Prevention a matter of diet, portion size and exercise
November 3, 2010
Judy Gerstel
SPECIAL TO THE STAR
Bob Clement is a man who lives on the brink.
Amiable and soft-spoken, the 64-year old veterinarian who works for an animal nutrition company doesn’t seem like the type to live dangerously.
But when he wakes up in the morning and before he goes to sleep at night, whether at home in Milton or at the cottage in Collingwood, Clement is aware that he is at risk.
“I’m pre-diabetic,” he explains.
He’s on the brink of being diagnosed with the disease, and the illness is a major risk factor for heart attacks and strokes.
Even people in a state of pre-diabetes are at greater risk for cardiovascular disease. Some studies show the risk to be two to four times greater.
At his annual physical three years ago, Clement was told his blood glucose level was 6.3 — with the upper limit of normal set at 6 — indicating that he had impaired glucose tolerance, the precursor to diabetes.
Clement’s risk factors for late-onset diabetes included his age, weight and lack of exercise — and his appetite for potato chips.
At 5’8”, he weighed 200 pounds, and, as for jogging or running to stay fit, he says, “It’s not going to happen. I have arthritis in one knee, and I’m just not built for that.”
Instead, he did lose 25 pounds on the South Beach diet, he does sometimes use his elliptical exercise machine, and he stays away, mostly, from bread, pasta and desserts.
“I would do better if lost a little more weight and cut out more calories overall, as well as the carbs,” he says.
“The occasional potato chip still manages to get past me.”
One weapon Clement uses to fight off the disease is a glucometer to check his blood-glucose level.
“It encourages you to watch your diet more carefully,” he says. “I take it some mornings and it’s 6.3, and then I know I’ve got to be a little more careful. I tend to eat a lot of salads and when I maintain that, my blood glucose stays in good shape.
“But I’m like the majority of the population,” he says. “I try to be more careful and then I do lose a little more weight and I’m back in a normal (glucose) range. And then I lose track . . . .”
Fortunately, most of the population is not prediabetic.
But the prevalence of the condition is increasing alarmingly.
The Public Health Agency of Canada estimates that the number of Canadians over the age of 20 with pre-diabetes was about five million in 2004, and is projected to increase to more than 6.3 million by 2016. Among those aged 40 to 74, this number is projected to increase from about three million in 2004 to 4.3 million in 2016.
Around the globe, in 2003, an astonishing eight per cent of people aged 20 to 79 had impaired glucose tolerance.
If left untreated, more than half the people with pre-diabetes are expected to develop the disease within eight to 10 years, according to PHAC.
In a way, the treatment for prediabetes couldn’t be more simple.
Lifestyle changes — diet and exercise — can be even more effective than medication, such as metformin.
“Exercising 30 minutes a day five days a week and losing seven per cent of one’s body weight can bring about a 58 per cent reduction in the progression to diabetes,” says clinician-scientist Dr. Bernard Zinman, director of the Leadership Sinai Centre for Diabetes at Mount Sinai Hospital. “And exercise is not only very beneficial in preventing diabetes, but also in preventing heart disease.”
This benefit does not necessarily occur with pharmacological intervention, says Zinman, although his team at Mount Sinai is investigating a new drug that could counter both diabetes and heart disease. (People interested in taking part in the clinical trial who already have Type 2 diabetes and a history of heart disease should call Mount Sinai research nurse Stella at (416) 586-4800, ext. 4447.)
Exercise is effective because it not only helps reduce the bad (LDL) cholesterol and raise the good (HDL) cholesterol in the blood, but also because it increases insulin sensitivity and helps to keep weight down.
Even an extra 15 or 20 pounds can be a contributing factor to pre-diabetes and its progression to a full-blown case of the disease.
And a five to seven per cent weight loss can bring glucose levels back to normal, says Zinman.
But as with many things that seem simple, lifestyle changes and coping with prediabetes can be difficult.
That’s because prediabetes is associated with metabolic syndrome that also includes hypertension, increased waist circumference, heart disease, arthritis and sleep apnea.
There’s also evidence, says Zinman, that mental health issues can affect a person’s risk of developing diabetes.
Stress and depression, for example, can lead to behavior changes — excessive eating, lack of exercise — that lead to diabetes, he says. “People who get diabetes may have more psychological issues.”
That’s also linked with sleep apnea. Atul Khullar, Medsleep Canada sleep specialist and psychiatrist, says 25 per cent of people with sleep apnea have depression or mood disorders.
“We don’t really know what causes what,” says Khullar. “It’s tightly correlated — different petals of the same flower. We don’t know if apnea causes diabetes or if it’s part of the disease complex.”
He says 25 per cent to 75 per cent of people with diabetes will have sleep apnea. And it’s estimated that up to 40 per cent of people with sleep apnea will have diabetes.
A Yale University study showed the risk of developing diabetes in the next five years was nearly three times greater in people with sleep apnea.
The increased risk may be linked to “all those critical things in (preventing) diabetes that people can’t do because they’re tired: Exercise more, eat better,” says Khullar.
The result, he says, can be a “bad cascade” that begins with prediabetes and progresses to diabetes.
Treating sleep apnea, however, he suggests, “can spur a good cascade.
“There are a lot of studies showing that sleep loss or fragmentation can increase insulin-resistance and glucose-tolerance impairment.”
Eating, especially, seems to be key to preventing diabetes.
A study, reported in the journal Diabetes, showed the Mediterranean diet may help people 50 and over lower their risk of diabetes — even without weight loss or exercise.
Bt that’s not all. “Even if you eat very healthy meals, if you eat too much you will gain weight, which is a factor in diabetes,” the report says.
“Portion size matters.”
The best evidence for the importance of portion size and healthy food comes from veterinarian Bob Clement.
Because we can control what and how much our pets eat and make sure they stay on the correct diet, he says, “we do a better job of maintaining their weight and health than we do for ourselves.”
“Of course, they don’t have to deal with family barbecues or Thanksgiving or Christmas,” Clement remarks. Nor Tim Horton’s.
Clement’s company, Medi-Cal Royal Canin Canada, provides veterinarians with a food for diabetic cats that can reverse their diabetes.
“Cats on insulin have been able to come off it,” he says.
Stress test
Inside the Diabetes Prevention Care Kits that Flemingdon Health Centre will be distributing is a squishy rubber ball.
It’s easy to understand how other components of the kit are intended to prevent or delay the disease that affects 14 per cent of South Asians, a community that makes up almost half of the population served by Flemingdon.
The incidence of prediabetes is 11 to 12 per cent.
The kit includes a booklet and video in languages spoken by South Asians, a pedometer, measuring spoons and a tape for measuring your waits. The items are meant to emphasize the importance of diet and exercise.
The squishy rubber ball is interesting because it points to something that does not help people at risk of developing diabetes, yet is often overlooked.
“The stress of the settlement process is a big, unacknowledged factor” in the prevalence of diabetes in the community, says Neil Stephens, program coordinator of the South Asian Diabetes Prevention Program at Flemingdon.
The stress ball is intended to help with reducing tension.
“South Asians generally come to Canada healthy,” says Stephens.
But people who experience stress often tend to eat more and to eat less healthy food. And South Asians who come to Canada find they have greater access to unhealthy food here and reduced availability of fresh fruits and vegetables.
Although some research suggests that stress hormones can increase blood glucose levels directly, not all agree.
Dr. Bernard Zinman, a renowned diabetes specialist at Mount Sinai Hospital, believes stress and mood disorders are a major factor leading to diabetes, because people who are depressed or stressed, for example, tend not to exercise or to eat regular, healthy portion-controlled meals.
“It’s never been demonstrated conclusively that psychological stress leads to deterioriation in sugar control in the blood,” says Zinman.
“Medical stress, such as a serious infection or major surgical procedure, have clearly been demonstrated to contribute to diabetes risk, and worsen diabetes control in those individuals with diabetes.”
Judy Gerstel