in Australia. At a minimum, people aged 50–74 years should have a faecal occult blood test every 2 years, and women aged 50–74 years should have a mammogram every 2 years. Women aged 40–49 years or 75 years or older can also access free screening mammography, but must self-refer to participate. The frequency of bowel and breast cancer screening is the same for people with and without diabetes. However, people with a family history of cancer or certain genetic conditions may require earlier, more intensive screening.

Infection

Diabetes increases the risk of many types of infections, including lung, skin, gastrointestinal and urinary tract infections. High blood glucose impairs the immune system. It also triggers inflammation, which makes the immune system work harder. As well as being more prone to infection, people with diabetes and infection may respond less well to therapy and may deteriorate more rapidly into severe infection.

One of the main risk factors for infection is a high blood glucose level. Lowering blood glucose decreases the risk of infection. If you have any concerns about your blood glucose levels, it is important to see your general practitioner or endocrinologist.

A healthy lifestyle and adequate, good-quality sleep can strengthen the immune system. Meanwhile, hand hygiene is important for reducing the spread of germs.

Liver disease

People living with diabetes have a higher risk of liver disease, primarily metabolic dysfunction-associated steatotic liver disease. This was previously called non-alcoholic fatty liver disease and is the most common cause of chronic liver disease worldwide. Untreated, metabolic dysfunction-associated steatotic liver disease can sometimes progress to cirrhosis and liver failure.

Liver health can be maintained with a healthy diet and lifestyle, including minimising alcohol intake. The National Health and Medical Research Council recommends drinking no more than 10 standard drinks per week and no more than 4 standard drinks in any one day — the lower the amount of alcohol consumption, the better.

Cognitive impairment

Diabetes increases the risk of cognitive impairment, including dementia. Compared to the general population, people living with diabetes are twice as likely to develop dementia. In addition to maintaining a healthy diet and lifestyle, it is important to keep mentally active, socially connected, and optimise your cholesterol and blood pressure to reduce your future risk of dementia.

Mental health

Diabetes can also have a negative impact on mental health. For example, people living with diabetes are 2 to 3-times more likely to experience depression than the general population. They are also at a higher risk of anxiety, eating disorders and burnout.

This is a bidirectional relationship. The stress of self-managing diabetes can have a negative impact on mental health; equally, when mental health is affected, managing diabetes may become more difficult as daily tasks can start to feel burdensome.

However, mental health conditions can be treated, and there are plenty of resources available. Further information...

Anaemia

Our recent study, published in Diabetes Care, found that people with diabetes were at higher risk of anaemia, especially vitamin B12 deficiency anaemia and iron deficiency anaemia. This is partly explained by diabetes-related metabolic changes (e.g. high blood glucose) and complications (e.g. kidney disease), as well as medications commonly used in diabetes (e.g. metformin).

The 2025 American Diabetes Association Standards of Care recommend that all people with diabetes receive a complete blood count test with their general practitioner. People taking metformin should also have an annual vitamin B12 check (blood test).

Reduce the risk

Improvements in vascular disease due to diabetes have revealed lesser-known diabetes complications. Diabetes increases the risk of cancer, infection, liver disease, cognitive impairment, mental health conditions and anaemia. However, there are ways to reduce the risk of developing these conditions. Addressing diabetes is more than just blood glucose management. It’s about embracing a healthy lifestyle that supports overall wellbeing and helps you stay ahead of potential diabetes complications.