Diabetes prevention and management
Diabetes is manageable, and complications are preventable. Also, if you have complications, worsening can be prevented, according to internal medicine specialist and endocrinologist Dr. Kristine Parker-Curling who encourages diabetics to take ownership of their disease and health and to know what their goals are and to be aggressive in taking care of their diabetes.
Parker-Curling’s advice comes as Diabetes Awareness Month is recognized to raise awareness about both Type 1 diabetes (when a patient is no longer able to make insulin, and for which treatment is to replace insulin); and Type 2 diabetes (insulin is present, but the patient is not very sensitive to it), especially as it is becoming more common to learn that someone you know has diabetes, and even more likely is pre-diabetic (have an elevated blood sugar level) and does not realize it.
“According to the International Diabetes Federation survey in 2014, we have about 34,900 people in the country with diabetes that we know about … that misses all the people that don’t come into the healthcare system or have no diagnosis,” said Parker-Curling at the most recent Doctors Hospital Distinguished Lecture Series. “Additionally, more statistics show that in 2005 the Ministry of Health did a communicable disease prevalence study – diabetes was present in just under 10 percent of the population. We’re not sure what that prevalence is now, so a lot of people in The Bahamas and the region are affected by this disorder.”
She described diabetes, of which there are many, as a disorder that affects the metabolism, making it difficult for a person to process the foods they eat.
“Type 1 diabetes is very much determined genetically, and there’s not much that you can do to prevent the onset, so we spend a lot of time talking about Type 2 diabetes because there is a lot we can do to prevent it and control it, and to delay the onset.”
Risk increases for Type 2 diabetes she said include strong family history, excess body weight, lack of exercise, poor dietary choices, the presence of pre-diabetes which she said increases a person’s risk of diabetes, and long-term steroid use and other medications which can put a patient at risk for developing diabetes.
“The normal sequence of things is that you eat, you chew, you swallow, you digest and you absorb your food, absorbing all of the nutrients into circulation in your bloodstream. One of the nutrients that you absorb is glucose [sugar], which has to leave your circulation and enter your muscles and the cells of your body where you use it for energy. Diabetes occurs when a patient is unable to get those sugars out of those blood vessels and into the muscles. A patient with Type 2 diabetes is resistant to the insulin, so the insulin is not doing its job.”
In diabetics as their insulin resistance increases, the ability of the insulin to control the blood sugar goes away, and the blood sugar levels start to rise. According to the internist, insulin resistance can be improved, and patients can be made more sensitive to insulin.
Diabetes is diagnosed through a number of blood tests, after overnight fasting; anything over 125 milligrams per deciliter she said is going to be diagnostic of diabetes. Other tests include an oral glucose tolerance test, or a hemoglobin A1c. The doctor said people don’t necessarily have to have extensive laboratory evaluations, and don’t technically need a blood draw, and that a test can be done by a simple prick of the finger.
“Once you have one abnormal test, you want to repeat, confirm that this is truly abnormal and then we would move on with management.”
In diabetes prevention she said it behooves people to know their family history, and follow-up regularly with their doctor for routine testing.
“You can pick up pre-diabetes. You can pick up evidence that your blood sugar control is getting worse before you develop diabetes, and there is actually things you can do at that stage to even prevent it. Early detection can delay the development of diabetes.”
In preventing the onset of the disease, she also encourages people to exercise and to be cognizant of their diet.
“You don’t have to do anything heroic. Recommendations are really about 30 minutes of walking, moderate physical activity five days a week – you don’t have to join a gym, you don’t have to do anything expensive or excessively strenuous, but consistency is important. And also you want to look at how you’re eating – the green, leafy vegetable component of the diet has to increase and the carbohydrate containing portions of the diet should decrease, because you don’t want to stress the pancreas. You don’t want to keep presenting excessive amounts of glucose that you then have to metabolize or get rid of.”
Parker-Curling said that there is a period that medical professionals refer to as glucose intolerance, or elevated glucose that can come before the development of diabetes, and that people can have for many years. She said a person could end up with a long warning window period during which they can do something to change the outcome if they find out before you develop the condition.
She said among people who are pre-diabetic, that about five percent per year are at risk of developing diabetes from their pre-diabetes state. She said early detection is important, because there are things medical professionals can do about it.
“We can decrease the risk of developing diabetes in someone who has pre-diabetes by about 58 percent with lifestyle interventions, compared to with medications, by about 31 percent. So, there’s still some help if you take medications and are unable to exercise for whatever reason. We want to detect diabetes and pre-diabetes early because we want to prevent complications. Not every diabetic patient has to develop complications from diabetes. And excellent control of your blood sugars can prevent or even delay the development of complications.”
Symptoms of Type 2 diabetes include excessive thirst, excessive hunger, dry mouth, blurred vision, extreme fatigue, excessive urination, and recurrent yeast infections (in women). Type 1 diabetes may also be associated she said with weight-loss.
Complications of diabetes she said can affect the large blood vessels and the smaller blood vessels. Large blood vessel diseases she said include heart disease and strokes and affect diabetics at least twice as much as non-diabetic patients, periodontal (gum) disease, and that sexual dysfunction is sometimes common; the small blood vessels affect the eyes, the kidneys and the nerves to the feet.
Depression and anxiety she said can occur in diabetic patients because of the constant pressure to monitor what you’re eating.
“I tell my patients to think of their blood vessels as pipes and if you think of a steel pipe, not necessarily designed to carry salty water, you know you can develop erosion, corrosion, rusting. A rusty pipe is weak – a weakened pipe can break, crack, rupture or leak – so if you think of your blood vessels as pipes carrying your blood around your body, the walls of those blood vessels were not designed to carry around a very sugary fluid. The sugar in the fluid can actually affect the structure of the walls of those blood vessels, causing weakening of those walls which can lead to rupture, which can lead to clogging, so these are the reasons that the blood vessels become very vulnerable in diabetic patients. And this is the reason we want to control those blood sugars, because we don’t want your blood vessels being exposed to such high concentrations of sugar, because they simply weren’t designed to carry that type of fluid around.”
According to Parker-Curling, there are several tenants of diabetes management, the most important of which she said is self-management. Lifestyle adjustments and follow-ups with medical doctors are a must for diabetics as well as referrals to appropriate specialists if needed, and medications when appropriate.
Diabetics she said are also encouraged to self-manage, and have the ability to check their blood sugars first thing in the morning after fasting overnight, and she said their level should be below 130; a good blood sugar fasting number she said is between 70 and 130; before meals she said you don’t want to see blood sugar levels above 180, and hemoglobin A1c should be less than seven percent.
“In diabetes self-management, if you know what the goals are, and you’re now checking, you would be surprised at how motivated you become to make changes. The knowledgeable patient is a great patient, because they start making changes on their own, based on the fact that they know what they should be looking for. “
Things that affect blood sugar include eating carbohydrates like white breads, white potatoes, white pasta, sugars.
As for meals, she said there is no one diabetes meal plan per se that’s going to fit everybody’s life, because people have other conditions that might dictate the type of choices they should be making – as well as their preferences and culture.
“The things you like to eat will also influence what you should eat, because there’s no point giving you a list of things to eat that you’re just not going to eat, because we want you to enjoy your life, so sometimes we have to have a consultation with a nutritionist to kind of guide you to make the best choices for yourself.”
As a general rule of thumb, the plate method of meal planning she said entails breaking a plate into two halves, with one half containing non-starch vegetables; the other half of the plate broken into halves again with one-quarter for starch or grains, and the other quarter for protein (two to five-ounces). To the meal diabetics can consider adding a serving of fruit or dairy, limiting glucose containing beverages and desserts. They are also encouraged to limit added fats. And the meal should not be piled higher than a deck of cards.
“Changing the way you eat is probably the safest way to naturally decrease the risk of diabetes, and control diabetes,” said Parker-Curling. “You’re going to fall off the wagon sometimes, and that’s a part of life, but just because you’ve fallen off doesn’t mean you have to stay off. When that happens, you get back on it. Life events will happen and derail you sometimes. You have to feel empowered to get back on whatever that goal is you were trying to achieve.”
According to the internist, there are many medications for diabetes, but she said the number one medication for the management of diabetes is a person’s lifestyle.
“If we’re unable to control your blood sugars with your lifestyle which will be the case for some patients, think of medications as an add-on. So even if you’re doing everything that you can, some patients won’t be able to reach the goals for their diabetic care without medications. And if that’s not occurring, you’re not a failure. You just need some help,” she said.