BITTER-SWEET! DIABETIC WOES! – Dr. Binoy John
MD DM (CARDIOLOGY) FCSI FACC FESC FSCAI FAPSIC
DIRECTOR & HEAD: DEPT OF CARDIOLOGY, INTERVENTIONAL CARDIOLOGY, ADVANCED HEART-DISEASES, HEART-FAILURE AND CARDIAC TRANSPLANT MEDICINE.
MIOT International, CHENNAI
Facebook@Binoy John Dr
“Roses are red and
Violets are blue,
Sugar is sweet,
But not really good for you!”
Diabetes mellitus* is a dreaded name and one that sends chills down spines, because its presence in one’s life takes away thefreedom, the care-free freedom, to eat and relish whatever and how-much ever one wishes to devour!
With urbanization, increasing stress, unhealthy dietary practices, sedentary life-style, lack of exercise and surging obesity, the number of people affected with diabetes are on a rapid rise, already affecting an estimated 200 million people globally and the World Health Organization predicts that by the year 2030, the numbers would reach a staggering 366 million.
Diabetes and complications:Broadly, diabetes mellitus is a disorder characterizedby abnormally high sugar levels in the blood, which arises from inability of specific cells of the pancreas to secrete the hormone insulin which reduces blood sugar levels to normal levels or can also be from the inability of the body or the cells to utilize the insulin that is already present, called insulin resistance. What makes diabetes a destructive disease is that it affects majororgans and organ-systems including the heart, kidneys, eyes, nerves, and arteries or the blood-vessels producing life-threatening complications and also causes a predisposition to infections.Diabetes,if undetected or uncontrolled for a long time can lead to blindness, kidney failure needing dialysis and kidney transplantation, nerve damage or neuropathy causing loss of sensation or the ability to feel things and thus resulting ininjuries, non-healing ulcers and infections requiring amputation of toes and legs. Pertaining to the heart and the cardio-vascular system, uncontrolled blood sugar causes increase in triglyceride levels in the blood and also increases the damaging potential of the bad LDL cholesterol, promoting atherosclerosis or the formation of blocks inside the arteries resulting in heart-attacks and also causing heart-failure or diabetic cardiomyopathy by reducing the pumping efficacy of the heart. The ravage to health from diabetes is especially amplified and severe, when diabetes occurs in combination with high blood-pressure or hypertension resulting in accelerated organ damage especially of the heart, kidneys and eyes.
Diabetes and prevention:However, even with all its potential for organ damage, there is no reason for dismay or despair for diabetics. Of course, there are strict restrictions in diet for diabetics, but still most of them can enjoy a good life and indulge within limits by leading a more disciplined life, with healthy life style modifications, a tailored diet and regular exercise.But, I would say, that the key to defeating diabetes is in its prevention. No step taken in the prevention of diabetes can be small considering the limiting impact of this disease on one’s routine and life itself. Periodic screeningwith check-ups help in the early detection of diabetes itself and in the detection of those who have not yet developed diabetes, but are at a risk for developing diabetes, called “pre-diabetes”. Such periodic check-ups are especially useful in those who have risk factors for developing diabetes. People with obesity and a higher body mass index (BMI) or a body-weight much greater than expected for height, have a higher risk of developing diabetes. Also, it is to be noted that, the genetic predisposition for diabetes is rather strong, so much so, that if one parent has diabetes, the risk of diabetes in the progenyis 10% and if both parents are affected,the risk of diabetes in their child isscaringlyas high as 40%.
Who are the people at risk for diabetes and need periodic screening? American Diabetes Association has formatted a Diabetes Risk Test (Table 1) with a seven set questionnaire, where by a score of ≥5 points places the person at a high risk for developing diabetes. Increasing age, male-sex, a family member with diabetes, presence of high blood pressure, physical inactivity, having had diabetes at pregnancy (gestational diabetes) and being over-weight are all considered as risk factors for diabetes.
Periodic screening is to be undertaken for all people, once they reach 45 years of age and for adults of lower ages if they are over-weight with a BMI ≥ 23 kg/m2 and have one or more additional risk factors for diabetes. Children and adolescents should also be screened for pre-diabetes if they are over-weight or obese and have two or more additional risk factors for developing diabetes.
How can we diagnose diabetes and pre-diabetes?Diagnosis of diabetes and pre-diabetes can be made from blood tests, by measurements of fasting plasma glucose, 2 hour plasma glucose during an oral glucose tolerance test or fromthe hemoglobin A1C levels which indicates the person’s average blood sugar levels for the past three months. (Table 2)
Treatment and treatment goals:Once diabetes is diagnosed, the key is to keep blood sugar levels under control, generally targeting fasting plasma glucose levels of 80-130 mg/dl, post-prandial plasma glucose levels of <180 mg/dl and A1C levels <7.0%. This has to be done mainly with life style interventions including dietary control, weight-reduction, regular exercise and medications if required. Self-monitoring of blood glucose levels with instruments like glucometers are recommended and encouraged as this form of monitoring helps the patient in understanding his own metabolism and his diet and thus aiding in the judicious selection of his food and quantity and thus a better control of his blood glucose levels. It is also of prime importance in the management of diabetes to effectively control blood-pressure levels and cholesterol and triglyceride levels to prevent accelerated organ damage and formation of blocks in arteries.Periodic check-up of the eyes and tests for nerve damage are also to be undertaken along with assessment of kidney function and the status of the heart with electrocardiograms (ECG), echocardiograms and exercise stress tests or tread-mill tests.
The importance of weight reduction in the control of diabetes:The huge impact of weight loss in the management of diabetes its prevention cannot be undermined. There is strong evidence that modest and sustained weight loss aids in better control of blood sugar levels and also helps to decrease the dosages of anti-diabetic medications, more so in those who are over-weight. Over-weight persons are encouraged to attain a sustained weight-loss of at least 5% of their initial weight in a span of six months which can be achieved with a combination of diet providing 1500-1800 kcal/day for men and 1200-1500 kcal/day for women or an energy deficit of 500-750 kcal/day and exercise strategies with high levels of physical activity of 200-300 mins/week. Though weight losses of 5% have been shown to be beneficial, a sustained weight loss of ≥7% is considered optimal. Those who achieve the six months weight-loss goals are prescribed longer term weight maintenance programmes.
The importance of weight reduction in the prevention of diabetes: Just as weight reduction helps in the control of diabetes, italso helps in preventing or delaying the onset of diabetes in those with pre-diabetes. Patients with pre-diabetes should be encouraged to have an intensive life-style intervention programme targeting a sustained weight-loss of 7% of the initial body weight in a span of six months, with moderate intensity physical activities such as brisk walking for at least 150 min/week, targeting at least 700 kcal/week expenditure from physical activity. There should be at least three sessions per week and each session should be at least 10 minutes each. In these 150 minutes, a maximum of 75 minutes could be used for strength training. It is recommended that the ideal pace of weight loss be 1-2 pounds per week. As for diet, the initial focus is to reduce total dietary fat and subsequently in the following weeks both fat and calorie restrictions are combined.
Food and prevention of diabetes: Low calorie eating habits are to be encouraged. Also, the quality of fat that is consumed is more important than the total quantity of dietary fat. The Mediterranean diet with higher mono-unsaturated fats is said to prevent diabetes. Certain types of food like whole grains, nuts, berries, yogurt, coffee and tea have been shown to be associated with a reduced risk of diabetes, whereas red-meats, sugar-sweetened beverages have been shown to be associated with a higher risk of causing diabetes.
Weight-loss drugs and gastro-intestinal surgeries:Weight-loss medications are available, but their use must always consider the advantages versus their potential side-effects. Gastrointestinal surgeries are available too, but are to be considered only in people with high BMI >30-40 kg/m2, who have poorly controlled blood sugars despite optimal life-style measures and medical therapy.
Thus diabetes does induce restrictions and an over-all sense of bitterness to one’s life. But, with good life-style practices and a nurtured discipline, life certainly can be made sweet after all!
I dedicate this small educational endeavour of mine to humanity in the backdrop of the World Diabetes awareness month, with sweet regards.
*The whole article refers only to Type II Diabetes Mellitus or Non-Insulin Mediated Diabetes Mellitus
Dr. Binoy John
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