Friday, March 25, 2016

Diabetes – The 800 Pound Guerilla Among Diseases
It’s no contest.  Among diseases, diabetes is the 800 pound guerilla.    
 In the U.S., 86 million are at risk for diabetes.  Medicare spends 1 of 3 dollars on diabetes related conditions.   One of 3 adults has prediabetes.  And diabetes is the cause of 2 deaths every 5 minutes in American. Directly or indirectly,  diabetes is the leading cause of deaths heart disease, stroke, obesity,  blindness, kidney failure, gangrene with amputations, neuropathies,  and diseases of large and small blood vessels.
Because of these stark statistics,  Medicare is spending $11.8 million dollars for grants to launch counseling programs for prediabetics in YMCA across the country. The programs will feature a lifestyle  coach who will advise patients on more physical activity, better diets,  weight loss as preventive measures.  Meetings will be held once a month  to see if patients are adhering to preventive measures.    The hope is that an ounce of prevention will be worth a pound (with prediabetice many pounds) of cure.
Diabetes is a sneaky disease. People go for years without knowing they have disease or are at risk for having it.  Its most common precursor is obesity, which in now rampant among Americans.  More than one-third (35.7 percent) of adults are considered to be obese. More than 1 in 20 (6.3 percent) have extreme obesity. Almost 3 in 4 men (74 percent) are considered to be overweight or obese. The prevalence of obesity is similar for both men and women (about 36 percent).
Diabetes  is guerilla disease.   It  can strike any organ or any limb containing  small  and large blood vessels – arterioles, capillaries,  small and larger arteries – which is everywhere in the body.   It  carries with it other harmful metabolic substances – such high blood sugars,   out-0f-control blood fats.   It is often insidious,  leading to slow blindness, or kidney failure,  or subtle neuropathies with pain,  tingling,  or loss of sensation.   But it can be dramatic as well,  causing heart attacks, strokes,  seizures from hypoglycemia,  or coma from excessive blood sugar levels.
This is not the first time I have written about diabetes as a guerilla disease.  
What follows is a blog I wrote in 2013.
JUNE 8, 2013
Diabetes – A Disease of Overeating
We are digging our graves with our own teeth.
Thomas Moffet (1820-1908), Irish Poet and Educator
It today’s world, many more people are dying from overeating than from starvation.
Jesper Hioland, Senior Vice-President  Novo Nordisk, world’s largest maker of diabetic drugs
Prosperity has its price.  In the realm of disease, that price is diabetes.   The price of diabetes -  blindness, gangrene, amputations, kidney failure, neuropathy,  diseases of large and small arteries, and premature death.   Among the world’s peoples, 371 million have diabetes.  Many of these people are in poor and developing countries where people are adopting urban lifestyles and consuming western foods.
Diabetes  is rampant in American Indians,  immigrants to America,  Pacific Islanders, Arab countries,  and in Vietman.  Today’s New York Times features an article “Prosperity in Vietnam Carries a Price; Diabetes.” 
The price of diabetes  in Vietnam is an epidemic of amputation  of gangrenous limbs.  Diabetes is a disease related to genetic predisposition, rich  diets,  lack of exercise, and obesity.   In Vietnam,  diabetes occurs in both the fat and the thin, and afflicts especially those who move from the country into urban areas.  In the U.S, diabetes in more prevalent in obese,  sedentary individuals.
Diagnosing and treating diabetes is like guerilla warfare.  Diabetic guerillas can strike at any time in unexpected locations in almost any organ in the body, often with little warning.  You can be born with it, but more often it comes later in the life in the form of type 2 diabetes.   In the morbidly obese (those 100 pounds or more overweight),  you can treat it surgically by shrinking  or partially bypassing the stomach.
Controlling diabetes is medical guerilla warfare.. You have to approach it from different directions – high tech and high touch, prevention and maintenance. Many high tech approaches, which are essential disruptive innovations – insulin, inhaled insulin, insulin-pumps, monitoring devices, other drugs, and transplants – have been tried and work for many but often fail to stem the tide of complications.
But   For most doctors, controlling diabetes demands attention to preventive details and instructing patients ( To get the attention of his patients, Stanley Feld, MD, an endocrinologist in Dallas, had his diabetic patients sign a contract saying they would either abide by his rules or not be his patients. He also issued patients T-shirts bearing the words: “In Control!”).
For doctors, prevention entails,

•Precise blood glucose control.

•Inspecting the bottom of patient’s feet – something many obese diabetics can’t do for themselves.

•Assessing loss of sensation in feet and lower limbs.

•Monitoring blood pressure.

•Checking blood lipids, blood creatinine  and creatinine  clearance, and urinary albumin.

•Protecting the kidney with new drugs.

•Making sure patients take oral diabetic agents and insulin correctly.

•Instructing patients on proper diets and having a nutritionist or dietician re-enforce their message.

•Encouraging patients to lose weight and exercise (obesity is considered the main  precursor to most adult diabetes).

•Managing complications – blindness (the leading cause of adult blindness), heart disease and stroke (causes 65% of deaths among diabetes), kidney disease (accounts for 44% of case of kidney failure), and amputation (more than 60% of lower-limb amputations occur in diabetics).

Among diabetics and their physician friends, there are few miracles, because old habits are hard to break, and treatment regimens are hard to follow. But there are disruptive innovations on the horizon. Until these disruptions mature and take hold, the physicians’ best bet for controlling the vascular catastrophes associated with diabetes is strict adherence to best practice guidelines and rapt attention to clinical details.

Diabetes is reaching epidemic levels in many countries  due to overeating and life style changes relating to urbanization.

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