Mystery Mechanism Protects Some Diabetics From Developing Complications

WHY are some diabetics free of complications? Researchers are now asking the question the other way around. They want to know why some diabetic patients do not develop complications. What is protecting them? It seems some people with diabetes possess yet-unidentified factors that reduce the risk for and even prevent them from developing diabetes-related complications, despite living with the disease for decades. If researchers can identify the mechanisms protecting these individuals ‒ who are clearly different because something protects them from devastating complications ‒ then it might be possible to develop drugs that can do the same thing.

I had reported end January that what current research provides is an admission that the fundamental mechanisms that create the environment for the development of diabetes complications are still very much unknown.

One aspect of the disease though that is very well documented is the damage that the disease wreaks on an individual’s blood vessels. Diabetes does not kill the individual but the complications often do.

Among the top of the list of complications is cardiovascular disease, as diabetics have three times of the risk compared to non-diabetics. The small blood vessels are also damaged. Nearly 70 percent of patients would have suffered from kidney damage leading to end stage renal failure. Many others suffer from eye complications, with nearly two percent of these diabetics going blind eventually.

Still, despite decades of intensive research on diabetes complications, the fundamental mechanisms are not yet fully known. Neither it is possible to prevent or treat the damage of the blood vessels that affects a majority of all diabetics.

“The blood vessels and other organs of the body are sugar coated and become stiff. It is reminiscent of a premature biological aging,” says Peter Nilsson of the Lund University Diabetes Centre in Sweden who isstudying diabetics with no complications in Sweden.

A just-published study conducted by the Joslin Diabetes Center on people who have lived with type 1 diabetes for more than 50 years presents a strong case for the existence of a protective mechanism in some individuals that allows them to live relatively free of the problems typically associated with long-term duration of diabetes. These mechanisms, the study found, may be different for microvascular (such as kidney, nerve and eye disease) than macrovascular complications (such as heart disease).

A press release issued by the American Diabetes Association yesterday quotes lead researcher George King, Chief Scientific Officer of the Joslin Diabetes Center and Professor of Medicine at Harvard Medical School saying: "If we can identify what constitutes this protective mechanism, we have the potential to induce such protections in others living with diabetes…That's huge."

The Joslin researchers looked at 351 U.S. residents known as the "Medalist" cohort and found that a subgroup of people who had lived with type 1 diabetes for more than 50 years remained free from such complications as proliferative diabetic retinopathy (PDR), a serious eye disease that can lead to blindness (42.6 percent of them); nephropathy, or kidney damage (86.9 percent of them); neuropathy, or nerve damage (39.4 percent); and cardiovascular disease (51.5 percent). Of those who did not develop PDR, 96 percent with no retinopathy progression in the first 17 years of their disease never experienced a worsening of symptoms, meaning that they likely possessed some type of protection specific to this complication.

Surprisingly, glycemic control was not a factor in providing this protective mechanism.

"That doesn't mean of course that glycemic control doesn't help to prevent complications. Numerous other studies have shown that it unquestionably does. In this case, it means only that there is a separate, protective mechanism in play that is not related to glycemic control that also helps to protect against diabetes-related problems. We are still working on identifying just what that is," King said.

It's important to note that most of the people in this study developed type 1 diabetes before strict glycemic control was even possible or used as the standard of medical care, the researchers write. The people in this study likely lived for several decades, therefore, without maintaining strict control.

The study also found that those with high plasma carboxyethyl-lysine and pentosidine, or advanced glycation end products (AGEs), were 7.2 times more likely to have some kind of complication than those who had low levels of this combination of AGEs. (AGEs are compounds that develop in the body after long exposure to high glucose levels and have generally been regarded as playing a role in diabetes-related complications.)

However, those with other types of AGE molecules exhibited protective features. Thus, this study suggests that not all AGEs are alike in their actions and raises the exciting possibility that some AGEs may be markers for protection against one or more diabetic complications.

In an accompanying editorial titled The Question Is, My Dear Watson, Why Did the Dog Not Bark?, Dr. Aaron Vinik, Director, Eastern Virginia Medical School Diabetes Research Center, writes that "the accumulation of AGEs may be one of the important factors in metabolic memory," a phenomenon in which an initial period of good glycemic, lipid and blood pressure control results in a prolonged period of health benefits that last beyond the period of control.

However, while it is clear that for some there is a protective mechanism at play, it's unclear whether metabolic memory is playing a role because glycemic control was not considered important until 1993, long after the study began.

What's most interesting, Vinik points out, is that sRAGE (the circulating soluble receptor for AGEs) is deficient in those who have the most severe complications, and is present at high levels in those with the most longevity. "If this is the missing link, it is huge for the possible emergence of a new biomarker and the potential for therapy that might increase circulating sRAGE or sRAGE itself," he said.

Few Diabetics Aware of Potential Kidney Complications

Too many people who have diabetes don't know about their increased risk of kidney disease, a British researcher says.

Researchers led by Gurch Randhawa of the University of Bedfordshire in England conducted a multicultural study -- including 23 white and 25 South Asian patients with diabetes. The residents of England were between the ages of 34 and 79 years and had all been referred to a kidney specialist.

The study, published in the Journal of Renal Care, said most diabetes patients are completely unaware of how diabetes can affect their kidneys until sent to a specialist. He added "Many of the patients we spoke to were much more aware of how diabetes could affect their eyes and feet than their kidneys. We believe this study highlights a serious need for more information about the risks that diabetics face from kidney disease."

"The people we spoke to experienced feelings of surprise, fear and regret when they found out their kidney had been affected," Randhawa said in a statement.

"Some patients saw their kidney referral as a 'wake-up call' that they needed to manage their diabetes more seriously, while others were concerned about their lack of knowledge about the disease."

However, the study finds South Asian patients tend to be a lot younger than their white counterparts. The finding confirms, says Randhawa, that South Asian patients tend to develop diabetic-related kidney problems at an earlier age.

Surgical Procedure Can Control Type 2 Diabetes, Claims Brazilian Surgeon

A new procedure which requires surgical intervention through Ileal Transposition (or small intestinal switch) can effectively control Type 2 diabetes, a Brazilian surgeon claimed in Hyderabad, India on August 21.

Dr Aureo Ludovico de Paula, was in the city to address the first international conference and live workshop on this procedure along with his Indian counterpart Dr Surendra Ugale.

Ugale who is also the organizing secretary of the workshop said, “the new research has shown that there are some intestinal hormones which have a great effect on the pancreas and insulin secretion especially in response to food intake. Dr Paula has devised a laparoscopic operation which he claims is proving to be a cure for Type 2 diabetes.”

Paula said, “The surgery can control diabetes without insulin, arrest the metabolic syndrome of the body organ deterioration, thus avoiding future diabetic complications.”

The doctor who has performed 700 surgeries with 95% remissions said the operation involves a long segment of ilium (ending portion of small intestine) which is shifted to the upper small intestinal area, where food particles will reach it very soon on eating a meal.

This causes an immediate secretion of good hormone GLP-1 which acts on the B cells of pancreas to secrete insulin and control blood sugar.

The fall out is a biochemical process that facilitates insulin secretion in the presence of undigested food and controls Type 2 diabetes, a metabolic disorder that is marked by the failure to absorb sugar and starch due to lack of the hormone insulin, Paula said.

Type 2 diabetes is the most common form of diabetes. In this disease, either the body does not produce enough insulin or the cells ignore it.

Ugale explained that Type 2 Diabetes affects several organs. The solution therefore is to stimulate these hormones in lower intestine that in turn secrete GLP which in turn stimulates the pancreas to stimulate the insulin and get fresh beta cells.

He said patients who already have diabetes for ten years and using medication, and are suffering from five associated diseases are ideal candidates for this kind of surgical intervention which costs less than US $10,000 (in India).

The surgery not only controls high blood pressure but also improves kidney cholesterol nerves reduces excess weight and also one need not take any medicines. He also can eat normally post surgery, including sweets.

However, doctors insist that first of all in any patient they would advise lifestyle changes, exercise followed by medication, if there is diabetes and if the patient is not doing well only then surgery is advised.

Presently a centre in Mumbai and Hyderabad are performing this surgery. A centre has also come up in Coimbatore.

Over hundred doctors from all over the country and endocrinologists are participating in the two-day seminar

Diabetes: Understanding Proteinuria

Proteinuria—also called albuminuria or urine albumin—is a condition in which urine contains an abnormal amount of protein. Albumin is the main protein in the blood. Proteins are the building blocks for all body parts, including muscles, bones, hair, and nails.

Proteins in the blood also perform a number of important functions. They protect the body from infection, help blood clot, and keep the right amount of fluid circulating throughout the body.

As blood passes through healthy kidneys, they filter out the waste products and leave in the things the body needs, like albumin and other proteins. Most proteins are too big to pass through the kidneys’ filters into the urine. However, proteins from the blood can leak into the urine when the filters of the kidney, called glomeruli, are damaged.

Proteinuria is a sign of chronic kidney disease (CKD), which can result from diabetes, high blood pressure, and diseases that cause inflammation in the kidneys. For this reason, testing for albumin in the urine is part of a routine medical assessment for everyone. Kidney disease is sometimes called renal disease.

If CKD progresses, it can lead to end-stage renal disease (ESRD), when the kidneys fail completely. A person with ESRD must receive a kidney transplant or regular blood-cleansing treatments called dialysis.

 

Who is at risk for proteinuria? 

People with diabetes, hypertension, or certain family backgrounds are at risk for proteinuria. Indeed, diabetes is the leading cause of ESRD. In both type 1 and type 2 diabetes, albumin in the urine is one of the first signs of deteriorating kidney function. As kidney function declines, the amount of albumin in the urine increases.

Another risk factor for developing proteinuria is hypertension, or high blood pressure. Proteinuria in a person with high blood pressure is an indicator of declining kidney function. If the hypertension is not controlled, the person can progress to full kidney failure.

 

What are the signs and symptoms of proteinuria?

Proteinuria has no signs or symptoms in the early stages. Large amounts of protein in the urine may cause it to look foamy in the toilet. Also, because protein has left the body, the blood can no longer soak up enough fluid, so swelling in the hands, feet, abdomen, or face may occur. This swelling is called edema. These are signs of large protein loss and indicate that kidney disease has progressed. Laboratory testing is the only way to find out whether protein is in a person's urine before extensive kidney damage occurs.

Several health organizations recommend regular urine checks for people at risk for CKD. A 1996 study sponsored by the US National Institutes of Health determined that proteinuria is the best predictor of progressive kidney failure in people with type 2 diabetes. The American Diabetes Association recommends regular urine testing for proteinuria for people with type 1 or type 2 diabetes. The National Kidney Foundation recommends that routine checkups include testing for excess protein in the urine, especially for people in high-risk groups.

 

What are the tests for proteinuria?

Until recently, an accurate protein measurement required a 24-hour urine collection. In a 24-hour collection, the patient urinates into a container, which is kept refrigerated between trips to the bathroom. The patient is instructed to begin collecting urine after the first trip to the bathroom in the morning. Every drop of urine for the rest of the day is to be collected in the container. The next morning, the patient adds the first urination after waking and the collection is complete.

In recent years, researchers have found that a single urine sample can provide the needed information. In the newer technique, the amount of albumin in the urine sample is compared with the amount of creatinine, a waste product of normal muscle breakdown. The measurement is called a urine albumin-to-creatinine ratio (UACR).

A urine sample containing more than 30 milligrams of albumin for each gram of creatinine (30 mg/g) is a warning that there may be a problem. If the laboratory test exceeds 30 mg/g, another UACR test should be done 1 to 2 weeks later. If the second test also shows high levels of protein, the person has persistent proteinuria, a sign of declining kidney function, and should have additional tests to evaluate kidney function.

 

What additional tests for kidney disease may be needed?

Tests that measure the amount of creatinine in the blood will show whether a person's kidneys are removing wastes efficiently. Having too much creatinine in the blood is a sign that a person has kidney damage. The doctor can use the creatinine measurement to estimate how efficiently the kidneys are filtering the blood. This calculation is called the estimated glomerular filtration rate, or eGFR. CKD is present when the eGFR is less than 60 milliliters per minute (mL/min).

 

What should a person with proteinuria do?

If a person has diabetes, hypertension, or both, the first goal of treatment will be to control blood glucose, also called blood sugar, and blood pressure. People with diabetes should test their blood glucose often, follow a healthy eating plan, take prescribed medicines, and get the amount of exercise recommended by their doctor.

A person with diabetes and high blood pressure may need a medicine from a class of drugs called angiotensin-converting enzyme (ACE) inhibitors or a similar class called angiotensin receptor blockers (ARBs). These drugs have been found to protect kidney function even more than other drugs that provide the same level of blood pressure control. Many patients with proteinuria but without hypertension may also benefit from ACE inhibitors or ARBs. The American Diabetes Association and the American College of Cardiology recommend that people with diabetes keep their blood pressure below 130/80.

People who have high blood pressure and proteinuria, but not diabetes, also benefit from taking an ACE inhibitor or ARB. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends that people with kidney disease keep their blood pressure below 130/80. To maintain this target, a person may need to take a combination of two or more blood pressure medicines. A doctor may also prescribe a diuretic in addition to an ACE inhibitor or ARB. Diuretics are also called “water pills” because they help a person urinate and get rid of excess fluid in the body.

In addition to blood glucose and blood pressure control, the National Kidney Foundation recommends restricting dietary salt and protein. A doctor may refer a patient to a dietitian to help develop and follow a healthy eating plan.

 

Points to Remember

• 
  
  Proteinuria is a condition in which urine contains a detectable amount of protein.
• 
  
  Proteinuria is a sign of chronic kidney disease (CKD).
• 
  
  Groups at risk for proteinuria include people with diabetes or hypertension, and people who have a family history of kidney disease.
• 
  
  Proteinuria may have no signs or symptoms. Laboratory testing is the only way to find out whether protein is in a person’s urine.
• 
  
  Several health organizations recommend regular checks for proteinuria so kidney disease can be detected and treated before it progresses.
• A person with diabetes, hypertension, or both should work to control blood glucose and blood pressure. 
  
  Source:  National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC)
  
  
  

Diabetes Symptoms To Never Ignore

Watch out for signs of heart disease, uncontrolled blood sugar, infection, eye problems, and more

People living with diabetes learn to manage their disease with proper diet, regular exercise, and medication.  Success is measured by how well you can control your blood sugar. 

However, many factors can affect blood sugar besides diet and activity. Illness, stress, social drinking, and women’s menstrual cycles can all influence blood sugar levels and upset your normal routine. 

If you have diabetes, you may know that and make adjustments accordingly.  But some symptoms of trouble are always reasons to seek medical advice, whether it’s a call to your doctor or a trip to the emergency room. 

“Truthfully, with the ability of people to test their blood sugar at home, we can treat many more things at home than we used to be able to,” says Andrew Drexler MD, who directs UCLA's Gonda Diabetes Center. 

This does not mean you should problem solve without your doctor’s help, he adds, but rather, that you might be able to substitute a phone call for a trip to the emergency room.    

Here are the diabetes symptoms you should never ignore. 

Frequent Urination, Extreme Thirst or Hunger, or Blurry Vision

These are three common warning signs of uncontrolled blood sugar.

With any of these symptoms, you should test your blood sugar and call your doctor.  Depending on how high your blood sugar is, medication may fix the problem or you may have to seek medical care to replace fluids and electrolytes and to get blood sugar back under control. 

If left unchecked, high blood sugar can lead to serious, life-threatening conditions.  Type 1 diabetes patients can develop diabetic ketoacidosis, which happens when the body starts breaking down fats instead of sugars and a dangerous buildup of ketones (byproducts of fat metabolism) occurs.

 In type 2 diabetes patients, hyperosmolar coma can occur.  “It’s essentially uncontrolled diabetes, which leads to dehydration and altered consciousness and which could be fatal if untreated,” says endocrinologist Adrian Vella, MD, of the Mayo Clinic in Rochester, Minn. 

Acting Drunk

Strange behavior can also signal low blood sugar. This can happen when a person’s medication works too well and overshoots the target. 

Drinking some juice or eating a snack usually is enough to raise sugar levels and normalize behavior.  Often, however, the diabetic patient is not in the state of mind to recognize that something is wrong.  If no one else is around to prompt you, your blood sugar may sink low enough to cause you to lose consciousness. 

Most of the time, patients will recover on their own, but if they are taking certain medications, emergency medical treatment may be required. 

“If it’s either a long-acting pill that can cause hypoglycemia,” such as the sulfonylurea drugs chlorpropamide, glyburide, or glimepiride, “or a long-acting insulin that can cause hypoglycemia, then it very well may be necessary to go to the emergency room,” Drexler tells WebMD. 

Infections, Swollen or Bloody Gums, Foot Sores

Have your doctor check a cut that’s infected, swollen or bloody gums, or a wound that won’t heal. And watch out for a sore on the foot, which may be the first sign of a diabetic foot ulcer. 

All diabetes patients should get regular foot exams by a health care professional -- and check their own feet on a daily basis -- even if sores are not present. And remember to bathe your feet daily in warm (but not hot) water, following up with a moisturizer, to prevent dry skin, which may crack and lead to infection.

“Infections in diabetics can get out of control and they need to be taken very seriously,” says Drexler. 

Fungal infections occur more frequently in diabetes patients, Vella tells WebMD.  “Fungal infections of the skin are more likely to occur when your blood sugar is consistently above the magic number of about 180-200 [mg/dL],” he says.  “That’s because hyperglycemia itself actually interferes with the white blood cells’ ability to respond to such infections.” 

A red, itchy rash -- especially in moist areas such as skin folds -- can signal a fungal infection.

Eye Problems, Including "Floaters"

If you develop sudden changes in vision, experience eye pain, or see spots or lights floating in your field of vision, call your doctor. You may need to see an ophthalmologist. People with diabetes are at increased risk of an eye condition called retinopathy, which can lead to vision loss.

Even without eye symptoms, diabetes patients should see an ophthalmologist yearly for a routine eye exam.

Heart Disease Symptoms -- and Not Just Chest Pain

Patients with diabetes have an increased risk of cardiovascular disease and twice the normal rate of related emergency events, such as heart attack and stroke. 

So get any potential heart disease symptoms checked out.And keep in mind that heart symptomsaren't always predictable.

 “It can sometimes be shoulder pain, it can sometimes present just as nausea," Drexler says. "But if there’s any suspicion that it’s cardiac in origin, it’s very important to go to the ER." 

It's also possible to have heart disease that doesn't have obvious symptoms, so make sure you see your doctor regularly and have your cardiovascular risk factors evaluated.

Taking Precautions

Will Ryan of Alford, Mass., who has had diabetes for 30 of his 70 years, was driving home one night a felt a sharp pain in his chest.  “It was more intense than just a muscle pull,” says Ryan, author of a blog called the Joyful Diabetic.  It lasted only a few seconds, but it happened again before he got home.  He went to the ER, where an ECG showed normal heart function. 

Taking Precautions continued...

Less than a week later, he woke up with his heart pounding and his pulse racing at 90 beats per minute - higher than usual for Ryan.  A second ECG was also normal, but given two possible heart-related events, a cardiologist ordered a heart monitor. 

Over two weeks, the monitor picked up more curiosities.  “I had a number of instances where my heart rate dropped below 40,” Ryan says.  “I was not aware of it because I was sleeping.” 

Ryan agreed to a stress test, which showed his heart was oxygen deprived, suggesting that one of the blood vessels feeding his heart was blocked.  Cardiac catheterization confirmed the blockage, but also showed that Ryan’s other blood vessels had taken up the slack such that no treatment was required. 

“I probably had a heart attack, but I never knew it,” Ryan says, adding that doctors told him this was not uncommon in people with diabetes. 

Ryan says he’s very aware of his body’s signals from living with his disease, but he has never been complacent. This recent experience has only reaffirmed that unusual symptoms deserved medical attention. 

Thank You WebMD

Diabetic Neuropathy: No Clear Answers

Do high glucose levels cause neuropathy? That's an issue that worries most diabetics. And unfortunately there are no clear answers.

Experts think of blood glucose values as a spectrum of numbers with no clear cutoff between nondiabetic and diabetic. In similar manner, there is a gray area of blood glucose that defines pre-diabetes. Many people use blood sugar and blood glucose interchangeably.

The definition of diabetes has changed over time. The numbers you quote might very well be considered diagnostic of diabetes today whereas they were not 20 years ago. In 1997, the American Diabetes Association definition of normal blood glucose decreased from 120 to 110 mg/dL (6.1 mmol/L). In 2002, the American Diabetes Association defined a normal fasting blood glucose as less than 100 mg/dL (5.6 mmol/L).

Today we consider fasting blood sugars of 100 mg/dl to 125mg/dl to be in the realm of glucose intolerance which is sometimes called pre-diabetes. These patients are at increased risk for developing frank diabetes. Several fasting glucose levels over 125 or a single random glucose over 200 mg are considered diagnostic of diabetes.

There are other tests used to make the diagnosis of pre-diabetes or diabetes. Pre-diabetes is defined as a blood sugar of 140 to 199 mg/dL (7.8 to 11.0 mmol/L) two-hour after drinking 75 grams of an oral glucose solution. The diagnosis of diabetes is confirmed with a blood sugar of 200 mg/dL or greater, two hours after ingestion of the glucose solution.

Hemoglobin A1C is a blood test that gives an estimate of blood sugar levels over the previous three months. Persons with a value of 5.7 to 6.4 percent are thought to have pre-diabetes. Those with a value of 6.5 percent or higher are considered diabetic.

About 30 percent of patients with frank diabetes for more than a decade have some neuropathy. It usually presents as numbness, itching or tingling in the legs but can also be pains. It can even present as digestive problems such as difficulty digesting food or diarrhea due to problems with nerves in the bowels.

Most diabetic neuropathy is caused by peripheral artery disease, in which the small blood vessels are obstructed or partially obstructed and cannot carry oxygenated blood to areas of the body. These areas have pain or other difficulties due to the lack of oxygen.

It is very possible for someone with numbers that are considered pre-diabetes to have some of the complications of diabetes This is especially true of big vessel disease such as myocardial infarction (heart attack), stroke and peripheral vascular disease. Retinopathy, neuropathy and kidney disease are rarer in pre-diabetics but can occur, especially in someone who has pre-diabetes and hypertension (high blood pressure).

The condition of pre-diabetes combined with hypertension is often referred to as the "metabolic syndrome." Elevated cholesterol and triglyceride combined with diabetes and hypertension increases risk of neuropathy even further. Of note, there are some nondiabetics with neuropathy and peripheral vascular disease caused by elevated cholesterol and triglycerides only.

It is prudent that you have a relationship with a physician who will measure not just blood sugar, but cholesterols, triglycerides and blood pressure. He or she may decide that lowering your blood sugars through diet or medication or both might be beneficial for your long-term health. Lowering blood sugar can sometimes even better the pain of diabetic neuropathy.

Many pre-diabetics and diabetic patients are also treated for cholesterol and triglyceride problems and get a baby aspirin daily to decrease risk of heart disease. There are also a number of treatments for pain caused by neuropathy.

In addition to having the above tests, people with pre-diabetes and diabetes should get an annual eye examination to rule out early diabetic retinopathy. Diabetic retinopathy is treatable and is the most common cause of blindness.

It is also prudent to examine the feet for wounds that the patient might not appreciate due to loss of sensation as a part of diabetic neuropathy. Assessment of kidney function and some studies of the heart and vascular system may also be called for.

By the way, there are other causes of peripheral neuropathy. Not uncommon are amyloidosis, which is a disease in which excess protein is deposited in nerve tissue, and vasculitic neuropathy, a rheumatologic disease in which the patient has inflammation near the nerve.

Also we must consider alcoholic neuropathy in someone with an extreme drinking history and even lead poisoning as a possible cause. Patients who have been treated with chemotherapy for cancer and some rheumatologic diseases can also get some painful neuropathies.

Thank you Dr Otis Brawley

Diabetes: Controlling Blood Sugar Is Not Enough

I'm sure all of you who live with diabetes or know someone who carries the burden of the disease will find their diabetes management has been inadequate.

This is because nearly all diabetics are fixated on keeping their blood sugar under control. As long as glucose levels are within acceptable limits, they feel the disease is under control.

Nothing can be farther from the truth. In fact, you may be deluding yourself that all is good even as your heart, kidneys, eyes etc are just rotting away, as it were.

In fact, my good friend Dr Shiv Harsh MD, a heart specialist, says he considers diabetes to be basically a heart disease.

To get this blog going, I'm paraphrasing a great article from New York Times that I came across a few years ago. It is made a difference to my diabetes management.

Most people discover they have Type 2 diabetes by accident, mostly after a routine urine test. The test reveals your blood sugar level is sky high and glucose is spilling into your urine.

"You've got diabetes," confirms your doctor.

So, from then on, like most others with diabetes, you become fixated on your blood sugar. Your doctor has warned you to control it or the consequences could be dire - you could end up blind or lose a leg. Your kidneys could fail.

You try hard. When dieting does not work, you begin counting carbohydrates, taking pills to lower your blood sugar and pricking your finger several times a day to measure your sugar levels. When they remained high, you agree to add insulin to your already complicated regimen. Blood sugar is always on your mind.

But in focusing entirely on blood sugar, you end up neglecting the most important treatment for saving lives — lowering the cholesterol level. That protects against heart disease, which eventually kills nearly everyone with diabetes.

Like I said in the beginning, Dr Shiv Harsh considers diabetes a heart disease. (I'm putting this in layman's language; Dr Shiv Harsh has a more nuanced approach. I'll get him to write on this blog sometime.)

Moreover, most diabetics also miss a second treatment that protects diabetes patients from heart attacks - controlling blood pressure. Most assume everything is taken care of if you can just lower your blood sugar level.

Blood sugar control is important in diabetes, specialists say. It can help prevent dreaded complications like blindness, amputations and kidney failure.

But controlling blood sugar is not enough.

Yet, largely because of a misunderstanding of the proper treatment, most patients are not doing even close to what they should to protect themselves. What is going on? We can only conclude that people are not aware of their risks and what could be done about them.

In part, the fault for the missed opportunities to prevent complications and deaths lies with the medical system. Most people who have diabetes are treated by GPs (family doctors) who have had just a few hours of instruction on diabetes, while they were in medical school. Then the doctors typically spend just 10 minutes with diabetes patients, far too little for such a complex disease, specialists say.

In part it is the fault of proliferating advertisements for diabetes drugs that emphasize blood sugar control, which is difficult and expensive and has not been proven to save lives.

And in part it is the fault of public health campaigns that give the impression that diabetes is a matter of an out-of-control diet and sedentary lifestyle and the most important way to deal with it is to lose weight.

Most diabetes patients try hard but are unable to control their disease in this way, and most of the time it progresses as years go by, no matter what patients do.

Ninety per cent of diabetes patients have Type 2 diabetes, the form that usually arises in adulthood when the insulin-secreting cells of the pancreas cannot keep up with the body’s demand for the hormone. The other form of diabetes, Type 1, is far less common and usually arises in childhood or adolescence when insulin-secreting pancreas cells die.

And, like many diabetes patients, you end up paying the price for your misconceptions about diabetes.

Most diabetics think the biggest risk from diabetes is blindness or amputations. You never think about heart disease and have no idea how important it is to control cholesterol levels and blood pressure mostly because doctors do not advise you to take a cholesterol-lowering or blood pressure drug. And you do not think you need them.

Indeed, most people with diabetes are unaware of the danger that heart disease poses for them.

A survey by the American Diabetes Association found that only 18 percent of people with diabetes believed that they were at increased risk for cardiovascular disease.

Yet, when you think about it, it’s not the diabetes that kills you, it’s the diabetes causing cardiovascular disease that kills you.

So, if you are one of those who don’t think you are at increased risk, finding out that you are and that you can decrease that risk substantially could literally change your life.

The science is clear on the huge benefits for people with diabetes of lowering cholesterol and controlling blood pressure.

With cholesterol, levels of LDL cholesterol, the form that increases heart disease risk, should be below 100 milligrams per deciliter and, if possible, 70 to 80. Yet, diabetes patients with LDL cholesterol levels of 100 to 139 often are told that their levels — ideal for a healthy person without diabetes — are terrific.

But many practicing doctors just don’t know that an LDL cholesterol number that is normal for someone without diabetes is not normal for someone with diabetes.

Not surprisingly, most diabetics do not know the other measures proven to prevent complications in diabetes.

Sure, high blood sugar is dangerous. It can damage the small blood vessels in the eyes, leading to blindness; the nerves in the feet, leading to amputations; and the kidneys, leading to kidney failure. But no matter how carefully patients try to control their blood sugar, they can never get it perfect — no drugs can substitute for the body’s normal sugar regulation.

So while controlling blood sugar can be important, other measures also are needed to prevent blindness, amputations, kidney failure and stroke. But, alas, most diabetics are doing none of them.

The common assumption that Type 2 diabetes is simply a consequence of being fat. And that losing weight will help cure it.

Obesity does increase the risk of developing diabetes, but the disease involves more than being obese. Only 5 percent to 10 percent of obese people have diabetes, and many with diabetes are not obese.

To a large extent, Type 2 diabetes is genetically determined — if one identical twin has it, the other has an 80 per cent chance of having it too. In many cases, weight loss can help, but most who lose weight are not cured of the disease. You can lose 20 kg but still have diabetes.

So if you're diabetic worried only about blood sugar levels, get ready for a new diabetes regimen: a statin to drive your cholesterol level very low, drugs to lower your blood pressure, besides insulin and drugs to reduce his blood sugar levels.

Remember, you’ll never be out of the woods. You’ve got to face that.

And it is not just that many diabetes patients are overweight, as people with Type 1 diabetes, who often are thin, also have a high risk of heart disease. There is something about diabetes itself, researchers say, that leads to high levels of LDL cholesterol and a form of LDL cholesterol particles that is particularly dangerous. Diabetes also leads to increased levels of triglycerides, which are fats in the blood that increase heart disease risk, and in diabetes is linked to high blood pressure.

Being obese or overweight, in contrast, are supposed to be “weak contributors to heart attack risk.”

Type 2 diabetes does not exist in isolation. Underlying diabetes are all these cardiovascular risk factors.

It has taken quite a while for the alarm bells to go off because it is heart disease researchers, not diabetes researchers, who have conducted the seminal studies.

The key to saving lives is to reduce levels of LDL cholesterol to below 100 and also control other risk factors like blood pressure and smoking. The cholesterol reduction alone can reduce the very high risk of heart attacks and death from cardiovascular disease in people with diabetes by 30 per cent to 40 per cent. And clinical trials have found that LDL levels of 70 to 80 are even better for people with diabetes who already have overt heart disease.

Studies of blood sugar control have been more problematic than those of cholesterol lowering.

In Type 2 diabetes, the most ambitious effort was a huge study in Britain. It found that rigorous blood sugar control could lower the risk of complications that involved damage to small blood vessels, a list that includes blindness, nerve damage and kidney damage. But there was no effect on the overall death rate. There was a small decrease in the number of heart attacks but it was not statistically significant, meaning it could have occurred by chance.

Since researchers are still groping in the dark, as it were, cholesterol lowering, for patients with Type 1 and Type 2 diabetes, is the most effective and easiest way by far to reduce the risk of heart disease and the only treatment proven to save lives. But doctors say achieving the recommended cholesterol levels usually means taking a statin.

Some patients resist, wary of intense drug company marketing to patients and afraid of side effects like muscle or liver damage which, although extremely rare, have frightened many away from the drugs.

Yet lowering cholesterol with statins is much simpler than anything else diabetes patients are asked to do. And the drugs are among the best studied and the safest on the market.

My own doctor says if he had to rate the different regimens for a typical middle-age person with Type 2 diabetes, the first priority would be to take a statin and lower the LDL cholesterol level. (I take one statin after dinner.)
Besides, two other measures to protect against heart disease, blood pressure control and taking an aspirin to prevent blood clots, should not be neglected.

Right now, without waiting for lots of exciting things that are almost in the pipeline or in the pipeline, starting tomorrow, if everyone did these things — taking a statin, taking a blood pressure medication, and maybe taking an aspirin — you would reduce the heart attack rate by half.

But even when you do take the right steps to control diabetes, the grueling process can simply wear you down.

In fact, a fistful of prescriptions, including a statin, blood pressure medications and one for the drug that most diabetics dread – insulin – besides regular checks for eye, nerve and kidney damage and watching what you eat and count carbohydrates is enough to drive anyone crazy.

Diabetes specialists say they are well aware of how daunting the program can be. Many go to the doctor once or twice and walk away saying, “I don’t want to do this.”
Meanwhile, no matter what they do, most people with Type 2 diabetes get worse as the years go by. Patients make less and less insulin and their cells become less and less able to use the insulin they do produce.

That is why it is not uncommon to start initially with diet therapy, then after a few years you need to add a drug that improves insulin sensitivity. Then when that drug isn’t enough, the doctor adds a second drug that improves insulin sensitivity by a different mechanism. Then he add a drug that stimulates that pancreas to make more insulin.”

Then patients with Type 2 diabetes may need insulin itself, but when that happens they have to take even more than a person with Type 1 diabetes — two or even three times as much — because their cells no longer respond adequately to the hormone.

Nevertheless, while it is not easy to re-energize burned-out patients, at the very least doctors and patients should know what is important.

We already have the miracle pills - statins and blood pressure medications – that are cheap but what is imperative is patient education and physician training that this stuff is out there and this is what doctors should be focusing on to make a difference in lives.

Note: I am NOT an expert. I am managing diabetes with moderate success and want to share published material appearing elsewhere. DO NOT start any medication without consulting your doctor. Get your lipid profile (12 hours fasting before test) and BP checked before you meet your doctor next.

If you have anything to share with other diabetics, do post your experiences on this blog