Prevention of Diabetes Mellitus Type-2 and related metabolic disorders

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 Prevention of Diabetes Mellitus Type-2
and related metabolic disorders

Preventive measures, health education, control of obesity,
ethical medical practice, rational prescribing and
population control will offer rich dividends

 Lt. Gen. (R) Mahmud Ahmad Akhtar,
Prof. Emeritus (Medicine and Clinical Therapeutics
Former Surgeon General Army/DGMS (IS)

Recently the Baqai Institute of Diabetes and Endocrinology (BIDE) has published its ‘Survey Report’ revealing that the incidence of diabetes-mellitus type2 in Pakistan the rise above the age of 20 has risen to 26% of its population-that is one in every fourth person is suffering from diabetes-mellitus-an alarming finding. About 19.05 percent are known diabetic while 7.14 percent are newly diagnosed and the diabetic prevalence of Pre-diabetes was seen as high as 14.47 percent- the rise has occurred within short period. More than half (52.2%) of the population are hypertensive and 24.7% are newly diagnosed with hypertension. Three fourth participants (76.2%) were over-weight. BMI>23 similarly high prevalence of obese (62.1%).BMI>25 as per Asian cut-of.


Lt. Gen. (R) Mahmud Ahmad Akhtar

Since long it was known that the diabetes-mellitus was spreading like a wild-fire in Pakistan even involving young adults and adolescents. In an editorial published in the PAFJM Journal 2013, I wrote about the necessity and urgency of taking a series of preventive measures. There was a news that the “Federal Ministry of Health” had established a “Cell” in the Ministry for the prevention of non-communicable diseases. As usual there was no evidence of any preventive measures being taken. I wrote a letter to “The Ministry of Health” and sent a set of my published articles on “Prevention” but without any response.

In the Pakistan Armed Forces Medical Journal a study on the incidence of ‘Metabolic Syndrome’ was published showing that the incidence of metabolic syndrome was higher in the Pak Armed Forces as compared to Saudi and Jordanian Armed Forces and most alarmingly even higher than the Indian Armed Forces. On investigations I noted that the cause of the high incidence was due to Pakistani soldiers diet high in calories, saturated fat and sugars and suggested preventive measures. It was published in the PAFM Journal in a “letter to the editor” column.

Metabolic syndrome consists of a cluster of obesity, glucose intolerance, diabetes-mellitus, hyper-dyslipidemias, hypertension, etc. leading to heart attacks, strokes, renal failures, peripheral vascular disease, fatty liver leading to chronic liver disease and carcinomas. The basis of metabolic abnormality is increase in “Insulin Resistance” mainly in the abdominal obesity i.e. apple-shaped. Genetically the South Asians are more prone to metabolic syndrome. World Health Organization (WHO) has recommended South Asians abdominal girth should be less than 35.5 inches in males (Caucasians 40 inches) and less than 31.5 inches in females (Caucasian 35 inches). This should be the main criteria of health and success. Unfortunately our many leaders in all spheres selected even in security forces and elected are not within these limits and present huge abdominal bulges. In the services there should be a strict rule- “anybody not keeping he/she within these limits should be invalided out of service.”

Prevention should start even before the child-birth. It has been established that the low-birth weight born babies suffer more from these ailments. In our culture girls and women generally have poor diet mostly left-overs, while boys and men get the lion’s share. Women suffer from iron-deficiency anemia’s and malnutrition, this further complicates the problem. Early marriage and poor spacing of born babies lead to poor weight babies . Pakistan is having highest population growth, its population is fifty million more than the Bangladesh while the former East Pakistan had much higher population than the former West Pakistan (now Pakistan). This has occurred within a short period. Pakistan’s low contraception use rate –lack of awareness has done out Pakistan. In Pakistan about sixty percent marriages are consanguineous of which 80 percent are amongst first cousins .These should be minimized keeping in view the genetic backgrounds of the families. Population control measures like avoiding early marriages ,proper spacing of birth should receive emphasis , women should be empowered and involved in family planning Bangladesh has achieved enormous success in population control by involving women in population control programs, women going door to door, also prayer leaders and clergy should also be involved as Indonesia has done, achieving substantial success. Breast feeding is preventive, it is the lowest in Pakistan .One major reason is poor nutrition of many females and not able to produce enough milk- more than 50% women are suffering from anaemia /malnutrition. It has been estimated that 45% of children suffer from mal-nutrition and its effects. Due to non-availability of potable water for the common people (over 60 percent) gastro-intestinal infections, bacterial, viral and parasitic are very common. In some areas water is also contaminated with harmful chemicals like arsenic etc.

Essential Medicines

Pakistan is not following the WHO’s recommended “Essential Medicines” system devised for the low-middle income countries therefore affordable medicines including iron preps and anti-microbials are not available to treat iron-deficiency anaemias and infections complicating the problem. Many of the children suffering from sub-nutrition later on develop obesity. In Pakistan obesity is also high amongst children and adults.

In the early 19th century a scholar said that we dig our graves with our teeth, much before the 20th century junk food was labeled as WEAPONS OF MASS DESTRUCTION (WMD).In order to prevent central obesity, the diet plays a pivotal role. It should consist of complex grains of low-glycaemic index (i.e. slow release of glucose) and not refined carbohydrates like white flour, naan, white rice etc. which are very commonly used .The use of sugars should be avoided but Sugars are consumed in very large quantities in Pakistan. It has been estimated that the sugar consumption per capita in Pakistan is six times per capita of China. The sale of sodas rich in fructose and sugary drinks should be banned or taxed heavily. Their sale should not be allowed in the children institutions or nearby shops. This has been banned in campuses in many universities of the USA. Diet should consist of at least five portions of vegetables/fruits mostly vegetables , pulses/legumes consisting of lentils, beans, peas , seeds like flax , pumpkins, chias, sesame(in- expensive, rich in proteins, vitamins and minerals). Diets heavily rich in oils should be avoided, deeply-fried foods like samosas, pakoras, should not be taken to prevent consuming trans-fatty acids. Low-fat dairy products should be used –smoking should be discouraged – intake of red meats, saturated fat and salt minimized, mono and poly-unsaturated fats should be used. Exercises, stretching, aerobic muscle strengthening and relaxation should be done - athletics and sports should be organized and promoted at the National level.

Anxieties, tensions, conflicts- all sorts of negative emotions should be avoided or minimized i.e., life-style Therapy Recent studies have shown that the diets high in salt increase insulin resistance thus contribute to metabolic syndrome, hypertension, diabetes-mellitus etc. Adequate quantity and quality of sleep following circadian rhythm is preventive. It should be given utmost importance.

Pollution has been found to lead to metabolic syndrome disorders including diabetes- mellitus, hypertension, heart attack, strokes etc. Pollution is very high in Pakistan harmful products of diesel, coal, other fuels, industrial waste, poor disposal of garbage, plastics, also water, light and sound pollution. Active measures should be adopted to mitigate these and use of plastic should be prevented at the commercial places. Use of reheated cooking oil is hazardous.

Recent studies have shown that type 2 diabetes can be reversed by consuming just 600 calories a day for eight weeks-can save the lives of millions of sufferers of the preventable condition Newcastle university scientists proved that excess calories lead to fatty liver which causes the liver to produce too much glucose .The excess fat then passes on to the pancreas, which cause the insulin-producing cells to fail, causing diabetes; loosing less than one gram of fat from the pancreas can restart insulin production reversing type 2 diabetes .The researchers concluded the reversal of diabetes remain possible for at least 10 years after the onset of the condition. Lead author professor Taylor confirmed such a diet helps bring about 15kg weight loss. Professor Taylor said that the study showed results within a week of starting the diet –causing a profound fall in the insulin resistance and high fasting blood glucose levels within a short time frame. The importance of this work is that even if one had diabetes for ten years, one is able to reverse it by moving that all important tiny amount of fat out of pancreas. At present this can only be done through substantial weight loss. In 2011 Dr. Mosley of Manchester university lost 20lbs in 12 weeks by using diet comprising five day regular eating and two days fast days of 800 calories. He lost 20lbs in 12 weeks –his blood glucose and lipid levels returned to normal after being pre-diabetic . This diet had been associated with improved DNA repair and brain function. The system of continuous dieting does not help in reducing the weight as the body lowers its metabolic rate and regains the weight. Intermittent dieting of two weeks followed by taking normal diet for next two weeks, having six cycles helps in loss of weight.

Not only the quantity and quality of food taken but also timings are important. Eating all the time keeps body in a state of increased metabolism (which promotes fat storage) Eating at night predisposes to obesity and metabolic syndrome. Taking good breakfast or taking early lunch in obese persons and early evening meal with an long interval of at least between 12 hours between evening meal and breakfast ie feasting and fasting (water allowed) is health-friendly helps in prevention of metabolic syndrome. In very obese patients bariatric surgery can cure or bring substantial improvements in diabetes-mellitus and metabolic syndrome.

 Adequate measures should be taken to prevent and treat complications like hypertension, dyslipidemias, heart disease, strokes, eye, neurological, renal, foot complications Statins are particularly useful in preventing dangerous cardiovascular complications. Prevention should be done at all levels from individual consultation to the National level. Patient counseling /education should be an important of consultation. Patient should be told about the preventive measures to be applied to family-from infancy, childhood onward. Unfortunately most doctors including specialists do not provide patients enough time to counsel/advice on the aspect.

Health Education

There is a dire need to act now. Situation is already out of control. No country can solve these problems by adopting, therapeutic measures like spending huge amounts on insulin and drugs also treating complications- doing stenting, cardiac, neurological operations, amputations etc. Pakistan’s medical professional bodies should also change their strategy- lay emphasis on prevention and take practical measures on prevention .Awareness through all means, media, prayer leaders, academia from school level to university, health education should be given top priority. Health education should be a part of the school and college curriculums. I tell my patients to consume diet taken by our Prophet (PBUH) and do exercises as a part of worship because our Prophet (PBUH) is known to have done regular exercises and a lot of physical activity. Countries all-over the world have achieved remarkable successes by using ‘Preventive Measures’ .In the19th century , Japanese seldom crossed 40 years of age and now they are on the top of the world’s health-indicators with woman average age is approximately 90 years and males 85. Even in the SAARC, Srilanka has achieved remarkable successes- its average age is 76.5 years, even the newly emerged Bangladesh has gone far ahead of Pakistan by adopting simple cost-effective preventive measure. On the other hand in Pakistan, easily preventable non-communicable diseases like diabetes-mellitus, hypertension etc. are spreading like wild fire and the incidence and prevalence of communicable diseases as well is very high. There is mushrooming of medical colleges/universities on commercial basis providing very poor education with rare exception of Agha Khan University running one institution of world standard.

Sub-standard private medical colleges

 In Pakistan emphasis is on tertiary luxurious health projects totally neglecting high-yielding cost-effective preventive aspect. This trend should be reversed. Prevention, promotion of health, early diagnosis, reversal of diseases (diabetes etc.), preventing complications, and early treatment should be given top priority. Pakistan’s health indicators are the lowest one in the world. The establishment of third rate medical colleges, universities highest in number in the world, this is a recipe of disaster. Medicines get a miniscule share-the money is wasted on non-cost-effective medicines as an example Insulin analogues which are three times expensive than human insulins without any advantage of lowering HbA1c accept in very rare patient having frequent hypoglycemic attacks. Analogues are banned in countries having successful universal health-care systems. The reason is a lack of knowledge but much more corrupt practices of having kickbacks- Pakistan’s lethal, corruption virus disease. Regular medical checkups should be done to diagnose complication earlier and treated. We should set over priorities right no doubt infrastructure are important but the water, nutrition, health , are for more important .In the health-section prevention and health-promotion are for more important not only better than cure but the real cure and the only cure primary cum secondary health care forms 99% of the health should have the highest priority 90% of Pakistan the real Pakistan lives in the slums of the cities, rural areas Baluchistan, Fata ,South Punjab , Sindh interior far flung Northern areas these should have priority.

Use of Statins: Statins have not only effects on lipids but have pleiotropic effects like anti-inflammatory, anti-oxidants , anti-thrombotic and cardio-metabolic effects .It has been recommended that men all diabetic at the age of 40 and women at the age of 50 take statins irrespective of their blood lipids levels unfortunately statins are under-used . Even many cardiologists are ignorant of their pleiotropic actions and do not use these .This amounts to medical negligence. Diabetics who have high risk of cardiovascular complications should take low dose Aspirin to prevent complications .Diabetics should always carry 300mg soluble Disprin, on feeling symptoms of ischemic heart disease or stroke, they should immediately take it sublingually and report to hospital .Flu vaccination should be done every year and pneumococcal vaccination at least once .Regular medical checkups should be done to diagnose complication earlier and treated promptly. We should set our priorities right no doubt infrastructure are important but the water, nutrition, health, are for more important.

CONCLUSION

In conclusion metabolic disorders like obesity, diabetes-mellitus, hyper-dyslipidemias, hypertension, fatty liver etc. has already assumed epidemic proportions and getting beyond control. It is high time to adopt preventive measures. At this rate the fatty liver with its complications/sequel will become the main reason for liver transplants. The measure of success should be mid-abdominal girth in males less than 35.5 and in females less than 31.5. This simple yard stick should be adopted to achieve desired results. The selected and elected leaders in all fields of life should set exemplary trend.

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