In our last issue, we understood that diabetes was due to a combination of carbohydrate excess with insufficient exercise, smoking and continued weight gain. 30% of working age obese males will become diabetic. This figure jumps to 90% for females.
We can stratify our advice according to where one is on the diabetic spectrum: Normal but rising glucose; prediabetic; newly diagnosed diabetic; long-standing diabetics. Most of it centres around understanding and implementing the most effective diet and exercise specifics together with your physician.
Normal But rising Annual Fasting Glucose
In this group, of which I also belong (my fasting glucose is 94mg/dL in 2014 compared to 76mg/dL in 2008), attention has to be brought to weight gain. The median weight gain in working population is 2-3kg/year. If one can keep his weight stable or reduce it towards normal, they would have beat the odds immediately.
For exercise, if young (<45) I would encourage starting vigorous exercise focusing on resistance training. Aim for individual muscle fatigue rather than whole body exhaustion (which is not beneficial). More circuit or interval exercises is advised as this has been shown to make the body more sensitive to insulin and bring down fasting glucose effectively. For long distance runners or swimmers , my usual advice is to break the distance into thirds: moderately fast pace / leg drills / short sprints. Not only will it make the distances covered more interesting, this brings in the interval and resistance exercises in a sustainable way.
For ages 45 and older who are not accustomed to exercise, starting with moderate intensity exercises such as brisk walking and cycling is a good start.
Prediabetic
( fasting glucose 100-125mg/dL or HbA1c 5.7-6.5%)
In this group, I advise halving the carbohydrates ( rice, bread, noodles, sugar, wheat, anything starchy) and taking small frequent meals to bring intake as close to the Harvard Healthy Eating Plate.
As most prediabetics are also obese with poor muscular tone, I usually ask them to start core exercises first to build a stable base on which they can do other exercises. The Bridge ( taken from Yoga) and Flutter Kicks will help increase core tone and hip flexor strength. For those complaining of painful knees and early osteoarthritis, the advise is to do static straight leg raises with their feet turned outwards to isolate the inner thigh muscles, which are commonly neglected and contribute to increased kneecap wear.
For certain individuals with a family history (genetic or cultural, or both), I may consider using the diabetes drug Metformin to sensitise the body to insulin and increase weight loss in addition to the above diet and exercise measures. Metformin will only be used for a year and is not meant as a pure weight loss tool.
Newly Diagnosed Diabetic
(FPG >126mg/dL or HbA1c >7%)
In PCS complex, as almost everyone will have an annual glucose test, there are hardly any persons who are left as undiagnosed diabetics for long.
A diabetic runs a lifetime risk of cardiovascular death 3-5 times more than the non-diabetic population and almost always will have cardiovascular event. The only question is WHEN?
Good control of the sugar, in terms of maintaining the HbA1c <7% confers many benefits - complications are delayed till a later age. Heart attacks, strokes, leg amputations, nerve damage, vision loss are all delayed. Most people go through a yo-yo relationship with their HbA1c – when praised about maintaining good control, their HbA1c almost always rises the next visit!
I usually emphasize that Resistance Exercises (free bodyweights, calisthenics, Zumba, circuit training, etc) is the key to controlling diabetes. The effect is constant and will never fade with time, as opposed to almost all diabetic medications (yes, all medication effects will wear out over time, necessitating higher doses and different drugs sooner or later – this is not the same as dependence).
If there are no contraindications, Metformin is the first drug of choice as it is not likely to causelow blood sugar. However, in the first 2 weeks, there may be bloatedness and increased flatus (passing gas) but these will improve with time. If the correct exercise is the basic intervention, most diabetics do not need additional medication for 1-5 years and the dose may be adjusted accordingly.
All diabetics will need an annual examination of their feet as a baseline to document the blood supply, nerves and skin condition. Once tests are abnormal, more attention needs to be paid to the feet everyday. A photograph of the back of the eye (retinogram) will need to be done annually to pick up extra blood vessels which if left unchecked may cause permanent vision loss.
I would still advise regular exercise as it serves as a periodic “ stress test” for the heart. Persons who regularly exercise can detect significant heart disease when they feel their exercise tolerance has reduced. At this moment, a few pick up blocked arteries (>75% blockage) this way and avoid suffering a heart attack. If one does not exercise regularly, you may not feel anything even when the vessel is >90% blocked, and run the risk of suffering catastrophic blockage when it reaches 99%. Caution is advised when increasing intensity in diabetics – always do this in consultation with a doctor who is trained or familiar with exercise medicine.
Long-standing Diabetics
People in this group would be familiar with the ups and downs of their HbA1c over the years and also minor issues of poor wound healing or metabolic emergencies due to very high or very low sugar levels. Hopefully, with this article, there will be less of such cases.
They may be taking more than one drug, and would almost have started cholesterol lowering drugs such as a statin to reduce their heart attack and stroke risk. They may also have early nerve damage in the feet, or had a silent heart attack only picked up on the following year’s ECG.
Regular follow-up with the doctor to look out for end-organ damage is now much more important
Eye - may need laser therapy if diabetic retinopathy is found
Heart - 3 yearly treadmill to pick up silent heart disease and institute stenting as an intervention
Bladder – may suffer weak bladders from nerve damage, or even frequent urine infections in both men and women
Feet – regular inspection and reducing fungal infections will become the norm. Some may also need a stent in the blood vessels of the legs if supply is poor. Nerve damage is permanent and shoes or gait may have to be modified. The risk of getting a poorly healing wound progressing to amputation is always there, although it happens most to smokers (95% lifetime risk).
Kidneys - the kidneys will leak protein when the blood pressure or HbA1c is too high. Frequent leaks will not immediately cause a deterioration of the kidney function, but once long standing, kidney function will drop drastically with no warning in future. Hence, each proteinuria (UACR >3) discovered is an opportunity to discuss adjusting medication with the doctor. Diabetes remains the largest cause of kidney failure in the working population.
Diabetics on oral agents may also see the effectiveness of these medications waning. A conversation about insulin will ineveitably occur sooner or later, although with the above measures, I hope that this will only happen as late as possible (preferably after retirement!).
