Diabetes: the heart and blood vessels

Maintaining blood sugar levels is not what concerns a cardiologist primarily. This is the province of the endocrinologist. Cardiologists are more concerned about the effects of chronically elevated blood sugar.

When the pancreas malfunctions, there is insulin deficiency, and blood sugar rises, sometimes severely. These issues are very well studied, and has been addressed with the use of insulin injections (discovered by Dr F. Banting and Charles Best in 1921) and also the drugs that work primarily in stimulating the pancreas to produce extra insulin, like glibenclamide.

In the 21st century, we have obesity by the ton, forgive my pun. Obese people can have high levels of insulin and yet high levels of blood sugar. This paradox was initially puzzling but we now know that the potbelly produces substances that cause the body cells not to respond to insulin. In our language, obesity causes insulin resistance.

This truncal obesity, together with hypertension, insulin resistance, high triglyceride and low HDL-cholesterol, form a syndrome that we call the "metabolic syndrome", truncal obesity being the main component of this cardio-damaging disease.

The potbelly is a very active organ (not as docile as it may seem), producing hormones and chemicals that cause insulin resistance, diabetes and hypertension and these two in combination severely aggravate heart disease.

Persistent high insulin levels, as often occurs with insulin resistance, changes excess blood sugars into fats, and this further aggravates the potbelly.

Hence, a potbelly begets a potbelly. What�s worse, the persistent high blood sugar causes the blood, blood cells and also the artery wall cells, including the heart, kidney and brain arteries, to be sticky. This promotes blockages in the artery wall.

Therefore, although pancreatic malfunction causes one type of diabetes, obesity and potbelly, very much a 21st century disease, causes another type of diabetes, which comes with hypertension. This latter variety is highly cardiac and blood vessel damaging.

To reiterate, obesity causes insulin resistance and fat metabolism disorder, which in turn causes hypertension and diabetes mellitus (metabolic syndrome), which in turn causes coronary artery disease. When we should be sitting on our fat, we are allowing the fat belly to sit on us and cause us all these problems. Now this bothers cardiologists, a lot.

Complications of diabetes

The saying is true that no one actually dies from diabetes itself anymore. The pre-insulin days where patients waste away from severe high blood sugar and diabetic coma is nowadays a rarity with the advent of insulin. That's why, I guess, Dr Banting and Best won the Nobel prize for Physiology in 1925.

Patients with diabetes nowadays develop kidney, eyes, brain and nerves, and heart and blood vessel complications. In fact all the diabetic complications are blood vessel related. Small blood vessel damage leads to eye problems, kidney disease, kidney failure and nerve damage. Bigger blood vessel damage leads to strokes, CAD with heart attacks and poor limb circulation resulting in amputation for some.

Eventually diabetes translates to cardiac and vascular disorders as blood vessel walls thicken and get clogged up with sluggish circulation and damaged blood vessel wall cells.

Yes, main target organs can be damaged, resulting in complications like kidney failure and renal dialysis, blindness, strokes, heart attacks, angina attacks, angioplasties, bypass surgery, limb gangrene, poor healing wounds and limb amputations.

What is also important to emphasise is that once you are afflicted with diabetes, your risk for every medical illness becomes worse. Even common cough and colds take longer to recover in diabetics, and is more likely to be complicated.

The bbcnews.com recently reported that obese people suffer more complications following motor vehicle accidents. It is as if diabetes weakens your whole body. All cardiac procedures carry a higher risk of complications and the outcomes tend to be worse, in the short and long term, be it angioplasties, or bypass surgery.

Management of diabetes

For those who are already diabetic, please realise that your life is in your hands. Proper treatment by qualified medical practitioners can do much to delay or even avoid complications.

A careless attitude and non-compliance to medical treatment invariably results in worse outcome and target organ failure.

The drugs for the insulin deficient type of diabetes is a little different from the drugs used for the obesity, potbelly type of diabetes. There are very good drugs for both types as our understanding of the disease has improved tremendously.

We have drugs that will help the pancreas to produce more insulin, like the sulphonyl ureas, and insulin injections (for the insulin deficient kind) and drugs that sensitise the cells and tissues to insulin, like the biguanides and "glitazones" (for the insulin resistant kind).

Soon we will have a nasal spray insulin for easier administration. There is also an anti-obesity drug about to be launched that promises to make subjects lose weight and lessen the risk of heart disease, acting through a new body system called the Endocanabinoid system. Interesting. Help for the potbellies is on the way.

Prevention is better than cure

But drug treatment for diabetes, though good, is not the best strategy, both for the patient and for the nation. It is much, much better that diabetes, especially the metabolic syndrome (potbelly type), is prevented.

Potbelly is invariably the result of eating the wrong food and a sedentary lifestyle. This is the age of computers and the remote control. We want instant gratification, without ever having to move from our seat in front of the big, flat screen. We do not exercise enough. We love the elevator, even to go up one to two floors, rather than use the staircase.

Cycling to work has been suggested as a way to overcome this problem. Well, let us see how many will follow. We love junk food. Fast food, almost synonymous with junk food, is springing up all over the place. French fries are many a child�s regular diet. Add to it salt and a sugar-rich carbonated drink, you have the classical diabetic, hypertensive diet.

We have identified some of the problems. Prevention then is relatively easy, but involves sacrifice. Promoting a low salt diet (3 gms a day), with avoidance of carbonated drink would be a good start.

Fruits and vegetables are healthy and should be encouraged. White meat is preferred. Except for service lifts, and lifts for the handicapped and infirm, lifts should go to every third floor. Remote controls for TVs and radios should be banned. Regularly walk 15km a week. Have regular check-ups. All males above 40 years and all females above 50 years should go for a medical checkup.