Prevention and rational treatment of Type 2 Diabetes Mellitus and its complications


Prevention and rational treatment of Type 2 
Diabetes Mellitus and its complications

Lt. Gen. Prof. Emeritus Mahmud Ahmad Akhtar
Former Surgeon General/DGMS (IS) Army

Diabetes mellitus (DM) has very high morbidity and mortality, it affects every system of the body – is called the mother of diseases. It has assumed epidemic proportion in Pakistan and is now seen even in teen aged children. It is due to very high consumption of sugar – one of the highest per capita in the world and high consumption of saturated fats – the junk foods dubbed as “Weapons of Mass Destruction” as well as lack of activity/exercises leading to high incidence of over-weight/obese population. Furthermore south-Asian population is also genetically prone to metabolic syndrome – i.e. cluster of glucose intolerance, D.M, hypertension, lipid disorders and apple shaped obesity (central abdominal). The gene has been located – it has not been tackled yet.

Lt. Gen. (R) Mahmud Ahmad Akhtar

Prevention: This is the key to the resolution of the menace of diabetes mellitus. It is not only better than cure – Infact it is the only cure and the real cure. It is a National problem therefore requires Nation-wide active campaign involving all strata of the population – Imparting awareness and health education through educational institutions, religious leaders, print and broadcast media, community leaders,  health care professionals, NGOs and International organizations. Health education should be a part of educational curriculum. Those nations who have implemented preventive measures have achieved substantial decrease in the prevalence of DM. This needs political will and commitment on the part of the Govt.

Preventive Measures

Health education is the bed rock of preventive measures. The preventive measures should start even before conception as it has been found that low birth weight babies suffer more from metabolic syndrome disorders. In order to achieve healthy newborns, better nutrition of female child is required which is not taken care of by many in our social milieu. There should also be better ante-natal care programmes. In our culture sixty percent marriages are consanguineous – of which 80 percent are amongst first cousins. These should be minimized keeping in view the genetic background of the families. Population control measures like avoiding early marriages – proper spacing of births etc should receive emphasis. Breast feeding is preventive – it should be promoted.

The foundation stone of preventive measures is “life-style therapy” originally propounded by Hippocrates, the father of Medicine and later developed by Aristotle and improved upon by medical scientists. This consists of a regimen of health friendly diet, healthy sleep, physical exercise and stress management.

Carbohydrate component of the diet should consist of low glycaemic index (GI). Items like five to seven portions of vegetables, one to three portions of fruits preferably of low GI, wholegrain porridges preferably of barely and oats, brown wheat flour and brown rice in moderation (avoid white ones), depending upon the weight and requirements of an individual, pulses in the form of beans, lentils, peas – these provide proteins and carbohydrates of low GI, two to three servings of oily fish per week, chicken without skin and not saturated in salt as is done to augment its weight, lean red meat in restricted quantities, unsaturated fats mostly mono-saturated ones and dairy products with low fat  content. Individuals, who have right weight and serum biochemical values, may take saturated fat preferably of dairy products in moderation while common salt called ‘white poison’ should be used in low quantities. Nuts are healthy if body weight is kept within normal limits, (ground nuts are inexpensive). Seeds like flax-seed called ‘Alsi’ in our native language, seasame seeds and pumpkin seeds are cardio-vascular friendly and in-expensive. Plenty of fluids should be consumed in the form of water, lassi, lemon water and tea (in moderation). Recently yoghurt has been found to prevent D.M. and heart attacks.

Avoid sugary food, drinks especially corn syrups and junk foods – they being the main culprits causing obesity and its sequalae – the metabolic syndrome disorders, corn syrups and Chinese salt form part of many junk foods – avoid these.

Recently trans-fatty acids have been found to be highly atherogenic. These acids increased small particle LDL and lower HDL serum levels, causing atherosclerosis. There should be zero tolerance for trans-fatty acids. These are produced by deep frying of foods and also by repeated light frying with the same oil. Trans-fatty acids are present in significant quantities in foods like Pakoras, Samosas, Kachori, and many other preparations. Avoid tobacco and alcohol.

The other components of life-style therapy are six to eight hours good sleep following circadian rhythm and regular exercise. The exercise should be a part of life, like diet and sleep. Exercises should be in the form of stretching, aerobic and muscle-strengthening – programmed according to the body weight, physical capacity and medical condition of the patient. In addition to programmed exercises, activities throughout the day have beneficial effects. Even working in the standing position instead of sitting posture has benefits in maintaining better blood sugar and lipids, blood pressure and body weight.

Body weight should be kept within the normal limits. It is most important to keep abdominal girth less than 35 ½ inches in the males and 31 ½ in the females in South Asians. Sports at all levels should be promoted, exercises and sports have enormous physical and mental benefits.

Excessive fat in any part of the body is undesirable but the excess of abdominal (visceral fat) is the major culprit which causes increase in insulin resistance – the pivotal point of genesis of metabolic syndrome, leading to DM, hypertension, dyslipidemia and their complications, including heart attacks, strokes, renal failure and peripheral vascular disease.

Mental well-being should receive high emphasis in life-style. Human being has tissues as well emotions. Mental relaxation exercises, meditation etc should also be used. Depression is quite common in diabetics – causes disturbances in glucose, lipid and BP levels and also causes non-adherence to treatment. Vulnerable population to metabolic syndrome – i.e. those with a family history of obesity, hypertension, heart attacks, strokes, peripheral vascular disease, females giving birth to overweight babies and with history of gestational D.M, should undergo screening at regular intervals to detect metabolic disorders in early stages and undergo treatment to prevent the disorders and their complications. Metformin, glucosidease-inhibitors, Statins and anti-hypertensives have a special role in this respect.

By employing lifestyle measures and anti-diabetic drugs many Nations have shown up to 60 percent reduction in the development of type 2 diabetes in pre-diabetic patients.

Statins:Surprisingly many doctors including cardiologists do not prescribe statins to the diabetic patients for primary prevention of heart attacks, strokes, peripheral vascular disease and even for secondary prevention and if prescribed, they are given in inadequate dose. It is usually due to lack of knowledge about drugs. These doctors think about serum lipid profile only. It should be kept in mind that statins have a number of actions beyond lowering cholesterol, called heilotropic effects. They suppress inflammation that contributes to lipid plaque formation, the basic pathological lesion of coronary heart disease – the rupture of which causes heart attacks. They also improve the function of cells that line the arteries, enabling them to expand as needed. Statins reduce the size of plaques, stabilize plaques, reducing the chance of their rupture and heart attacks. Statins also act on coagulation cascade. Therefore moderate intensive statin therapy should be used for primary prevention for all patients of diabetes mellitus irrespective of their cholesterol levels – starting at the age of 40 in men and 50 in women and earlier if the risk is high. Risk should be calculated taking into account all risk factors. Those having high risk should be placed on high intensive statin therapy. After the occurrence of heart attack, all patients should be placed on high intensive Statin therapy. Not prescribing statin to needy patients amounts to professional negligence. That is the reason that the subject of clinical pharmacology and clinical therapeutic is very important. A renowned American cardiologist remarked that if he suffers a heart attack in the desert – one drug – Statin he would like to have.

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