Stop Diabetes In Its Tracks

"Your blood sugar is too high. You have prediabetes." When Gail Tudor heard her doctor say that in July 2015, the 55-year-old UK wedding videographer was shocked. How could she? She had a normal body mass index of 24 and she followed the recommended diet -- low in fat and high in fruits, vegetables and healthy grains. Plus Gail, a mother of two who lives in Wales, was very active -- skating, walking, kayaking and more. Since she already did those things, her doctor said, it was unlikely she could reverse her path to type 2 diabetes. She was offered a treatment plan including drugs, and was told that it was likely she'd need them for the rest of her life. "I couldn't believe it," Gail says. She was determined to learn what else she could do to prevent diabetes from developing -- without resorting to drugs.

When Anuradha Katyal*, 52, joined the Diabetes Community Lifestyle Improvement Program, or D-CLIP, a trial by Madras Diabetes Research Foundation to determine sustainable lifestyle intervention for the prevention of type 2 diabetes mellitus in India, she was 77 kilos. This mother of an 18-year-old had a waist circumference of 91 cm and an HbA1c of 6.1 per cent. Doctors told the Chennai-based school administrator that she needed to make a change sooner than later.

In August 2015, at age 57, I, too, was told by my doctor that my fasting blood sugar was in the prediabetes range. I wasn't overweight. I exercised three times a week and walked 10, 000 steps every day. Moreover, as a health writer for more than 25 years, I had been following all the recommended dietary guidelines for three decades. What more could I do?

I began searching the medical literature for the most up-to-date facts and views. Prediabetes, I learnt, is a warning flag of health troubles down the road for millions of men and women who will be told that they have it. The World Health Organization states that globally, the number of people with diabetes has skyrocketed from 108 million in 1984 to 422 million in 2014. According to the International Diabetes Federation, in 2013, 50 per cent of those with diabetes lived in just three countries: China (98.4 million), India (65.1 million) and USA (24.4 million). "The largest epidemiological studies on diabetes in the country -- the Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study -- revealed that over 80 million people in India have prediabetes," says Dr V. Mohan, diabetes researcher and a top diabetologist based in Chennai.

Prediabetes increases the risk up to ten times for developing eventual type 2 diabetes with its dire rates of heart disease, stroke, blindness, nerve or kidney damage and limb amputations. What's more, damage to the body's tissues and blood vessels can start well before full-blown type 2 diabetes occurs.

Often causing or accompanied by hyperglycaemia (high blood sugar), prediabetes is linked to a problem with the body's insulin, a hormone that moves sugar out of the blood and into cells for energy use or storage as fat. When prediabetes occurs, higher and higher amounts are being churned out that no longer work as effectively, a process called insulin resistance. The result is that too much sugar is left circulating in the blood, which leads to higher blood sugar levels and a higher risk of type 2 diabetes.

Soaring rates of type 2 diabetes are a massive health problem, not only for the individuals facing its consequences, but for health systems burdened by the burgeoning numbers. In India diabetes has reached epidemic levels -- it is estimated that by 2040, a whopping 140.2 million people will have diabetes in the South East Asian region. In 2015 alone, 78.3 million adults in the region (20-79 years) were diabetic.

The good news is that prediabetes is reversible with lifestyle changes. The choice is yours. In fact, Gail Tudor, Anuradha Katyal and I have all eliminated our prediabetes since our diagnoses and greatly improved our health. So have thousands of others.

If you or a loved one has been told you have prediabetes, here is what you need to know.

1. Who is at risk?

Being overweight or obese, inactive or from a family with a history of type 2 diabetes makes you more likely to get a prediabetes diagnosis. "Other risk factors are: an abdominal waist circumference of more than 90 cm in men and 80 cm in women, high blood pressure and cholesterol, and dark, thick skin over the back of the neck, known as acanthosis nigricans," says Dr Anoop Misra, chairman, Fortis C-DOC Hospital for Diabetes and Allied Specialties. Women -- like Gail -- who have had gestational diabetes (a type that affects women during pregnancy) are at much higher risk of eventually developing prediabetes or type 2 diabetes. So are women who have given birth to a baby bigger than four kilos -- as I did 23 years ago.

I also had a related condition that one in every 10 Indian women may have: a genetic, hormonal condition called polycystic ovary syndrome (PCOS), which causes lowered fertility, potential weight gain and other symptoms. A key feature of PCOS, just like diabetes, is insulin resistance.

"Insulin's action is the key," notes Dr Jason Fung, a Canadian nephrologist, a majority of whose kidney failure patients have type 2 diabetes. Fung has written The Obesity Code in which he describes how insulin, insulin resistance and the stress hormone cortisol are the key hormonal triggers to type 2 diabetes and obesity. To reverse them you need to address those triggers.

2. How is prediabetes diagnosed?

Since prediabetes generally has no symptoms, the way to detect it is by a blood-screening test, generally in one of three ways: 1) a blood sample called a fasting blood glucose, drawn in the morning before you have eaten anything, shows blood sugar between 100-125 mg/dl; 2) a blood sample after drinking 75 grams of glucose (called an oral glucose tolerance test or OGTT) shows blood sugar two hours later between 140-199 mg/dl; or 3) a test called haemoglobin A1c (a single blood test that reflects a three-month average of your blood glucose levels) averages between 5.7-6.4 per cent. A combination of tests is often ordered to confirm diagnosis. Higher rates on all these tests mean full-blown T2 diabetes. "An abnormal blood glucose level after a fasting blood glucose test is termed impaired fasting glucose (IFG). If it is abnormal after OGTT, the person is said to have an impaired glucose tolerance (IGT). Both these conditions constitute prediabetes," Misra adds.

3. Lose weight, but how?

It has been known for years that losing 5 to 10 per cent of your body weight -- no matter how you do it -- can reverse prediabetes for a time. Due to an increasingly sedentary lifestyle, most of us consume more energy than we expend and weight gain is inevitable.  "This energy imbalance is one of the important factors contributing to escalating obesity," says Mohan.

Thousands of people like Gail Tudor, Anuradha Katyal and me have lost weight and reversed diabetes risk factors by cutting sugar and refined or starchy carbohydrates (bread, potatoes, rice, pasta, cereals, cookies, savoury biscuits and cakes) out of our diets. "Under guidance nearly 50-60 per cent of patients can return to a non-diabetic status with moderate-intensity physical activity and a healthy diet. This window of opportunity is maximum during the first six months from diagnosis," says Misra.

"Among Indians excess carbohydrate intake is the main culprit -- polished rice in the south and east and refined wheat in the north and west of India. Hence, reduction in carbohydrate portion size is very important," adds Mohan.

All carbohydrates get turned into sugars by digestion in our body. That sugar then triggers the release of insulin. So limit total carb intake to 50-60 per cent of your diet. The greater part of your diet should be unprocessed complex carbohydrates (whole grain cereals, unpolished rice, barley or jaun, buckwheat or kuttu, oats, millets). "Avoid simple carbohydrates (like sugar, refined flour and sweets) as they break down much faster and cause insulin levels to spike quickly," says Misra.

 Fat isn't all bad. Good fats in the right quantity are satiating, ideal for the heart and brain. Misra recommends that fats should provide 25-30 per cent of your daily calories, including both visible (oils) and invisible fats (dairy products, cereals, pulses). Monounsaturated fats (olive, canola, mustard and groundnut oils) and Omega-3 polyunsaturated fats (fish, flaxseed oil and walnuts) are the healthiest types. Restrict saturated fat (red meat, butter, ghee) to less than 7 per cent of daily calories. Choose non-fat or low-fat dairy instead of whole milk products. Limit trans-fats (hydrogenated fats like vanaspati/margarine) found in snacks, fried foods and commercially baked goods to less than 1 per cent of your total calories.

A recent study published in the British Journal of Nutrition (2017) indicates that increasing protein intake may help in the reversal of prediabetes. Misra says that about 10-15 per cent of your daily calories should come from protein. Do keep in mind that this may vary depending on a person's ideal body weight and health requirements. "Adequate protein is a must, as Indians tend to be protein deficient. More protein and fibre in your diet will keep you satiated longer, curbing unhealthy eating habits," says Dr Shashank R. Joshi, endocrinologist at the Lilavati Hospital and Research Centre, Mumbai.

"Considering the quality of protein in a usual Indian vegetarian diet, the ideal intake should be about .80 gram per kilogram of body weight every day," says Misra. So a 60-kg woman, for example, should be eating 55 grams of protein every day. Those with kidney disease should consult their dietician to limit their protein intake depending on their condition, suggests Misra.

Gail Tudor started the low-carb/high-fat (LCHF) approach in July 2015; by May 2016 she had lost more than six kilos -- mostly within the first three months, even though weight loss was not her intention -- and her blood sugar had returned to healthy ranges, her prediabetes under control. I started the diet in autumn 2015 and after seven months had lost four kilograms and had my blood glucose return to normal. Better yet, the food is delicious and satisfying.

"In India we have a 'skinny fat' phenomenon which is marked by a protruding belly on a seemingly thin person. We tend to store fat easily. Therefore, LCHF won't work for our body types. We need to reduce the quantity of simple carbs, exercise portion control with both carbs and fats," says Joshi. As Mohan puts it, a weight-loss diet should be culture- and population-specific and above all economically viable and sustainable in the long term.

Anuradha by modifying her diet and exercising (moderate-intensity for 150 minutes a week) managed to reduce her weight by 10 kilos, waist circumference by 12 cm and push HbA1c within the normal range of 5.1 per cent. All this in a matter of four months.

4. What else can you do?

Exercising regularly, improving sleep quality and reducing stress help improve blood glucose control, Joshi says.

Exercise: Our muscles act like a sponge to sop up glucose in the blood. The more we move them, the more they soak up. It doesn't have to be training for a marathon. Anuradha realized that all she needs to do is walk around the house or up and down her stairs and reduce the intake of rice to bring her blood sugar levels down a few points. At least 30 minutes of low-stress movement daily is a must. Try to fit in a brisk walk if you're unable to keep your body moving with other activities. "Our guidelines recommend at least 60 minutes of activity daily for people with prediabetes," says Joshi.

Improve sleep quality: In recent years the link between poor sleep quality, insomnia and sleep deprivation have emerged as risk factors for both weight gain and increased risk of diabetes. Getting seven to eight hours of good quality sleep reduces the risk. Some tips for a better sleep include  not having TV, mobile phones and laptops in the room, keeping pets off the bed, minimizing alcohol before bedtime, keeping the room cool and having a regular sleep routine.

Stress reduction: Stress increases the body's hormone cortisol (insufficient sleep raises cortisol too), which in turn can raise blood sugar levels. Chronic stress may increase insulin resistance, lead to abdominal weight gain and increase the risk for prediabetes and type 2 diabetes. "Reducing stress is vital," notes Joshi. Some tips to reduce chronic stress include mindfulness meditation, yoga, massage and relaxing exercise.

I was fortunate. As a health writer, I immediately understood the dangers of a prediabetes diagnosis. Since my wake-up call in 2015, I have focused on making all these lifestyle changes, restricting carbs and sugar in my diet, lifting weights, walking everywhere and getting a good night's sleep. I've lost a total of six kilos, and I've kept them off. I bought a blood glucose monitor and check my blood sugar regularly. I am now always in the healthy range. In fact, I feel lucky that I got that prediabetes scare: It has helped me improve my health and avoid type 2 diabetes. All it takes is eating healthy, moving more and plenty of 'me' time to unwind.

With additions by Gagan Dhillon