( By Dr. Krishna Murari Modi )

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2-No Sugar Please, We are Diabetic

In diabetes mellitus, the body cannot use sugar normally. In diabetes insipidus, the pituitary gland or hypothalamus, a part of the brain, does not function normally. The leading cause of death in India is diabetes mellitus.The body of a diabetic person cannot make normal use of sugar, and so sugar builds up in the blood. The kidneys discharge some of the excess sugar in the urine. In severe cases of diabetes, fats and proteins cannot also be used normally. Most physicians once believed that all cases of diabetes were caused by a lack of the hormone – insulin –which is produced in the pancreas and enables the body to use and store sugar.

Many diabetics especially those who become diabetic, after the age of 40, have normal or even above normal production of insulin. But their bodies do not respond efficiently to the insulin. This is "Type II" diabetes and is a miler from. Symptoms of diabetes are excessive urination, great thirst, hunger and loss of weight and strength.

The "Type I" diabetes strikes some people so suddenly that the lack of insulin causes an emergency condition called diabetic ketoacidosis. There is excessive urination, thirst, loss of appetite, nausea, vomiting and difficulty in breathing. If the victim is not treated promptly, he may go into diabetic coma, with fatal results. Most "Type I" diabetics follow carefully planned diets consisting of measured amounts of carbohydrates, fats and proteins. The "Type II" diabetes can be controlled by a diet low in calories. The nerves can be affected by diabetes leading to a loss of feeling or abnormal sensations in different parts of the body. It can cause stroke, heart failure or gangrene.

Diabetes Mellitus
Is it a disease of the rich? The affluent western world has more cases of diabetes than the third world countries. Urban population has more cases of diabetes than the rural population. The urban rich have more victims than the urban poor. Affluence leads to eating rich food, less physical labour, and more mental tension: an excellent breeding ground for diabetes.

Diabetes mellitesis is derived from the word mellitus which means honey. So the name diabetes mellitus is given when the urine is sweet like honey. The glucose level in the urine and blood is high. A high level of blood sugar is due to deficiency of insulin the hormone which facilitates the sentry of glucose in body cells. This occurs when the pancreas fails to produce sufficient insulin of due to antibodies which are formed in blood which interfere with the normal functioning of insulin. In either case there is a high level of glucose in the blood. When we consume more sugar, more insulin is produced to check the blood sugar and does not let it go higher than normal level. If the pancreas is overburdened for a long time due to increased consumption of sugar it starts failing. Some volunteers were given a high sugar diet for 14 days and in one-third of the number the insulin level in the blood rose. It proved that there is a group of people who are more prone to diabetes if they consume more sugar. Few have a high glucose level and it is easy to identify them. When there is early diabetes and the glucose level is not so high, then we have to perform a special test called glucose-tolerance test. Blood and urine are tested for glucose early in the morning before food. Later 75 grams of glucose are given by mouth and blood samples collected at half hourly interval for 2 ? hours.

Minutes Normal levels of Blood Glucose level (in mgm/100 ml)
0 90
60 160
90 140
120 120
150 100

A fasting blood level of over 120 mgm/100 mg. would establish diabetes. In cases where fasting blood sugar level is over 140 mgm/100 ml. after 2 hours after taking in 75 gm glucose then the person is said to be diabetic. The fasting blood level sugar can reach upto 250-300 mgm/100 ml in severe cases. Even a level of 450 mgm/100 ml has also been recorded.

Our Profess of Medicine, at the college, Dr. B.K. Gupta stressed in his opening remarks on diabetes "if you know diabetes you know your medicine" Medicine is a vast subject which includes all diseases of the body. Diabetes can aggravate any disease of the body, cause complications and make it more difficult to cure.

Diabetes generally appears as polyuria (frequent urination), you may have to get up a few times for urination in night, polydipsia (increased thirst). It may cause itching of vulva in women and inflammation of the glans penis in men. You may lose weight inspite of normal or increased appetite. You may have aches and pains in the body, weakness, a boil or carbuncle of skin which does not heal rapidly. You may have variety of infections like tuberculosis, infection of kidney (pyelonephritis). You may have retinal detachment or even loss of vision, may develop infection in the feet which may turn into gangrene and require amputation if the disease is not checked in early stage.

There is an increase in still births of pregnant women in a diabetic condition. The child born could be heavy (death of the baby within 28 days after birth). It may cause amenorrhea (stopped periods). Diabetes can complicate arthritis. You name any problem of the body and diabetes could be there to complicate the situation. It is always essential to check for diabetes if a person is suffering from any ailment and is not recovering fast, particularly approaching 40 check for diabetes every year.

Diabetes can be treated effectively with the co-operation of the patient. If you have a high glucose level in the urine and blood the first and most important thing to do is to control the diet. Cut down sugar completely if you are a clear cut diabetic case. This will bring down the sugar level to some extent, increase physical activity, do walking, jogging, exercises and if sugar is still high then probably you will need some medicine for the time being, but it you supplement the effort with controlled diet and increased exercise you can gradually cut down on medicine and be able to completely stop it in most cases.

In England people used to consume only 18 lbs of sugar per head per year (till 1850). Now the per consumption has reached 90 kg. per head in UK and 80 kgs. in the USA. Figures for others are not available.

Eminent professor of nutrition in the London University, Dr. John Yudkin said that this great increase in the consumption of sugar has come so quickly measured on evolutionary scale, that the humans had no time to adapt to it. He infers that due to increased consumption of sugar there is a great increase in heart disease and diabetes.

During World War I and II the sugar consumption declined due to rationing and there was marked decline in diabetic mortality. Nutritionist, Dr. Yudkin showed the relationship between the high sugar consumption and diabetes in 22 countries.

Since the time sugar and white bread have been introduced the incidence has increased. These refined carbohydrates are pinpointed as causing unprecedented increase in diabetes and heart diseases. On the food front – things are slipping from our hands. We have to gear up our energy and try to reverse the process by changing the food habits. The best part of diabetes is that even if you have it, you can have a normal active prolonged life if you keep tabs on your sugar level through regular check-ups.

Diabetes can attack the kidneys, heart or any of the vital organs of the body and cause the end of a useful, productive and purposeful life. Since most diabetic are over weight, reductive and weight is advisable. This can be done by reducing the number of calories consumed per day. This will benefit to decrease the sugar level in blood. Exercise will be an added advantage as it increases the use of calories and reduction of weight will be faster.

The average amount of calories spent by a sedentary worker is 30 kcal/per kg bodyweight per day. 25 kcal for basal metabolic rate and 5 kcal for physical activity. If physical activity is increased without changing the diet, the use of calories will go up and the weight will reduce.

The fat deposits are always there in fat people. The fat tissue is an inert mass and does not participate in the activity of the body. Greater the fat deposit in the body less will be the calorie requirement per kg body weight.

If you take less calories than normally required you will reduce the weight. It is always advisable not to cut down calories drastically. It is better to have a slow weight loss for a prolonged period than to reduce drastically in a short period. If you restrict calories (food) to a modest degree your energy will be maintained, you will be able to carry on routine work and take exercises also. It is important to decide the source of calories. The food taken must be balanced and there should be good psychological support.

To lose weight is not a big problem. But to maintain it at the desired level is difficult. Less calories you take, bigger the weight loss. The diet should be restricted in calories but full of vitamins and micronutrients. In an obese person the diet can be low calorie diet but it should be nutritionally sound. This can be done in a health farm as you can get easily a supportive environment. At home there will be need for a lot of motivation and regular visits to the physician.

The level of glucose in plasma (the liquid part of the blood) starts going down as soon as we go on calorie restrictive diet, even before there is significant weight loss. The glucose level achieved can be maintained on calorie restricted diet.

Generally the diet recommended should have a lot of green vegetables, salads, fruits, sprouted grains, crud, pulses and chapatis. Concentrated high calorie food should be avoided like cheese, butter, ghee, sweets, samosas, bhajias, sugar, ice creams, cold drinks and alcohol.

Different fruits with sprouted grains on different days for breakfast and salad, green vegetables, curds and chapatis for lunch are ideal. Some fruits in the afternoon or a glass of juice. The dinner could be the same as lunch. Fruits can be used freely, except bananas. In the mornings a one-hour brisk walk. Yoga-asanas in the evening are important. Bowels should move well and if needed a plain water enema can be used.

The response to the diet in the lowering of blood sugar is faster. It takes longer in chronic cases. In patients with high fasting blood sugar (above 200 mgm/100 ml)on a diet as low as 300 kcal diet per day is useful for bringing down blood sugar level and for weight loss. The weight loss is a source of moral support to patients and they are motivated easily.

How the low calorie diet brings down blood sugar may be explained: As the patient loses weight the production of glucose by liver is slowed down. Insulin resistance comes down with the increase in the number of insulin receptors. The insulin action becomes more effective and the secretion of beta cells is increased.

When the patient is given a low calorie diet, the calories are distributed throughout the day, evenly in major meals. The body should not be loaded with calories in one meal. This is essential as the metabolic activity of the body is impaired in diabetes. If the blood sugar is high, insulin or other anti-diabetic drugs may be needed and then the time of meals should be adjusted according to medication.

The quantity of the drug is gradually reduced as the blood sugar level goes down and in most cases it can be completely withdrawn. A regular check of blood sugar level and regular consultation with a physician will be necessary for this purpose. In adult diabetics, the insulin secretion is still present and as the low calorie diet proceeds in can be stimulated further and the need of the drug will no more be necessary.

Carbohydrates should be spread throughout the day in all meals and liberal quantities of all fruits including dates and bananas could be added, if sugar levels are not very high. Avoid refined food, like sugar and white bread. Take plenty of complex starches, found in small quantities in lentils and plenty in rice, wheat and potatoes.

You are allowed to have potatoes, wheat and rice even if you are a diabetic. These carbohydrates are complex starches. Root vegetables need not be restricted at all. Fruits can be taken in plenty, they hardly play any role in raising the blood sugar level and they do not need insulin for their metabolism. Fructose (sugar found in fruits) is absorbed from the gastrointestinal tract more slowly than sugar and is taken up and metabolised by liver. By this non-insulin dependent mechanism the liver fructose is ultimately converted into glycogen and tryglycerides.

You can be liberal with fruits even sweet fruits like grapes, chikoos and mangoes. You can take a glass of fruit juice with beneficial effect. Fruits are always preferred to fruit juices. If you eat apples or carrots you are taking in a lot of fibres along with the juice. A few carrots or apples will give you ample supply of fibres for the whole day. When you have juice you remove all its fibres. Add liberally fruits in all the meals.

Fibres should be plenty in the diet, they are the constituent of food which the body does not absorb. They are plenty in green salads, vegetables, fruits, in bran of rice and husk of wheat, also in unrefined carbohydrates and complex starches. The sugar raising quality of carbohydrates is much reduced if there are plenty of fibres. The fibre is a friend of the digestive system. It forms a gel in the digestive system which slows down absorption of sugar. So the sugar level of the blood is more steady. It cuts down the absorption of fats and so the bowels move speedily and clearly. Fibres promote good health. Generally one item is proved good for one disease only. But fibres have proved beneficial in many diseases of modern time e.g. diabetes, heart diseases, cancer, gall stone and obesity.

There are two types of fibre

  • Those found in fruits and vegetables called pectin. They help bring down cholesterol and glucose level in the blood.

  • Fibres found in whole grain (wheat bran, wheat germ), tone the intestine for quick elimination. They protect us from constipation, haemorrhoids and cancer.

The first man to advocate fibre was Dr. John Harvey Kellog, founder of Battle Greek Sanatorium, michigan, U.S.A. He preached the "benefit of roughage", as he called it. This was by turn of the century. But it was not taken seriously in the medical world till the 1960s, when Surgeon Captain T.L. Cleave of British Royal Navy attempted to develop the concept in a more fashionable manner. He was struck by the fact that few diseases common in the west were not common in third world countries, like diabetes and heart diseases. He concluded that the growing consumption of refined sugar and white bread was responsible for it. Refining carbohydrates has several consequences one of which is the removal of fibres.

This has an undesirable effect on digestive and circulatory systems. When the fibre diet is taken, absorption of nutrition is slowed down due to following reasons: Gastric emptying is delayed and overall absorption and digestion of carbohydrates is slowed down. In Western diets a large amount of fibres, need to be added. In the Indian diet high carbohydrates and high fibres are naturally available. This is why the Indian diet is far superior to that of the westerners for prevention of many diseases. Several adaptations to food health requirements are to be made here and there. The average Indian diet contains 60% carbohydrates, 20% proteins and 20% fats, according to a study conducted by Prof. Vishwanathan and a team of diabetologists at the Diabetic Research Center (Madras) over a period of 25 years.

It shows that high carbohydrates-high fibre diet is ideal for diabetes. The Indian diet is mostly vegetarian and cereal based. In the western diet the fibre content has to be increased by adding gaur gum, bran and other sources of fibre, but the Indian dietary pattern, cereals and pulses are a natural source of high fibre. We only need to stop refining food, stop using white flour (maida) and sugar which is refined food with no fibres. All non-vegetarian foods do not contain fibres. So a vegetarian diet is better for diabetes. We need to cut down using oil, butter and ghee. Extra large quantities of salads, green vegetables, wheat with bran and impounded rice are strongly recommended.

The West is suffering most because the diet consists of less fibre. The diet has non-vegetarian foods (no fibre) fats (no fibres), milk products (no fibre) and sugar (no fibre). Children and pregnant mothers need not take high fibre diet. Children and pregnant mothers need more nutrition and fibre food is only high bulk food. To guide a patient regarding his diet to which he will adhere for life is a complex job. This will need considering the life style, economic status, food preferences and social pressures.This will also need special training on the part of a physician to guide his patient to the satisfactory goal which is when the patient can eat to his taste and satisfaction. The doctor is then happy that he could include a diet where the fibre content is large.

Stress can be a causative factor for diabetes. Many a times diabetes is detected after a stressful event. Stress increases the sugar level in the blood in the diabetics. Due to stress, the hypothalamus in the brain is stimulated, which in turn stimulates the pituitary gland. This discharges a hormone: ACTH (Adeno-Cortico Trophic Hormone) in the blood. ACTH stimulates the adrenal cortex to secrete more corticoids to increase the level of sugar in the blood. Modern life is full of stress and strain and the relaxation techniques will help the diabetics.

In diabetes mellitus there is always the production of insulin in the pancreas. But either it is insufficient or it is not effective due to the formation of antibodies. They can be controlled in most cases by diet and exercises only. There are other conditions where the production of insulin may completely cease as in the case of cancer and infection of pancreas. Here the patient will need insulin alongwith diet control.

In a few cases, diabetes may develop in childhood, juvenile diabetes. There is no insulin production in these cases. These children are always underweight. So the diet must have sufficient calories. They cannot be controlled without insulin. The insulin injection and food timings are so adjusted that the intake of food coincides with the optimum level of drugs in the blood. These patients are much fewer in number than those with diabetes mellitus. Diabetes mellitus affects 2-4% of the total population, whereas 2% of the total diabetic patients are juvenile diabetics. Juvenile diabetes, if uncontrolled, can develop into ketosis. In extreme insulin insufficiency ketone bodies are released in blood and there by pass out it urine. Such a patient feels unwell, may develop nausea and vomiting and abdominal pain. Subsequently becomes drowsy and goes into come. The condition is fatal if left untreated.

In 1970 it was bound by a research organisation called University Group of Diabetes in U.S.A., that oral drugs which reduced the sugar level in blood increased incidence of sudden death is mild diabetics. The hope that these drugs would be a salvation diminished. These drugs should be given only when diet and exercise have failed to control the disease. In severe diabetes, insulin is given atleast initially and then switched on to oral drugs.

It is given by injection, just under the skin. It is short or long acting and can be combined in one injection so that it will suffice for a whole day. During pregnancy and in case of a diabetic child there may be need for higher doses twice daily. Exercise will reduce the insulin requirement.

Patients may have a hypoglycemic reaction when the sugar levels reaches levels lower than required. If the patient misses a meal after taking insulin or when diabetes is not properly controlled. These patients should carry sugar cubes or biscuits and eat them when such a situation arises. There can be absorption of subcutaneous fat at the site of injection, skin rashes, fluid retention and visual disturbance.

Oral Antidiabetic drugs
They are sulphonyl urea drugs and include tolbutamide, chlorpropamide, acetohexamide, tolazamide and glybenclamide. They are given only when diabetes is not controlled by diet and exercise. This drug acts on pancreas and stimulates it to excrete more insulin. It is to be given 2/3 times a day. An American study suggests that tolbutamide has failed to prevent the disease and even made it worse. It may cause the lowering of sugar to levels much lower than required and this may affect the brain.

Eight hundred patients taking oral anti-diabetic drugs were researched for 3-8 years. The study showed that during this period 89 patients died. The moral is: dietic control is definitely better, try hard to avoid drugs. The side effects may be serious if the patient is for a long time on this drug. There may be allergic reactions. It increases intolerance to alcohol and causes facial flushing. They may cause blood dyscrasias.

Biguanides like phenformine and metaformine drugs have been prohibited in the United States by Food and Drug Administration. Side effects are loss of appetite, nausea, vomiting, diarrhoea and lactic acidosis. 10 to 20 percent patients do not respond to oral agents and treatment is termed as primary failure. Few patients respond initially. They cease to respond in one or two years. New onset of disease responds better than old standing diabetes.

In the case of mild to moderate diabetics (fasting sugar 140 to 230 mgm per 100cc) dietary regimentation should be tried first. If it cannot be controlled by diet then oral drugs can be added. The problem is greater if fasting blood sugar level is more than 230 mgm/100cc inspite of dietic control. These patients are first given oral drugs and if this fails then doctors take recourse to insulin. When diabetes is controlled the patient is put back on oral medication.

Drugs cannot take the role of diet and exercise. With exercise and diet your expectancy of youthful years will not reduce. If you are careless, cannot control yourself, cannot push yourself to doing exercise or you do not have enough determination to stick to the right diet, then you are taking a great risk. The time you know you are diabetic, gather courage and compel yourself to change the way of life. It is not an easy task because you have lived in a particular style for years and being used to it, it is difficult to give up old habits: the food you eat, the routine work you do, the tension you take on. These are the way you have been used to. You have lived this way and got your diabetes.

If you are a diabetic you must exercise vigorously. If you are old cannot do exercise, then at least you must walk morning and evening one hour each time. A one hour walk at least in the morning is a must. Stop refined sugar or sweets completely. Have fruits and sprouts on different days. Take boiled vegetables (preferably 250 grams), salads, curds and dry chapati for lunch and dinner. Take fruits in the afternoon. By cutting on oil, ghee and sugar, you will reduce weight. Even before the weight starts falling, the sugar level begins decreasing. Maybe for a few days you will feel weak due to cutting down on calories but in 2-3 weeks you will get more strength and energy to walk longer distances. In two to three months the blood sugar will come to normal, if you are mild to moderate diabetic.

If you are highly diabetic, oral antidiabetic drugs will be necessary. But you can drop the drug in 6 months to one year time if you stick to routine. Once you have reached the normal blood sugar level, the most difficult task starts. Because you will be tempted to return to old ways of life, old type of food and the old sluggish life. This is the critical time when you have to be strong. If you are carried away by the craving for good food etc. your sugar level will rise again and all the hard work will be wasted. Stick to the new diet and routine which has brought down the sugar level, and if you continue for a year or two, it will become a habit and you will remain cured for ever.

Many a time when the patient goes for blood test he is told that his sugar is slightly high. The patient comes back with the impression that there is nothing wrong and he need not worry and that he can carry on with almost the same diet with little restrictions. It is not true. The diet should be restricted completely to bring down the blood sugar to normal. It should not be allowed to cross the normal level of blood sugar. Such a patient should have a regular check of blood sugar, at 6 months intervals or at least once a year.

Many patients to vigorous dieting when they have detected that they are diabetics. Unfortunately, once the sugar level comes down they feel that they have been cured and start eating everything. They do not bother to check their blood sugar again. Once a diabetic, always a diabetic. after brining down the sugar level by dieting, do not start gobbling all sorts of food because the sugar level will climb in no time. Regulate your dietary habits for good.

There are many patients who do not bother to restrict their diet and keep on taking drugs. If they go for a celebration they try to counter the sugar increase by swallowing a tablet. This is not good at all, if you want to prolong life and enjoy a healthy life. Restrict your diet to bring down the sugar level to normal, supplement it with a drug if sugar level is still too high. If you depend on drugs only, these will shorten life and cause harm. Stop regretting and beating the chest that you got diabetes. May be you are lucky. Diabetes has given you enough time to mend you ways. It is better than having a heart attack or cancer ailments which hardly give any time to mend the ways, even if you are willing to do so.