Authors :Dr.S.Srikanta [MD, Ph.D, FEDM]
:Dr.A.Sharada [MD, DNB, FEDM, MRCP]
:Dr.Tejeswini Deepak [MD, FEDM, CDE]
:Ms.A.H.Mamata [M.Sc., RD, CDE]

Faculty Center for Endocrinology Diabetology, Sagar Apollo Hospital

Diabetes has been labeled as a "Silent Killer". However, in 2003, this is absolutely wrong: Diabetes is a just a gentle "Life Partner." A full healthy and productive life is possible despite Diabetes. What are needed are a) disciplined healthy life-style b) systematic & aggressive preventive medical care. The cornerstone for both these is patient and family empowerment through organized in depth health education and counseling ("The answer is in your hands"). This is the message to the people with Diabetes of Karnataka form the center for Endocrinology Diabetology at Sagar Apollo Hospital, Bangalore on the World Diabetes Day (14th November)

Diabetes: The Global and Indian burden:
Diabetes mellitus, with its attendant acute and long-term complications, and the myriad of disorders associated with it, is a major well-known health hazard. The 1997 WHO report had shown that there is a marked increase in the number of people affected with Diabetes and this trend is scheduled to grow in geometric proportions in the next couple of decades. In the recently concluded International Diabetes Federation Conference 2003 in Paris, India was labeled as Diabetes Capital of World, as more than 33 million Diabetics are Indians out of about of 190 million Diabetics worldwide. The worldwide Diabetic population is expected to rise to 330 million by 2025, largely due to population growth, ageing, urbanization, unhealthy eating habits and sedentary life style. In 2025, India is expected to harbor 52 million people with Diabetes.

Type II Diabetes (non-insulin dependant, at least initially) is the most common form of Diabetes (90% to 95%) and occur primarily in adults but is now affecting children and at large young adults. At least 50% of all people with Diabetes are unaware of their condition (symptom free). Type I Diabetes (Insulin dependant since onset for survival), affects predominately children and youth, and is the less common form of Diabetes (5 to 10%)

Everybody is at risk of developing Diabetes. Family history (genetic / heredity), age, excess body weight, lack of exercise and bad dietary habits all contribute to the onset of Diabetes. Being over weight considerably increases the risk of developing Diabetes (80% of people with Type II Diabetes are obese).

Diabetes: The "mother" of all diseases:
If neglected or improperly treated Diabetes can cause serious long term complications affecting every organ of the body:

v Heart Attack - Diabetes are 4 to 5 times more likely to suffer
Heart attacks - No.1 cause of death.

v Strokes - People with Diabetes suffer 3 times more stroke compared to non- Diabetics
v Amputation - People with Diabetes are 15 to 40 times more likely to require and amputation of limb - the common cause of disability.
v Kidney problems - Diabetics are 20 times more likely to develop kidney problems (kidney failure)
v Blindness - Incidence in Diabetics is 25 times higher than non- Diabetics because of retinopathy.
v Diabetes shortens on an average life span by a decade.
v Causes economic disability.

HOWEVER THESE COMPLICATIONS ALMOST COMPLETELY PREVENTABLE.

Power of Prevention:
Most people with Diabetes can look forward to a long, complication free healthy life, if they take simple measures to avoid complications. It is important to understand these complications and the importance of good self care as well as good medical care and Diabetics itself can be prevented to a great extent. The preventive tools are :

v Healthy eating
v Regular physical activity
v Maintenance of ideal body weight
v Tight control of blood glucose levels
v Very good blood pressure control
v Normalization of blood cholesterol and fats.
v Proper foot care
v No smoking
v Stress management
v Annual health review

Diabetes and target organ damage

Steps for prevention

Preventive steps Heart Brain Feet Kidneys Eyes Nerves
Tight blood glucose control v v v v v v
Tight blood pressure control v v v v v ?
Normal blood cholesterol and fat levels v v v ? ? ?
No smoking v v v ? ? ?
Aspirin v v v ? ? ?
Health review v v v v v v

Healthy eating:
The right type of food, in right amounts at right time are crucial. Choosing from different food groups, like, cereals, pulses, nuts and meat, fish, poultry, milk and it's products, fruits and vegetables, oils and fats is very important, as no single food will supply all the nutrients needed by the body. Diabetic meal plan is no different from following a healthy diet plan. Foods rich in fiber are healthy too (whole grains, pulses, fruits and vegetables). They help in reduction of blood cholesterol levels and blood glucose. Try using lean cuts of meat, reduce use of butter, cheese etc., use low fat skim milk, improve upon intake of fruits and vegetables and restrict on use of salty foods. Recent studies have provided evidence for reduced risk of diabetes with increased intake of whole grains and dietary fiber.

Good physical activity:
The journey of thousand miles begins with a single step. Exercise works the same. Taking the first step can be hard., there are various excuses not to exercise (too busy, too tired, no proper place for walk etc.), but what we need to remember is that exercise plays a vital role in preventing Diabetes and its complications by aiding in reduction of weight, increasing insulin sensitivity, strengthening cardio-vascular system, controls, blood pressure and reduces need for medicines and improves overall sense of well being. Studies have proved that even 30 minutes of exercise per day is enough to give you all the benefits. Regular physical activity produces long term weight loss of 5 to 7 % of starting weight and reduce risk of developing Diabetes

Ideal body weight:
Achieving and maintaining ideal body weight is very important in preventing Diabetes and its complications. Ideal body weight is a standard for weight and height. Being over weight (specially apple shaped obesity) is a major risk factor for development of Diabetes, hypertension, feet problems and heart problems. Many studies have proved that a modest weight loss of even 5 to 6 kilos from the current weight are helpful in lowering blood pressure, reduction in medication requirement, lowering and control of blood cholesterol and reduction in foot problems due to Diabetics.

Tight blood glucose control
Poor blood glucose control is an important cause of for onset of diabetes complications. Excess blood glucose damages the small blood vessels that carry blood throughout the body which become clogged, causing various problems. Researches suggest that tight control of blood glucose levels by itself, can reduce complications of Diabetes by 50 t0 75%.

Target blood sugar levels
Blood sugar mg/dl Fasting 2 hr after food
Normal Upto 115 Upto 140
Acceptable Upto 140 Upto 180
Poor Over 140 Over 180

Good blood pressure control:
High blood pressure have a dramatic effect on the rate at which the complications of the Diabetes develop and progress. Even a mild rise in blood pressure can quickly make kidney functions to worsen. Untreated blood pressure can lead to eye damage, strokes and heart attacks. Research studies have shown that lowering of blood pressure by as little as 10 to 15 mm/Hg, can reduce Diabetes complications by about 50% or more. However, the goal is to achieve perfectly normal blood pressure levels throughout the life. Besides healthy life styles (diet low in salt and fat, regular physical activity, no smoking), one or more drugs are often necessary. Many excellent groups of blood pressure lowering drugs are available. The important groups of drugs include - angiotensin converting enzyme (ACE) inhibitors, angotensin receptor blockers (ARBs), Beta blockers.

Blood Pressure Classification (for adults)
Blood pressure mmHg Systolic Diastolic
Optimal < 120 < 80
Normal < 130 < 85
High Normal 130 - 139 85 - 89
Hypertension > 140 > 90

> Greater than ; < Less than

Normalization of blood fat and cholesterol levels:
Once again healthy life style is crucial. However, it has been shown, more closer to normal levels of blood fats, lesser is the chance ofatherosclerosis(hardening of arteries) leading to heart attacks, strokes and gangrene. In all people, improving Diabetics, medicines which lower blood cholesterol and fats are often necessary, and need to be taken life long. They include miracle drugs like statins, fibrates, nicotinic acid etc.

Normal values of blood fats (lipids)
Blolod lipids mg/dl Normal Border line risk High risk
Total cholesterol < 200 200 - 239 > 240
LDL cholesterol < 100 100 - 129 > 130
Triglycerides < 200 200 - 399 > 400
HDL cholesterol (M) > 45 35 - 44 < 35
HDL cholesterol (F) > 55 45 - 54 < 45

Ø Greater than ; < Less than

Proper foot care:
Foot ulcers and amputations are a major cause of morbidity, disability, as well as emotional and physical costs for people with Diabetes. Peripheral neuropathy, the most common form of Diabetes complications is responsible in development of foot problems. People with Diabetes should understand the implications of the loss of sensation in feet. Proper foot care (neatly cut nails, soft skin, smooth heals, avoiding bare foot walking) and proper selection of foot ware (soft cushning, broad toe box and preferably one size bigger which will fit well with socks) are all important in preventing foot complications besides good control of blood glucose and regular physical activity.

No smoking:
Smoking and Diabetes are a dangerous combination, especially if you also have hypertension. A large body of evidence from studies provides convincing documentation of link between cigarette smoking and health risks. Cigarette smoking is the leading avoidable cause of premature death in the world. Smoking is also associating with development of Diabetes complications. Smoking accelerates the hardening of arteries leading to heart attacks, strokes etc. studies have proved that quitting smoking improves blood cholesterol and better control of blood pressure.

Stress management:
Medical researchers have been suspicious of stress for quite a long time, but in last couple of decades it became obvious that stress indeed is a major cause of disease. It is implicated now in almost every disease from heart disorders and hypertension to cancers, not leaving out Diabetes. Yoga and meditation have been proved to show beneficial effect in stress management. There are also studies which have shown that having happy thoughts and relaxed mind causes bio-chemical changed in the brain which in turn have profoundly beneficial effects on body's physiology.

Annual health review:
Diabetes complications are symptom free at an early stage, which can be reversed to normal if detected early. Hence annual health review is very important in early diagnosis and prompt intervention for the complications. The health review must include complete cholesterol counts, kidney functioning test, eye check up, feet examination and heart check up. Apart from annual health reviews, insist on blood pressure check up and a feet examination at every visit to the doctor.

Prediction:
Healthy discipline life style along with advances in medical science, are holding increasing promise in the prevention and eradication of many human maladies. This is especially true for Diabetes and its numerous complications. One special prediction has been made with reference to heart attacks. It has been scientifically predicted that, with healthy life style combined with tight control of blood glucose level, blood pressure, blood cholesterol and fats and avoidance of smoking, use of aspirin (and similar drugs), hearth attacks, angioplasties, bypass surgeries may be almost completely eradicated from the face of earth in this century. Because of all these developments, scientists expect on an average human life span to be stretched to 120-140years in this century. Will this really happen? And if so, will human happiness follow the suit?