I've heard so much about diabetes lately-workshops are being given, newspapers and news broadcasts are talking about it. It seems to be affecting people all around the world. Is there something more I should know about it?
Diabetes is ranked number seven as a leading cause of mortality in Canada. It is the United States' fifth-deadliest disease. About 80 percent of diabetes patient deaths are by stroke or heart attack. Among people of working age, the most common cause of blindness is diabetes. A third of a nation's people with diabetes don't know they have the condition. It is estimated that in Western societies approximately 5 percent of the population are known to have diabetes. As our populations age, the condition will become yet more prevalent. Some populations seem genetically more predisposed, such as the Asian population in Natal, South Africa, or the North American Indians of Canada's northern populations. African-Americans, Latinos, Native-Americans, Asian-Americans, and Pacific Islanders are more likely to suffer with diabetes than Caucasians.
What is this disease? Is it reversible? If it's genetic, can a person do anything about it?
Not counting the diabetes associated with pregnancy, there are two clinical forms of the disease. In typical imaginative medical style they are labeled Type I and Type II. Type I can be best understood as a failure of the pancreas to produce sufficient amounts of insulin to take care of the proper handling of glucose. This is the result of destruction of the insulin-secreting cells, called B cells, of the islets of Langerhans caused by an autoimmune process.
Type II is a development of a resistance to insulin in the tissues of the body, and it accounts for about 90 percent of all cases of diabetes. There is then either a deficiency of insulin, or relative deficiency because its action is being resisted. Type I has a strong genetic component. It can occur in children and lean athletic people and is not lifestyle-induced, whereas Type II is directly influenced by factors such as diet, obesity, and physical activity. A pregnant woman who develops carbohydrate intolerance or gestational diabetes has a 25 to 60 percent chance of developing diabetes in the ensuing 20 years.
When diabetes begins, the inability to cope with carbohydrates manifests itself by a rising blood glucose level. Glucose may then begin to spill into the urine if more is present than what the kidney can reabsorb. Because glucose is not being pushed into cells by insulin, the cells cry out for glucose as a source of energy. Because there is "starvation" inside the cells, they switch to fats as a source of energy. Fat is less efficiently metabolized than glucose, and so a by-product of incomplete fat metabolism called "ketones" build up. These impart a sweet smell to the breath and also drain energy, because they are lost still holding energy within their chemical structure. A person with diabetes, losing both glucose and incompletely metabolizing fats, will experience fatigue because of this energy loss. In addition, there is an increase in the volume of urine excreted, which is an osmotic effect of the glucose in the urine. Passing more urine causes thirst, so the symptoms of increased urination and thirst are often prominent.
If any of these symptoms are troubling you, it could be important to have your doctor check you for diabetes:
Unusual intense thirst
Tingling and numbness in hands or feet
Frequency of urination
Slow healing of cuts and bruises
Weight loss
Dizziness and nausea
Lack of energy; fatigue
Irritability
Tendency toward infections
Abdominal cramps
Visual changes
Sweet-smelling breath
Skin, gum, or bladder infection
Recurrent leg cramps
Patients may feel bad, but sometimes even when they are symptom-free, diabetes is not well controlled. Silent damage predominantly to small blood vessels takes its toll and can lead to nerve damage, visual changes, kidney damage, and of course more rapid progress of atheromatous change in coronary vessels. Severe damage is not reversed once it has occurred, even though blood sugars may return to normal. This is why purists do not talk of "reversing" diabetes. Nevertheless, control of Type II diabetes is sometimes excellent with lifestyle modification.
Glucose control is associated with delay in the onset of complications.1 Many persons attending lifestyle-modifying programs, notably some held in Adventist-owned lifestyle centers operated as supporting ministries, are greatly benefited. While I would not want to recommend one over the other, many offer extremely helpful programs that a newly diagnosed person with diabetes would be wise to heed. The cost of a couple of weeks living in such a center would be repaid many times over (if the learning is applied) in the health of a person with Type II diabetes. Such claims are not as readily applicable to Type I diabetes, even though the positive lifestyle benefits apply, but in a less obvious way.
Insulin resistance is a forerunner of Type II diabetes. The condition is associated with elevated insulin levels, a tendency to atheroma formation, obesity, hypertension, abnormal blood lipids, increased blood coagulability, and raised uric acid levels. The factors contributing to this condition are the genetic predisposition; a high-fat, high-refined-carbohydrate, and low- fiber diet; physical inactivity; and obesity.
Lifestyle Management An understanding of these risk factors leads naturally to the key lifestyle management interventions. These are: dietary control, weight reduction, and exercise.
Dietary control. A fair amount of evidence suggests that those eating a plant-based diet have lower rate of Type II diabetes. While this evidence is not conclusive, it is suggestive and comes from the Adventist health studies.
The 1960 Adventist Mortality Study did not specifically study diabetes, though its presence at the commencement of the study was noted. In 1976 the next study found there were 8,500 subjects who had been in the earlier study, which enabled the researchers to note the change in diabetic status between the two studies and to try to correlate it with a plant-based diet.
In 1960 2.4 percent of males and females were living with diabetes. In the 8,500 subjects an increase to 5.1 percent in males and to 6.4 percent in females was noted over the 16-year period. This large increase was a cause for concern, but only hypothetical answers, such as the "aging process," "increasing obesity," and "increased physician acumen," were found.
It is noted that persons consuming a plant-based diet weigh less than others. For persons age 45-64 years old this difference is of the order of six kilograms, or 13 pounds. Persons consuming a plant-based diet in the two studies were noted to have a lesser weight gain, and to be more likely to have lost weight over the 16 years than their omnivore counterparts. Many investigators have documented the fact that those consuming a plant-based diet as a group weigh less than omnivores. Obesity is, of course, highly linked to diabetes. Death certificates from Adventists made mention of diabetes only half as often as in non-Adventists, suggesting that some component of their lifestyle reduces the risk of diabetes. Could this be the increased number of persons eating a plant-based diet in their ranks?2 G. A. Colditz and his colleagues, in 1997, reported that increased "vegetable" fat (as opposed to "animal" fats) and higher potassium and magnesium intakes, as found in plant-based diets, were protective.
It seems reasonable to state that the plant-based diet is associated with a diminished risk of Type II diabetes. Whether it is the fat intake, or obesity often associated with a high fat intake, that predisposes to Type II diabetes is being unraveled. Not all types of fats have been linked to diabetes-in fact, monounsaturated fats and polyunsaturated fats may be beneficial.3
Several researchers have noted that saturated (animal) fats are more likely to promote obesity than are the unsaturated (vegetable) fats. Drs. E. Haddad and J. Sabate, from Loma Linda University, also demonstrated that the addition of 320 extra calories in the form of almonds per day was not associated with increased weight gain over a six-month period. In contrast, beef- eating populations were noted by K. West4 and J. Gear5 to have increased risk of diabetes.
As already mentioned, an increase in fiber intake is associated with a lower risk of Type II diabetes.6 Because foods high in fiber are often of low glycemic index, the role of each factor is not easily teased apart. A glycemic index is related to how rapid a rise in blood sugar is associated with a particular food. It is suggested that foods with more fiber have a lower index. Of course, the glycemic load of the whole meal must be considered, because the whole meal, not a single component, is what is eaten. Diets that favor high intakes of beans, soy, and other legumes, tend to decrease the risk of developing diabetes.7 Among a Canadian Native American community it was observed that consumption of "junk" foods and large amounts of bread and butter were associated with an increased risk of Type II diabetes and of impaired glucose tolerance.8
The American Diabetes Association recommended (1998) that patients with Type II diabetes should take:
Sufficient calories to maintain a normal weight (not necessarily the usual weight).
Ten to 20 percent of these calories from protein, unless there is kidney disease present, where a lower intake is required because of diminished ability on the part of the damaged kidney to cope with protein.
Less than 30 percent of the calories from fat (preferably unsaturated and monounsaturated fats).
Fifty to 60 percent of the calories from carbohydrates. The whole foods containing such carbohydrates are vastly superior and more beneficial, especially to the diabetic, than are refined flours and sugars. Other sucrose-, fructose-, and lactose-fortified foods are not recommended. (A rule of thumb is to avoid foods in which sugar is in the top five listed ingredients.)
Fiber: 20-35 grams per day, and a maximum of 2.4 grams of sodium per day is advocated.
Obesity. Weight control is a key element to the management of diabetes. Several problems have contributed to obesity, which, simply put, is a result of consuming more calories than are expended. We have become accustomed to gluttonous-sized portions of food. A typical serving is much greater than the servings recommended by the food pyramids. A visit to McDonalds can result in astronomical caloric intake from a Big Mac (+ 500 calories), a large serving of fries (+ 400 calories), a whopping big milk shake (+ 350 calories), and a piece of apple pie (+ 250-300 calories). Such a meal (+ 1,500 calories) is nearly enough for a whole day's caloric intake, but is poor in phytochemicals, antioxidants, and many of the other micronutrients. Lots of people-especially kids-wolf down such meals regularly. No wonder we have an epidemic of juvenile obesity. Our high "hidden" sugar and fat intakes also are cause for concern. Sugar-laden soft drinks, of which the average American youngster drinks four or five a day, each with five to seven teaspoons of sugar per can, are big culprits. Once a person is obese, weight control is not easy, because metabolic patterns become disturbed by eating habits, and leptin, insulin, glucagon, and other controlling substances are thrown out of balance.
Exercise. Not only do we tend to eat like a certain proverbial farm animal; we tend to move about as such, too. Our entertainment is the television, a bag of chips or popcorn (butter-soaked) nearby. We drive everywhere, ride escalators or elevators, grumble at our spouses if they don't park next to the door of the stores, and often won't bend down to pick up a penny. Even in church we park ourselves in our pews for the Sabbath school class so we won't have to get up and move. If evolution were correct, we would be growing wheels instead of legs by now.
Studies have shown we need a regular 20 to 30 minutes of aerobic exercise about four to five times a week. Some piously quote the demise of a friend on a treadmill as a reason not to exercise. They completely ignore that most people die in their beds, which, if their reasoning were correct, would mean they would never sleep. It is true, however, that one should always begin exercise cautiously. If one has diabetes, is obese, or has another medical condition, consulting with a physician prior to commencing exercise is recommended. It is wise to begin with walking rather than attempting running, and to increase to the limits of comfortable tolerance very gradually.
It is also wise to build some muscle mass, as this results in tissue that has a higher metabolic rate than other tissue and helps consume calories. To do this, resistance or weight training is advisable. For a person with joint problems, swimming (or aqua walking) is highly recommended, as the water will dampen any stress on the joints, yet permit exercise.
These represent the three main lifestyle modifications. Though the need for the use of insulin or hypoglycemic agents in many people may be reduced or even obviated, a group remains that requires medication. Close cooperation with a physician or clinic is advised.
Glucose control is only one part of the equation. Some three quarters of persons with diabetes die, not from renal or gangrenous changes, but from heart attacks. Aggressive management of abnormal lipids is required.
Keeping blood pressure regulated is a second very important factor in controlling the progress to myocardial damage.
Measurement of glycosylated hemoglobin, or the A1C test, gives an idea as to how sugar levels are over the long term, which is better than an occasional finger stick here and there.
It is for the monitoring of these more subtle indicators that we advise close cooperation with your endocrinologist.
Once more the blessing of the Lord on His people through the health message is demonstrated in this disease of diabetes. We should give thanks for His benevolence to us as a people. It's time we applied the lessons.
For those seeking a reliable Web site we recommend:
1 Diabetes Control and Complications Trial Research Group, "The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-term Complications of Insulin-dependent Diabetes Mellitus," New England Journal of Medicine 329 (1993): 997.
2 D. Snowdon and R. Phillips, "Does a Vegetarian Diet Reduce the Occurrence of Diabetes?" American Journal of Public Health 75 (1985): 507.
3 C. C. Low et al., "Potentiation of Effects of Weight Loss by Monounsaturated Fatty Acids in Obese," Non-Insulin-Dependent Diabetes Mellitus 45 (1998): 569.
4 K. M. West, Epidemiology of Diabetes and Its Vascular Lesions (New York: Elsevier North-Holland, 1978).
5 J. Gear et al., "Biochemical and Hematological Variables in Vegetarians," British Medical Journal 281 (1980): 1415.
6 J. Salmeron et al., "Dietary Fiber, Glycemic Load, and Risk of Non-insulin-dependent Diabetes Mellitus in Women," Journal of American Medical Association 277 (1997): 472.
7 P. B. Geil et al., "Nutrition and Health Implications of Dry Beans: A Review," American Journal of College Nutrition 13 (1994): 459.
8 J. Gittelsohn et al., "Specific Patterns of Food Consumption and Preparation Are Associated With Diabetes and Obesity in a Native Canadian Community," Journal of Nutrition 128 (1998): 541.
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Allan R. Handysides, M.B., Ch.B., F.R.C.P. (c), is director of the General Conference Health Ministries Department; Peter N. Landless, M.B., B.Ch., M.Med., F.C.P.(SA), F.A.C.C., is ICPA executive director and associate director of Health Ministries.
In 1960 2.4 percent of males and females were living with diabetes. In the 8,500 subjects an increase to 5.1 percent in males and to 6.4 percent in females was noted over the 16-year period. This large increase was a cause for concern, but only hypothetical answers, such as the "aging process," "increasing obesity," and "increased physician acumen," were found.
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