Friday, September 12, 2008


Diabetes mellitus, has become a very important disease in our war against heart disease. Whether it be lack or insulin ( as originally postulated by Best ) or lack of ability of insulin to act ( insulin resistance ), the outcomes appears bleak, affecting the human macro and micro vasculature. This results in vascular damage causing angina, heart attacks, strokes, peripheral limb ischemia and gangrene, renal failure and eye failure. It is a very chronic debilitating disease. Not only that, although control of diabetes is possible, a cure is not yet possible. We struggle very hard to balance a patient's blood sugar by use of diet, exercise and drugs or insulin ( or both ). And because the effects of vascular damage is not seen until the final stages of the disease, patients have a very careless atitude towards the management of the disease until all the complications have set in, usually too late. The various professional bodies in the WHO, Europe and America, have formalised definitions for diabetes diagnosis and managment. The latest one in the Clinical Practice Guidelines included a definition of pre-diabetes, obviously trying to focus on early detection of the patient at risk, and hoping to prevent the disease. This seem a very good strategy, just as the hypertension boys are doing.
Well, being able to define a pre-condition of a disease allows us to identify patients at risk( actually they are not patients yet, in the strict sense of the term ). What then shall we do to help these patients at risk of diabetes, from actually developing diabetes. Shall we give them drugs ( but then, they have no disease and may never get the disease )? Or shall we teach them vigorous life-style modification. Well, this was the title of a gladitorial debate, held ( wherelse than in the home of the gladitors ) in Rome, at the just concluded Annual Scientific Meeting of the European Association for the Study of Diabetes, 2008. What was the outcome?
Dr P Zimmet, an eminent Diabetologist felt that giving a drug like metformin was the best way to go, and Dr N Wareham of Cambridge eloquently put forward the view, that in these otherwise healthy individuals, life-style changes was the best thing to do. Well, with a simple show of hands, Dr Wareham's views prevailed.
The point that I am making is that for these chronic, devastating diseases, early detection with prevention is the best way to go. Obviously giving a drug ( with known side-effects and dangers ) to some one who is well, may not be the best strategy. The natural way ( lifestyle modification ) with all the attendant inconveniences, is the best way to go. And just to reiterate, that these includes, greens ( veges ), fruits, low carbs, and low salt, with white meat. Basically, regular exercise and lose weight. Physicians can set the tone, by weighing all patients in the clinic routinely and spending the first 5 mins of the consult on a small pep talk on achieveing the ideal weight, in all patients and especially those with cardiovascular disease or risk factors. Afterall, cardiovascular disease and diabetes and obesity are all in the same family, brothers and sisters. What affects one will eventually affect the other.

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