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Weighing Up the Risks - Look After Yourself
VEGA returns to diabetes and Syndrome X
to reinforce our alert to readers of the insidious bodily
damage that can occur with signs unnoticed or ignored until
irreversible harm sets in and is diagnosed. The effects of
diet and use of drugs will be of special interest to veggies.
Prevalence of known diabetes in the total UK populations
is about 2.8%, probably half the actual figure. The UK is
about 10 or 15 years behind N America in the epidemic, where
evidence of Jumbo Bumbo and other signs of overweight and
insulin intolerance abound in a national scourge. Authorities
in the UK are working to avert a similar drift into degeneration
and misery under the lure of excessive consumption of all
commodities, but especially of junk foods, which may exact
a higher toll of human misery than vCJD from BSE in cattle
(and, possibly, sheep).
In the Indo-Asian population the prevalence rises to 20%
in the 40 to 75 age group. While the microvascular complications
of diabetes (retinopathy, nephropathy, and neuropathy, i.e.
disorders in eyes, kidneys, and nerves) contribute to considerable
morbidity, it is the macrovascular disease (i.e. of the major
vessels of the cardiovascular system) that prematurely kills
75% of patients with diabetes. Patients with diabetes and
glucose intolerance comprise 17% of the population with coronary
heart disease. Diabetes mellitus can be defined as an infliction
characterised by premature and accelerated cardiovascular
and microvascular disease and chronic hyperglycemia.
McDonalds, Burger King, and Kentucky Fried Chicken are likelier
terrorists inducing curtailed life in the USA than the lately
notorious agents of death. A glut of slimming regimes of dubious
reliability and safety has erupted, with dire consequences
among people inclined anyway to rigorously restrictive eating
disorders. This influence is heightened by circulation in
countries such as the UK, where the scourge of overweight
and obesity is bad but not yet as severe as in N America and
where patterns of eating out and grazing are grievously following
the American pattern. Some convenience veggy-foods can be
included in these strictures. There’s many a slip between
cup and lip: what’s in the cup – if anything –
and what - if anything – smoulders on the lip?
Type 2 is Numero Uno
In clinical management type 2 diabetes is best considered
as the Insulin Resistance Syndrome, defined as the following
constellation of cardiovascular risk factors: hypertension,
obesity, hyperglycemia, dyslipidemia (low HDL-cholesterol,
elevated LDL-cholesterol, high triglycerides, elevated plasminogen
activator inhibitor 1, i.e. PAI1). VEGA recommends readers
with suspicions of risk to acquire and know their figures
and to discuss them and some others they may deem necessary
with their health advisers. VEGA suggests also a measurement
of uric acid in the blood, a cheap indicator of possible trouble
with type 2 diabetes and gouty symptoms.
Despite a strong public perception to the contrary, cardiovascular
disease (CVD) remains the leading cause of death in women
in the UK: a woman is 5 times likelier to die from coronary
heart disease (CHD) than from cancer of the breast. Moreover
cardiovascular disease (CVD) in women accounts for more deaths
than all forms of cancer put together. Diabetes is a major
risk of CVD (heart attack and stroke) in both sexes, but it
is a more powerful coronary risk factor for women than for
men. An adult woman with diabetes has a risk of dying from
heart disease 3 to 7 times higher than for non-diabetic women,
whereas such a ratio for men is 2 to 4 times. A woman aged
over 45 years runs double the risk of developing diabetes
as a man of the same age. The prevalence of diabetes in the
UK (at about 2.4m people) is likely to double in the next
decade; likewise, the world’s population of diabetics
is set to increase from 150m now to 300m in 2025.
Part of the explanation for the rapid rise in the prevalence
of diabetes is the current epidemic of obesity in developed
countries. In the UK more than half the adult population is
currently overweight, and about 1 in 5 are obese (21% of women
and 17% of men). By the year 2025 the level of obesity in
the UK is forecast to be at 30 to 40% and 40 to 50% or even
higher in the USA. A combination of physical inactivity and
over-consumption of high-fat energy-dense foods account for
this nutritional disaster, which emphasises the split between
the rich and poor worlds and the consequent tension in economic,
social, and political affairs.
Resistance
The association between diabetes and obesity is very strong;
more than 80% of diabetics are overweight at diagnosis, Dyslipidemia
in obesity and diabetics is common and requires (in medical
talk) “aggressive treatment and monitoring”. VEGA
advises people to assess themselves and to consult their medical
advisers before it is too late. Appropriate interventions
include reduced intake of dietary saturated fatty acids, weight
loss, and recourse to plant stanol esters, which can reduce
low-density lipoprotein (LDL-C) by about 14%. Drugs called
statins will reduce CVD “events” by 30% in non-diabetics
and by more than 50% in diabetics. When used in combination
with statins plant stanol esters have an important additional
cholesterol-lowering effect of around 10%. Plenty of dairy-free
spreading fats and products such as yoghurts are now available
in British shops, some emphasising as well their high content
of omega 3 and DHA polyunsaturated fatty acids, otherwise
obtainable in fish oils. Strict veggies won’t resort
to fish oil derivatives (nor will many consumers because of
the taste) and some of the plant stanol (and phytosterol)
products contain lactose and whey, as well as dubious sources
of vitamin D. VEGA is dealing with manufacturers to remove
these obstacles for the earnest veggie.
Tipping the Scales
“Overweight is multifactorial in origin and reflects
inherited, environmental, cultural, socio-economic, and psychological
conditions”, writes Dr Henry Purcell, Senior Fellow in
Cardiology and Director of the Clinical European Studies in
Angina and Revascularisation, and Cardiovascular Pathology
of Obesity research groups at the Royal Brompton Hospital,
London. He acts as editor-in-chief for the British Journal
of Cardiology. He adds that “the roots of the obesity
epidemic, and recent data from a nationally representative
sample of 2830 English children show an excess of overweight
and obesity in children before the age of school entry, with
obesity rates ranging from 10% at age 6 to 17% at age 15 years.
Overweight in adolescents influences a broad range of adverse
health effects in adulthood including certain forms of cancer,
osteoarthritis, and a raft of disorders such as diabetes mellitus,
hypertension, and dyslipidemia, which are major contributors
to CVD. Obesity, invariably associated with a central distribution
of body-fat, is now recognised as an independent predictor
of cardiovascular atherosclerosis, leading to increased risk
of myocardial infarction and strokes”.
Doctoring the Diet
Surgery and medication are becoming so successful that they
allow some of the consequences of bad diets to be overcome.
Many survivors of a myocardial infarct have aspirins at the
ready to prevent recurrence after the surgeon has done his
work. Now the statins have been proven in an enormous 7-year
epidemiological Heart Protection study based at Oxford University
to “leave no room for doubt: they’re the sort of
results you dream of” states the Study’s Director,
Professor Rory Collins (Some of our readers, aged between
40 and 80 may have volunteered as subjects). This is a patented
(until 2003) drug called simvastatin that reduces blood levels
of LDL-C (and thus heart attacks and strokes) by a third among
all those at risk. It helps women and the elderly with heart
problems, as well as diabetics.
Simvastatin also reduced the need for surgery or balloon
angioplasty to clear clogged arteries and the need for amputations
required for blood flow to limbs, usually a result of smoking
(“Smokers’ legs” are a sign of intermittent
claudication). Nor were there any serious side effects, such
as the muscle wastage that last August led to the withdrawal
of Baycol, another statin. But simvastatin doesn’t come
cheap: a year’s course costs £360. There are many
good reasons to avoid beggaring the NHS with expenses of this
sort when the stern resolve of self-discipline and caution
would offer less exceptionable solutions for the common good.
Blockers such as cimetidine and ranitidine have coined millions
for the pharmaceutical industry from a public slipping back
into bad ways as the drugs begin to work. Stomach and duodenal
ulcers persist because of the presence in the gut of an unusual
bacterium, which can be knocked out with antibiotics and thus,
with doctoring and advice, a permanent cure can be achieved,
treating causes, rather than symptoms. However, most importantly,
there are preventable causes that can be avoided by adoption
of prudently enjoyable lifestyles and don’t need offensive
experimentation on animals (although some pets and their owners
share needs for dietary adjustments and medication).
Recent developments require the exercise of insight and self-discipline
affecting people as patients, doctors and health-care professionals.
Compromises abound in the interpretations of the safety, efficacy,
and acceptance of the findings of food technology and care
in what should be fundamentally a national HEALTH Service,
with minimum recourse for ourselves (or the dog or cat, for
that matter) to present for heroic feats of surgery or for
drugs well beyond the means of most of the world’s populations.
What do we advocate for the Africans in the thrall of HIV?
Protesters who normally oppose the use of vaccines and the
experimentation that attends their development importune unabashed
for the greater use of these agents to counter foot-and-mouth
disease in sheep, citing the argument of the least-of-all
evils with the vigor of developers of drugs for rich people
and their pets.
 High
consumption of junk foods and animal fats is to blame for
the epidemic of obesity. In the UK household spending on “healthier”
poultry meat is increasing. The British Heart Foundation made
the point in its submission to the Commission on Farming and
Food that a move toward a more plant-based diet would benefit
the nation’s health as well as the environment.
Fat Plus Sugar – Danger Ahead
Hazy perceptions of “sugar” diabetes relate to
the juvenile, insulin-dependent form that is now much less
common than maturity-onset diabetes, which may not need treatment
with insulin and can be kept under control with changes in
diet and lifestyle (e.g. increased exercise and cessation
of smoking) and, possibly, drugs. The 2 forms, now distinguished
as types 1 and 2, respectively) are broadly differentiated
by the age of onset and by body-size and shape: type 1 as
the lean and hungry and type 2 the fat-and-40 and diet naughty.
There are also genetic predispositions that are complicated
but can be traced in family histories, which are always worth
reconsideration. The fatties at the highest risk are apple-shaped;
development in the
pear-conformation, with the bulk lower, definitely at the
bottom, carries less risk, not just by lowering the body’s
centre of gravity. Overall weight at either site does no good
to the undercarriage of joints in the pelvis, knees, ankles
and feet, and raises the risk of trouble in the lower limbs
(e.g. as osteoarthritis).
The roots of the obesity epidemic often begin in childhood
and the psychological stresses of growing up and finding “identity”
in the changes of fickle fashion. The greed and sloth and
other eccentricities of jolly Billy Bunter and Fatty Arbuckle
have apparently given way to rejections like those suffered
by the poor little fat girl who nobody loves and by the child
whose parents fail to buy them designer trainers. The attractions
of field athletics have given way to disposal of the field
for development and pursuit of the sports on a screen with
joystick in the centrally heated lounge in Acacia Villas.
Evidence that real veggies are lean (but not emaciated) gains
weight. The reputation of sandals, shoes made for walking,
and fresh air can be approved and cultivated. Possession of
a “corporation” bulging behind a waistcoat adorned
with the loops of a watch-chain and dangling medallions is
unlikely to ease acceptance into milieus in which brain power
is now valued more than a surfeit of gut feelings. Desks for
portly mayors and their aldermen were designed with cutaways
to accommodate the worthies’ ample dimensions as they
lowered themselves, with fitting haemorrhoidal care, into
the robust furniture appropriate for the occasion and their
station. The community that will prosper has to have
gravity in the brain rather than in the belly or bum.
What’s Cooking?
VEGA has been in touch with Dr Vinod Patel, Consultant Diabetologist,
George Eliot Hospital NHS Trust, Nuneaton, and Hon Senior
Lecturer in Medicine, University of Warwick, on his alphabet
strategy to head off complications of diabetes and to inform
doctors, nurses and health-carers in a constructive dialog
in pursuit of good health. Some of our readers will have been
guinea pigs in a study carried out at Hammersmith Hospital,
London, where they will have contributed to the language of
insulin resistance and benefits (but not totally) of strict
veggie diets to the consumer, but with little advantage for
“lactovarians”).
Dr Patel’s strategy goes as follows:
Advice. Emphasise adherence to diet and medication, cessation
of smoking, exercise, and weight reductions; also remind enquirers
of the services of dieticians, chiropodists (podiatrists),
and nurses, and emphasise the need for annual reviews and
follow-up. These objectives will require dietary reductions
of over 5% in the obese and of fat consumption reduced to
less than 30% of total-energy intake and saturated fat to
less than 10% of energy intake; fibre intake should be raised
to over 15g per 1000 kcals and exercise (e.g. vigorous walking
to 4hr per week). Many of the interpretations can be worked
out in conjunction with practice nurses or dieticians, such
as the BMI (body mass index), as follows:
- Patients clinically obese have a BMI of 30kg/m² or
more and are at high risk.
- Patients with a BMI of 28kg/m² already suffering
from comorbidities are also at high risk.
- Patients with a BMI under 28kg/m² who are highly
motivated to lose weight or who are finding it difficult
to maintain lost weight are good candidates for advice in
primary care.
Blood Pressure. Aggressive control is necessary if it exceeds
140/80; if complications, such as nephropathy, arise, the
action level should be at 130/80. Patients may hear doctors’
talking in this respect of drugs such ACE-inhibitors, diuretics,
angiotensin 2 receptor antagonists, calcium-channel blockers
and doxazosin. Dietary intake of salt will be assessed, as
well as sources of dietary potassium (which are mainly in
fruit and vegetables).
Cholesterol. Levels to aim at, as maxima, are: total cholesterol
below 5.0 mmole/L, LDL-C below 3.0 mmole/L, HDL-C below 1.0
mmole/L, or LDL-C reduction by 30%, whichever is the greater.
Plant stanol spreads lower LDL by around 10%. Genetic differences
in the population mean that for some people the statins are
ineffective; for other others the plant stanol spreads don’t
work. Fortunately one or other agent is effective in people
with these deficiencies (In N American usage older units are
sometimes quoted for cholesterol as mg/100ml; division of
the number by 40 gives the generally accepted international
measure, e.g. 120 to 200mg/100ml equals approximately 3 to
5 mmol/L).
Diabetes Control. Aim at an HbA1c% less than 7%. This measurement
reflects long-term control, smoothing out day-to-day variation.
In type 2 diabetes insulin-resistance is usually present.
Metformin is a drug deployed in this role, with or without
glitazones (thiazolidinedione drugs). Glicazide and acarbose
are other names that the patient may hear. Glycemic control
needs to be tight in pregnancy. Lifestyle changes will be
included in treatments of impaired glucose tolerance.
Eye Screening. People at risk should ensure that their optician
examines the retina annually, preferably with a special camera.
Untreated diabetic retinopathy can result in blindness. It
can be an indicator of damage to delicate blood vessels elsewhere
in the body.
Feet Screening. Likewise the feet of people at risk should
be reviewed annually by a doctor, nurse or chiropodist (podiatrist).
Neuropathy or ischemia in the feet is an indicator for urgent
medical attention, because the warnings of pain from infected
extremities will not be felt and be overlooked.
Guardian Drugs. Diabetes UK now advocates consideration of
prophylaxis with aspirin against cardiovascular events in
all diabetic patients older than 30 years with or having had
any of the following: myocardial infarction, angina, hypertension,
diabetic retinopathy, peripheral vascular disease, and microalbuminuria.
Other preventive drugs patients may have to consider are ramifril,
lisinopril, and perindopril. Simvastatin must now be considered
as another possibility. Herbalists and homeopathic practitioners
may have products for similar purposes. Well-qualified practitioners
should be consulted for such information. (The statins derive,
like the penicillins, from micro-organisms, and such compounds
may be discovered in plants). Earnest veggies cannot be assured
that the drugs are formulated without exceptionable ingredients
such as lactose.
How Fare Hindus?
“Sattvic (good) people like food which is pure; which
gives health, mental power, strength, and long life; which
has taste, is soothing and nourishing, and which makes glad
the heart”
Bhagavad Gita
(The Song of God) 17:8
There are about 1.4 million Indo-Asians in the UK, of whom
1 in 3 are reckoned to be Hindus. The prevalence of diabetes
in the predominantly Hindu population in the UK runs at about
4 times higher than in the white European population (15.2%
against 3.8% in the age-range 25 to 74 years); a further 16.2%
of the Indian population have impaired glucose tolerance.
An article shortly to be published deals with Diabetes Care
in the Hindu patient: Cultural and Clinical Aspects. It describes
the main adjustments to the diabetes care in the UK as “the
special attention needed to diet, exercise, and advice around
festivals (often combinations of fasting and feast) and specific
advice with respect to CHD risk factors”.
Diabetes mellitus was described in the Ayurvedic texts many
centuries ago and was divided into a fatal condition of childhood
and a state of affluence and obesity in middle age, which
nicely agrees with general modern definitions of types 1 and
2, respectively. Hindu physicians recognised the attraction
to ants of diabetic urine, probably because of its sweetness.
Diabetes was called medh meah (honeyed urine). Diet was involved
in the treatment of the disease, and various herbal remedies
and plant foods, such as the popular karela (the bitter gourd,
momordica charantia) are esteemed for their hypoglycaemic
properties: they suppress gluconeogenesis in the liver and
reduce the rate of intestinal absorption of glucose. Some
greengrocers in the UK sell karela. Commonly-used components
of curries enjoy acclaim on various grounds, including a reputation
for being “good for the heart”; and in some anglicised
versions at least onions and garlic may be included with probable
nutritional benefit.
Hindu patients are likelier to be self-described as vegetarians
than any other group in the diabetes clinic, but only 24%
were found to be consistently (lacto) vegetarian in a recent
census in India. Nonetheless, the numbers and the need for
care and advice engage VEGA, which offers counselling to all
peoples, veggie or not. Coronary artery disease is the commonest
cause of death, and the corresponding mortality is 3.7 times
higher among Indo-Asians in the UK than in the national population.
The Indo-Asian patient with type 2 diabetes at diagnosis is
on average 5 years younger than a comparable population of
white Caucasians. The Indo-Asian population is not homogeneous,
and coronary risk factors vary. Lack of exercise, obesity
(especially in Indians), impaired glucose tolerance, diabetes,
lower HDL-C, higher triglycerides and Lp(a) lipoprotein are
more prevalent in Indo-Asian subjects, who also deny themselves
the cardioprotective effect of safe alcohol consumption. Ghee
or clarified butter is frequently used in Hindu cooking and
is an important source of oxidized lipids that are more atherogenic
than ordinary butter. A study in Leicester found only 8% of
Indo-Asian diabetes patients physically active versus 33%
of the white Caucasian diabetes patients.
Indian communities may be reluctant to admit the danger and
progression of diabetes from “mild” to more serious
decline into the need for insulin, because they perceive it
as a failure of self-care. They aren’t alone in this
shyness, and they may be put off by medical services untutored
in their customs and unsympathetic with the stigma attaching
to the diabetic state and its origins. “Food apartheid”
carries a social stress, which probably exacerbates the problems
and may not be relieved by family, religious, and spiritual
customs, especially when communication in the UK with Hindus
may not be fluent in the languages – Gujarati, Punjabi,
or Hindi – they are familiar with. Hindus generally have
a lower-than-average consumption of meat or they are lacto-veggies,
so they need to watch – even if, regrettably, their advisers
don’t – that some of the medical treatments, e.g.
with the drug metformin, may compromise their vitamin B12
status.
Diabetes care for the Hindu patient enshrines principles
for adoption by all communities. In the UK “eating Indian”
is much enjoyed, even if this anglicised cuisine would seem
odd to a Gujarati family sitting down to their meal in India.
The offerings of most Indian restaurants in the UK have not
benefited much in the transition.
The Universal Message
Diabetes is a scourge increasing worldwide and associated
with affluence and high standards of living, among which consumption
of animal-derived foods is rated highly. The dreaded obesity,
even in children, is rising in China, as the population hastily
“improves” its diet to the N American standards
that experts there and in Europe are beginning ruefully to
abandon – towards diets more in keeping with the physiology
we’ve acquired through the slow processes of evolution.
VEGA’S testimony to the Food Standards Agency and other
organisations emphasizes practicable assessments and reforms
for the common and individual good in communities of varying
customs and cultures.
Specific advice to consumers in the Indian style may be offered
as follows:
- Use less or no ghee/butter on chapattis and naan breads
- Use rapeseed, soya, or olive oil instead of animal fats
in cooking and in dressings and spreadable fats
- Reserve high-fat, high-sugar snacks for very special occasions
(such snacks would comprise jalebis, ladhus, barfi, gulabjambu,
rasmallai, penda). Traditional Indian sweets are atherogenic
“time bombs” comprising one-third, fat, one-third
sugar, and the rest carbohydrate with some protein
- Consecrated foods given out in temples after all services
and after the numerous festivals and feastings-and-fasting
celebrations in the Hindu calendar should be based on fruit
and nuts, rather than snacks high in refined fat and sugar
in the traditional style and abundance, consumption of which
disrupts glycemic control
- Restrict consumption of high-fat fried snacks (e.g. samosas,
kachori, chewdo Bombay mix, etc)
- Avoid adding sugar or ghor to curries and other dishes.
Ghor (unrefined solid brown sugar) is often perceived wrongly
as “healthy” sugar. Unfortunately fat and sugar
combine – as the UK food industry appreciates all too
well – with cheap culinary delights in a marriage in
which they go together like grief and injury.
- High-fat, sugar-rich snacks, such as kulfi, can be made
with artificial sweeteners, such as aspartame. Far better,
lose the sweet tooth without grief and injury.
 Buttering
Up the Customer - Anchor proclaim their “Free Range”
cows eat “fresh green grass all year round” to appeal
to the health- and welfare-conscious consumer.
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