Preventing Diabetes and its Complications
By Dr. Rajeev Chathanath, MD in Internal medicine
Type 2 Diabetes Mellitus is an increasingly common disease primarily because of a sedentary life style and Obesity. It results from the interaction between a genetic predisposition and behavioral, cultural and environmental risk factors.
Can Diabetes be Prevented?
Recent studies (Diabetes Prevention Program Research Group) have come up with an optimistic answer to this question. They have found out that a reduction in incidence of diabetes can be achieved with life style intervention in at risk population.
Who is at Risk of T2DM
If both parents are diabetic children have 90% chance of developing diabetes in their life time. If only one of the parents is diabetic chance is 60%. If parents are not diabetic but a fist degree relative is diabetic, chance is 20 %. Those who have no relative with T2DM should not get re-assured - you still have 10% chance of developing this disease during the life time.
Obesity and Physical inactivity are the main non genetic risk factors for diabetes. Although there are about 35 genes identified linked to diabetes, the application of this knowledge in prevention or treatment of the disease is still far away from reality. So the main focus on diabetes prevention is on the modifiable risk factors, such as obesity, unhealthy diet and physical inactivity.
What is Impaired Glucose Tolerance (IGT)?
This is an intermediate category of people between normal and overt diabetes. Subjects with IGT have an increased risk for developing type 2 diabetes. People with this condition can be easily identified by a Fasting blood sugar test or an Oral Glucose Tolerance Test (OGTT). We can consider IGT as a pre-diabetic state and therefore these people form an important target group for interventions aimed at preventing diabetes.
Life Style Changes
Studies have shown that diabetes can be prevented by changes in the life style in both women and men at high risk of developing this disease.
Physical Exercise
It is likely that any of the regular physical activity - whether sports, house hold works, gardening or work related physical activity - is beneficial in preventing or at least delaying the onset of diabetes. Exercise that improve cardio respiratory fitness such as brisk walking, jogging, aerotrics, swimming etc and those to improve muscle strength such as moderate weight training are effective in preventing diabetes. Intensive life style intervention to prevent diabetes puts much emphasis on physical activity of moderate intensity.
What is the adequate exercise to prevent or control diabetes?
This is a frequently asked question. Brisk walking for at least 150 minutes per week is considered adequate. Brisk walking at about 20 minutes per mile results in energy expenditure of 3.5 to 4.00 METS per hour.
Diet
A reduction in weight by 5% or more, results in a remarkable increase in glucose tolerance. So weight loss of minimum 5% is the initial target of all diabetic prevention strategies. General advises are as follows:
. Reduce total fat intake to less than 30% of the total energy consumed
. Reduce intake of satured fat to less than 10% of total calorie intake
. Increase fiber intake to at least 15 gm per 1000 K.cal
. Frequent ingestion of whole grain products, vegetables, fruits, low fat milk, fish, soft margarine and vegetable oils rich in mono unsaturated fatty acids.
Drug Therapy to Prevent Diabetes
Metformin - a drug which reduces insulin resistance is effective in preventing the onset of frank T2DM in individuals with impaired glucose tolerance. But at this time the use of metformin in the primary prevention of diabetes remains ambiguous. The ability of metformin to induce weight loss and reduce BMI also helps on preventing T2DM. This drug is also used to treat a condition in obese women with infertility - Poly cystic ovarian Disease. When metformin is used in women with PCOD, it is found to prevent the onset of type 2 diabetes.
Hypertension
Effective treatment of high blood pressure in patients without diabetes is found to delay the onset of this disease in them. A class of drugs - angiotension receptor blockers - is found to be particularly effective in delaying the onset of diabetes in this population. Tight control of blood pressure in diabetic patients in turn will prevent and sometimes reverse the complications of diabetes. The target blood pressure in diabetes is 125/85 mmHg.
Cholesterol and Diabetes
Diabetes patients are found to have peculiar lipid abnormalities. They usually have high LDL cholesterol, high triglycerides and low values of HDL cholesterol (HDL is protective against diseases of the blood vessels and heart). Cholesterol abnormalities should be controlled more vigorously in diabetic population than in general population. The LDL cholesterol target is 70 mg/dl in diabetes. This level is difficult to be achieved with diet and exercise alone. Therefore, most of the diabetic patients may have to take a statin tablet to control their cholesterol levels.
Kidneys, Eyes and Feet
These are the commonest targets for diabetic complications apart from arteries. Renal disease is a leading cause of death and disability in diabetes. About half of the cases of end-stage renal disease are now due to diabetic nephropathy. Meticulous control of diabetes can reverse microalbuminuria (an early sign of diabetic nephropathy), and the progression of diabetic nephropathy may be slowed. Hypertension must be treated aggressively whenever present. Two classes of medicines, ACE-inhibitors or ARBs, used in hypertensive patients with diabetes reduce kidney disease and may have a role even in subjects with normal BP and microalbuminuria.
Diabetic retinopathy is a leading cause of blindness. Early detection and treatment for diabetic retinopathy by photocoagulation can prevent blindness in diabetic patients. Regular ophthalmology check-up by a specialist every 6 months can help to pick up this complication early and prevent blindness.
A special problem in the diabetic patient is the development of ulcers of the feet. Callus formation is usually the initial abnormality. Alternatively, the ulcer may be initiated by ill-fitting shoes that cause blister formation in patients whose sensory deficits preclude recognition of pain. Cuts and punctures from foreign bodies such as needles, tacks, and glass are common initiating events.
All diabetic patients should know about proper foot care in an attempt to prevent ulcers. Feet should be kept clean and dry at all times. Patients with neuropathy should not walk barefoot, even in the home. Properly fitted shoes are essential.
There are strong evidences now to suggest that diabetes and its complications can be prevented. We can achieve this only through better awareness about this disease among the public. Strategies of health education to increase public awareness are the back bone of all Diabetic Prevention Programs. "Know diabetes and take control" is the slogan of the International Diabetes Federation for this year.
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