21 May 2014

By Dr Amir Farid Isahak

Reducing the incidence of diabetes, the scourge of modern living, needs to be one of healthcare’s top priorities.

NOVEMBER was diabetes awareness month, with Nov 14 designated as World Diabetes Day. Many programmes were organised throughout the month to increase public awareness and education about this scourge of modern living.
The last National Health & Morbidity Survey (NHMS 2011) reported that about 21% of Malaysian adults above 30 years old are diabetic. This is a 6% absolute increase over the 2006 figures (15% in NHMS 2006), which also means a whopping 40% relative increase.
This is typically what happens when a society gets affluent, with the increase in obesity rates coupled with sedentary lifestyles. A higher standard of living means people consume more food (especially unhealthy fatty meals with processed meats), and they shy away from menial jobs in favour of cushy desk jobs.
And the chase for more money, plus the incessant traffic jams (now that almost everyone can buy a car or two), also mean that there is no time left for daily exercise.
The impact of diabetes is tremendous. Recently, an old friend of mine died of diabetic complications, another had his legs amputated, while another almost had his big toe amputated too.
In a span of three months, three people I know had to start dialysis due to diabetic kidney failure.
Diabetes is also linked to heart disease, stroke and many other problems. And the men also have erection problems.
The situation is getting worse as people take a lackadaisical attitude towards this major health problem, despite our Health Ministry’s efforts to educate the public.
Once, I was having breakfast at a hotel with an obese man who happily gobbled a sugar-frosted donut, mee goreng, bread with butter and jam, and several other items.
After he finished his food, he then took out his pill box and started to swallow the many pills like an obedient patient.
I asked him what they were for, and was told that they were for hypertension, diabetes, cholesterol, “blood thinner”, etc.
I was speechless.
In such a case, I wonder whether his doctor counselled him enough on the need for discipline in his diet, or that he is recalcitrant beyond reproach.
Judging from the many diabetic patients that have very high and uncontrolled glucose levels in their blood, I believe the problem of dietary indiscipline is a major issue with Malaysians. The many choices of delectable and delicious dishes on offer here make it hard to control the appetite too.
Much research and many articles have been written about the prevention and treatment/management of diabetes, but very little can be found on curing diabetes. The official medical position is that there is no cure for diabetes – a stand I totally disagree with.
Sometime back, I wrote about a study that showed it is possible to reverse (cure) diabetes with a nutrient-dense, fibre-rich, low-fat diet, combined with weight reduction and exercise. The Journal of Applied Physiology (Dec 15, 2005) published by the American Physiological Society reported that 50% of patients with type 2 diabetes and metabolic syndrome were cured after three weeks of a diet and exercise programme. The team studied 31 overweight and obese men (ages 46-76 years) with diabetes or metabolic syndrome (a precursor to diabetes and a host of other diseases).
However, even with that study’s conclusion, the push for cure does not generate much interest in research, as opposed to the push to find newer drugs that can “control” diabetes better, with less side-effects.
That is the sad reality of the medical industry now. Every year, there will be new drugs launched with “superior” control and safety profiles. The prices, of course, keep increasing, just like new car models.
So, I was pleasantly surprised that the theme for this year’s Global Diabetes Walk is “Walk for Cure”. The event (Nov 25) was organised by the Columbia Asia Hospital group, along with Lions International, in support of the World Diabetes Foundation and Persatuan Diabetes Malaysia.
I hope that the theme signals an acknowledgement that diabetes can be cured. Diabetes does not mean sufferers are condemned to a life of pills and injections, provided they can discipline themselves to do whatever is necessary to achieve the cure.
Curing obese diabetics
For obese diabetics, the first thing they need to do is drastically lose weight. Drastic does not mean unhealthy crash diets, but a drastic reduction in weight, even though that takes time.
While obesity is a known risk factor for diabetes and a host of other diseases (including cancer), evidence-based medicine demands that we cannot just assume that the reverse is true – that reducing weight will reverse the disease. It must be proven.
Well, this has been proven many times. There are many clinical records of obese patients curing themselves of diabetes (also hypertension, arthritis and other problems too) after losing much weight.
If you have been watching The Biggest Loser on TV, then you know that it takes a lot of hard work and discipline to lose weight the healthy way. However, the participants subject themselves to the punishing regime because they compete to win a prize. It need not be that torturous, but much discipline is still required to lose weight healthily.
Those with morbid obesity (very severe obesity, and therefore having a higher risk of developing many diseases) can opt for bariatric surgery, which makes the stomach smaller, or by-passes the stomach altogether. Studies have shown that many of those with diabetes cured themselves of it after they regained their normal weights following the surgery.
I personally know of someone who is a totally different person (literally) now that he is half his former size, minus the diabetes and hypertension.
The results achieved after bariatric surgery can be fast because the weight reduction starts immediately after the surgery, and the effect is permanent.
The patients only need to learn how to eat smaller healthier meals. As there are risks associated with the surgery, anyone contemplating going through it should get sufficient advice from the experts first.
The good results achieved after bariatric surgery proves conclusively that diabetes can be cured in obese patients. What can we learn from this?
Fats first
Insulin is an important metabolic hormone. It is anabolic (makes the body grow). It instructs cells to assimilate (take in) glucose and fatty acids.
Type 1 diabetes sufferers do not make enough insulin. Their only recourse is insulin injections (or sprays in the future). They can still keep their insulin doses low if they lead healthy lifestyles, with a healthy diet, optimum weight and plenty of exercise.
Transplants of pancreatic tissue or stem cells may be innovations we can look forward to that may free them of daily injections.
Type 2 diabetes sufferers make more insulin than healthy people, but their cells have become “resistant” to the hormone’s instructions. There are many possible explanations for this.
First, the insulin receptors on the cells may be deficient or defective. So, even the higher level of insulin does not result in adequate instructions for the cells to assimilate the glucose. Diabetics have high sugar (glucose) levels in their blood, but their cells are starving and cannot function well. The high circulating glucose also causes more problems.
The most effective drugs are those that improve insulin sensitivity. Exercise, building muscles, weight reduction, and a whole list of nutrients also improve insulin sensitivity.
The effect on fats is similar, but not as drastic as the hyperglycaemia. Diabetics also have problems with their lipid profiles. Most diabetics are fat before they become diabetic. Many years of consuming excess calories (usually carbohydrates and fats, and even excess proteins) will cause the body to increase its “fixed deposit” store – that is the fat or adipose tissue.
When the mass of fat tissue gets too much, insulin resistance sets in (by whatever mechanism). Thus, some diabetics actually experience rapid weight loss (mainly fat loss, which gives a haggard look) as a symptom (apart from persistent thirst and frequent urination), prior to being diagnosed as having diabetes.
In such cases, the effect of insulin on both glucose and fats is strong, and they actually regain the fat to look healthier once they are treated.
My theory is that the body utilises the insulin to store the fats first, in preference to sending the glucose into the cells. This is because a high level of fats floating in the blood is more dangerous than a high level of glucose.
We all know that the risk of getting a heart attack and stroke increases for several hours after a fatty meal. So the body has to prioritise the removal of fats from the blood. Many untreated or poorly-treated diabetics are walking around with glucose levels that are many times the normal levels. Although they are at high risk of getting into trouble, the risk is even higher if it were the fats that are that much higher.
This may explain why a consistent low-fat, low-calorie diet (better still, with plenty of exercise) or bariatric surgery that drastically reduces fat and calorie intake, will cause the fats to be utilised for energy production, and fat storage to be significantly reduced.
This spares the need to utilise insulin to store fat. That means whatever insulin available can now be fully utilised to manage glucose.
While this theory explains the situation in obese diabetics, we have to look for other explanations for the non-obese diabetics. Genetics (family history) is, of course, one major contributor. But while we are still at a loss as to how to explain those who do not have a family history of diabetes and are not overweight or obese, but are still afflicted with the disease, we do know that everyone can reduce his risk by having a healthy diet as described above, maintaining a healthy weight, and doing sufficient exercise.
I have a relative who was overweight, but not obese. He was hooked on carbonated drinks. After many years of consuming several cans/bottles of those drinks daily, he developed the classic symptoms of diabetes and lost weight rapidly, causing him to look gaunt.
After starting treatment for diabetes, he is now better disciplined with his diet and drinks. His diabetes is “well controlled” on anti-diabetic drugs, and he looks much healthier.
However, I am not able to convince him that he can try to reverse the disease (maintain normal glucose levels without drugs, ie cure). He is a doctor.
This article was first published in www.thestar.com.my on 9 December 2012.