Deterring diabetes

The UAE has experienced a rapid increase in diabetes and its prevalence will continue to soar in the future.
Deterring diabetes
By Partners Harvard Medical International
Sun 19 Oct 2008 04:00 AM

Discover how to keep diabetes at bay or prevent it getting worse.

First world countries are in the grip of a diabetic epidemic. About 21 million Americans have the disease, and many more have pre-diabetes. The UAE has also experienced a rapid increase in diabetes cases and all indications suggest that its prevalence will continue to soar in the years ahead.

Elevated blood glucose (sugar) levels define diabetes. A fasting blood sugar reading of 126mg per decilitre (mg/dL) or higher is enough to diagnose the disease, and levels between 100 and 126 indicate pre-diabetes. But since diabetes is a leading cause of heart attack, stroke, kidney failure, visual loss, and memory loss, it's much more than a simple blood sugar problem.

Men who exercised at least once a week enjoyed a 29% lower risk of diabetes than sedentary men.

Treatment can help protect diabetics from many of the complications that cause disability and premature death. But preventing diabetes from developing in the first place is even better. And while treating the disease usually requires multiple medications, prevention can be accomplished without drugs.

To be most effective, though, prevention requires multiple lifestyle modifications. Here is a rundown of the things that matter most and the little things that may help a bit more.

Weight control

When it comes to preventing diabetes, weight control is the biggie. That's because excess body fat is the strongest single risk factor for diabetes. In a Harvard study of 27 270 male health professionals, men who were even mildly overweight (body mass index/BMI, 25.4-27.1) were 2.9 times more likely to develop diabetes than the leanest men. And the more fat a man has, the higher his risk. In the Health Professionals Follow-up Study, the most obese men were 7.9 times more likely to become diabetic than their leanest peers.

Any excess body fat increases risk, but abdominal fat is particularly culpable. In the Harvard study, waist circumference was a more powerful predictor of diabetes than BMI. Men with waists larger than 40 inches were at particular risk.

Why is abdominal fat so harmful? One theory holds that abdominal fat cells produce hormones that actually counter the effects of insulin. Even without these substances, abdominal fat does not respond properly to insulin's actions.

Instead, the fat cells release free fatty acids into the blood. According to the concept of lipotoxicity, these fatty substances settle in the pancreas, damaging the beta cells and impairing insulin production. And there's more: the free fatty acids also find their way to the heart and liver, where they form deposits that lead to organ damage.

Further, the liver converts excess free fatty acids into abnormally high levels of triglycerides. In fact, the combination of abdominal obesity, insulin resistance, and elevated triglycerides are major components of the metabolic syndrome, an important precursor of heart attacks and strokes.

If abdominal fat is such a big problem, can removing it by liposuction help? Unfortunately, it can't, because the fat that really counts is deep within the abdomen, surrounding the internal organs. Subcutaneous fat within a surgeon's reach is insulin-sensitive and metabolically similar to the fat around the hips, buttocks, and thighs. In the last analysis, weight loss is the only way to correct the visceral obesity that really matters.

Although weight loss is difficult to achieve, fortunately, even a little bit can help. In the Diabetes Prevention Program, for example, each 2.2lb of weight lost reduced the risk of diabetes by 16%.

Not coincidentally, exercise and diet are the keys to comprehensive diabetes prevention.

Exercise

Physical activity requires energy, much of which is supplied by glucose. Exercising muscles need more sugar, so the body makes these muscles more sensitive to insulin, allowing them to take in more glucose from the blood. Regular exercise also makes fat more responsive to insulin.

Research shows that exercise reduces the fat cells' production of a protein (RBP4) that contributes to insulin resistance. And exercise also reduces the liver's ability to turn its glycogen stores into glucose, which would otherwise pour into the bloodstream.

Since type 2 diabetes is characterised by insulin resistance, all these effects of exercise should help prevent the disease.

Many studies from around the world reinforce the notion that exercise reduces the risk of diabetes. Three Harvard reports tell the tale. A study of 37 918 men found that the most physically active men were 49% less likely to develop diabetes than the least active.An investigation of 21,271 male physicians reached similar conclusions; men who exercised at least once a week enjoyed a 29% lower risk of diabetes than sedentary men. And among 70,102 female nurses, those who walked the most were 26% less likely to develop diabetes than non-walkers.

Regular exercise can help prevent diabetes - and moderate exercise will do the job nicely. Walking for just 30 minutes a day is a great help. And for people who already have diabetes exercise is every bit as important. It can lower blood sugar levels and reduce - or even eliminate - the need for medication. Above all, physical activity reduces the death rate in diabetics.

Some examples: A 2003 study of 2 896 Americans linked walking for at least 2 hours a week to a 39% lower death rate; a Harvard study of 2,803 men associated walking with a 43% lower death rate; and a study of 3 708 Finnish diabetics linked moderate physical activity to a 39% reduction in the death rate.

The Diabetes Prevention Study found that metformin (Glucophage) could reduce the risk of diabetes by 31%.

But exercise does much more than lower blood sugar levels. Other benefits include better cholesterol levels, lower blood pressure, reduced body fat, and reduced stress. All this makes exercise one of the 2 pillars of diabetes prevention for everyone. The other pillar is diet.

Diet

Nutrition is just as important as exercise for prevention, and 2 studies remind us that overall dietary patterns matter most.

Researchers from Harvard and Finland identified 2 broad dietary patterns. The healthy "prudent" pattern featured fruit and vegetables, whole grains, fish, and poultry, while the "Western" pattern was high in whole-fat dairy products, red meat, refined grains, and desserts.

On both sides of the Atlantic, the "prudent" diet was associated with a lower likelihood of developing diabetes. And the "Western" diet was linked to increased risk.

Here are some types of food that can affect your diabetes risk:

• Sugars Diabetics should avoid simple sugars and concentrated sweets. One report from Harvard's Nurses' Health Study linked the consumption of sugar-sweetened beverages to an increased likelihood of weight gain and type 2 diabetes. Even 1 beverage a day nearly doubled a person's risk. A second study found that a diet with a large amount of rapidly absorbed carbohydrates increased the risk of developing diabetes by 59%.

• Fibre Not all carbohydrates are created equal. Dietary fibre is a "good carb" that reduces the risk of diabetes and improves metabolic, cardiovascular, and intestinal health. Studies from the USA to Finland agree that eating large amounts of whole grains and cereal fibre protects against diabetes, ranging from about a third to 2/3 reduction of risk.

• Dietary fat A multinational study linked a high consumption of animal fat to a high prevalence of diabetes. One Harvard study linked saturated fat to risk, another implicated red meat and processed meats, and a third found that low-fat dairy products appeared to be protective.

10 Prevention tips

Even if you have diabetes, a preventive approach can help. Here are 10 ways to prevent serious complications:

1. Control your blood sugar Aim for fasting blood sugar levels between 90 and 130mg/dL, blood sugar levels after meals below 180 mg/dL, and a hemoglobin A1C level below 7

2. Control your blood pressure Aim for readings below 130/80mm of mercury (mm Hg)

3. Control your cholesterol Aim for an LDL ("bad") cholesterol below 100

4. Protect your kidneys Get tested for tiny amounts of protein in your urine (microalbuminuria) and get treatment if necessary. ACE inhibitors and angiotensin receptor blockers can be helpful

5. Protect your vision with regular eye care

6. Protect your feet with good foot care

7. Stay active Walking for 30 minutes a day is a great start. Check with your doctor before starting an intense exercise program. And remember that exercise will lower your blood sugar, so monitor yourself to prevent it from getting too low

8. Control your weight with exercise and a good diet

9. Consider low-dose aspirin to reduce your risk of cardiovascular events

10. Don't smoke.

The Iowa Women's Health Study reported that replacing polyunsaturated fats from vegetable sources with saturated fat from animal sources appears to reduce the risk of diabetes. And the Nurses' Health Study linked polyunsaturated omega-3 fatty acids from fish to a reduced risk of heart disease and a lower death rate in women with diabetes.

Other factors

The dietary factors that have the greatest impact on the risk of developing diabetes are calories, carbs, fibre, and fat. Still, other things may help as well.

• Coffee A 2005 review of 15 studies reported that habitual coffee consumption is associated with substantial protection against type 2 diabetes. People who average 6 or more cups a day enjoyed a 35% lower risk. And 4 more 2006 studies add to this impressive body of evidence.

• Alcohol A 2004 review of 32 earlier studies found that people who average 1 to 3 drinks a day are 33% to 56% less likely to develop diabetes than abstainers. But having more than 3 drinks a day was linked to a 43% increase in the incidence of diabetes.

• Nuts A Harvard study reported that eating nuts and peanut butter appears to reduce the risk of diabetes. Similar benefits have been reported for fruit and vegetables, antioxidant-rich food, vitamin D, calcium, and even cinnamon.

• Smoking In 2006, researchers in Alabama evaluated the effect of tobacco exposure on the risk of developing glucose intolerance ("pre-diabetes") over a 15-year period. Both active smoking and exposure to second hand smoke were strongly linked to risk. The people with the greatest exposure were the most likely to develop a resistance to insulin.

• Medication A report by the Diabetes Prevention Study found that metformin (Glucophage) could reduce the risk of diabetes by 31%. It's more good news about an excellent drug, but the same study found that a program of a healthy diet and regular exercise was nearly twice as effective.

Does lifestyle prevention work?

You bet it does. Four randomised clinical trials show that it can work in a research setting, and a major observational study suggests that people can make it work on their own.

The Multiple Risk Factor Intervention Trial (MRFIT) evaluated 11,827 men with normal glucose metabolism. Half received special lifestyle counselling, the others, standard medical care. Among non-smokers, the men who received information about diet and exercise were 18% less likely to develop diabetes than the men who got standard care. Unfortunately, lifestyle counselling did not protect smokers.

The Finnish Diabetes Prevention Study evaluated lifestyle interventions in 527 men and women who were obese and already had pre-diabetes. Diet and exercise reduced the risk of developing full-blown diabetes by 58%.

In the US, the Diabetes Prevention Program studied 3,234 adults with pre-diabetes. Diet and exercise reduced the progression to diabetes by 58%. In comparison, treatment with metformin reduced risk by 31%. And a similar study of pre-diabetics in China found that diet and exercise could reduce the progression to diabetes by 46%.

It's clear that simple lifestyle changes can prevent diabetes in volunteers who receive education, motivation, and monitoring. But does prevention work for people left to their own devices? According to Harvard's Nurses' Health Study, the answer is an emphatic yes.

Among 84,941 female nurses, the combination of a healthy diet, regular exercise, weight control, abstinence from tobacco, and moderate alcohol consumption was linked to a 91% reduction in the risk of diabetes - and it even reduced risk by 88% in women with a family history of the disease.

Now remember that the same healthy lifestyle that cuts the risk of diabetes by 91% also cuts the risk of coronary artery disease by 83%. A double benefit for those who take preventive steps.

Medical terms used

• Glucose intolerance is a pre-diabetic state of dysglycaemia, that's linked to insulin resistance and increased risk of heart disease

• Insulin resistance is a condition in which cells display "resistance" to insulin by failing to take up and utilise glucose for energy and metabolism

Source:Harvard Health Publications. Copyright  2008 President and Fellows of Harvard College.

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