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Diabetes, Obesity and Heart Disease: How to Win the Losing Battle Against Insulin Resistance

Director Cardiology, Fortis Escorts Hospital
Jun 9, 2019 5:18 AM 5 min read

As discussed previously, the prevalence of diabetes has been growing inexorably over the last century. Last four decades have witnessed a veritable explosion of this disease. Despite the availability of a wide variety of drugs for lowering blood sugar, we appear to be waging a losing battle. Only recently have a new group of anti-diabetic drugs emerged, appearing to be effective in reducing the risk of heart disease and strokes, thereby signaling a possible change for the long-term.


This Brings Us to The Question


What was wrong earlier, and What has changed now?


The logical approach tried initially was probably a little too simplistic...


It was thought that the best treatment for diabetes, a disease characterized by high blood sugar, would be to lower those sugar levels. This approach was successful but only partially.


It reduced some diabetic complications, particularly, its impact on the kidneys, eyes and nerves, apart from foot and leg infections and gangrene. However, the major cause of mortality in diabetes is due to cardiovascular diseases (CVD) i.e., heart attacks and strokes. Incidentally, their occurrence is reduced only marginally by most available drugs, including insulin.


Trials have been conducted to test the efficacy of strict control of diabetes. However, these failed to improve the chances of survival. If anything, survival appeared to be better with moderate control (HbA1c of 7-8 approximately) than with tight control of sugar with drugs (including insulin).


SGLT2, Incoming


A change has come about recently with the arrival of a new group of anti-diabetic drugs, called SGLT2 inhibitors. While a detailed discussion of their impact is beyond the scope of this piece, it would suffice to say that they lower blood sugar by increasing the amount of glucose passed in the urine. These are the first group of drugs demonstrating significant reduction in hospitalization due to heart failure. One among them (empagliflozin) has been shown to reduce mortality as well.


What is so different about the SGLT2 inhibitors? What differentiates them from other glucose lowering drugs?


To understand this, we have to review the previous article that discusses the underlying abnormality behind Metabolic syndrome, i.e., insulin resistance (IR). Evidently, IR is the common metabolic abnormality in people with diabetes, obesity and CVD.


Until recently, guidelines reinforced that diabetic individuals should take a low-fat diet, since fat in one's diet (especially saturated fats) was considered to be responsible for CVD risk. This obviously meant taking more carbohydrates (about 50-60% of total calories).


But, considering the fact that these individuals were suffering from IR, it appears obvious that eating foods which stimulate higher insulin release (refined carbs and sugar) would only worsen the problem. Glucose lowering drugs permitted people to eat more carbs, and IR persisted or perhaps increased, with its antecedent complications.


The solution hence would be to restore insulin sensitivity by restricting the refined carbs and sugar (that worsen IR in the first place).


Diet -  A Way to Win the Losing Battle Against Diabetes


This was very controversial however, until the first drug that effectively lowered the amount of sugar absorbed by the body showed salutary effects in lowering CVD mortality. It stands to reason that restricting refined carbs should similarly benefit IR.


In this light, let’s look at some strategies that can lower IR.


As we know, the underlying problem is persistently high levels of insulin leading to resistance to its effects on body tissues, mainly liver, skeletal muscles and fat (or adipose) tissue. Logically, reducing the amount of insulin released in response to meals and increasing the gap between meals should be able to do the trick.


1. Reducing the Carbohydrate Content of our Diet


This means cutting down on refined carbohydrates (foods made from refined white flour, starch, polished rice etc.) and sugar (desserts, sweetened beverages like soft drinks and juices). As carbs are the most potent stimulants of insulin release, this would be the first step in the correction of our diets.


2. Increasing the Gap between Meals


Consuming food/snacks regularly every 2-3 hours, as is often recommended in diets would keep the insulin levels persistently elevated, preventing any improvement in insulin sensitivity. Restricting one’s diet to 2-3 filling meals in a day would conversely allow insulin levels to fall down for several hours at a time.


3. Fasting


Fasting (like the 5:2 diet or the 16:8 or 18:6 diets) would contribute still more to lowering insulin levels, further giving a chance for tissue insulin sensitivity to improve.


4. Exercise


Regular exercise exhausts the glycogen in muscles (the storage form of glucose in muscles and liver), and thus improves the insulin sensitivity of muscles for 2-48 hours after a bout of exercise.


How to Win the Losing Battle Against Diabetes


These four, along with weight loss (a rather definitive result if the above strategies are applied faithfully) are most effective for reversing IR. Other steps that work include, but are not limited to:


5. Adequate sleep


A normal adult needs 7-8 hours of sleep daily, and sleep deprivation has been shown to cause IR.


6. Special foods


Cinnamon and apple cider vinegar have been shown to reduce the speed at which glucose is absorbed, thus lowering both blood sugars and insulin levels. Green tea and fatty fish are also useful. Increasing the intake of soluble fiber (legumes, lentils etc.) is very useful for vegans and for everyone else as well.


How to Win the Losing Battle Against Diabetes


There are, however, certain caveats to the above.


If one is to reduce the amount of sugar and refined carbs one eats, one has to compensate with something else - namely fats and/or proteins. Therefore, one has to choose between healthy fats and proteins along with carbohydrates that are digested slowly (low glycemic index) and have lots of fiber. This means that one should prefer vegetables, fruits, salads, lentils (dal), nuts and milk products like curd/yogurt and cheese (cottage or processed) to carbohydrates.


Further on, one should seek to replace unhealthy food items with healthier options. For instance, eggs are healthier than bread-jam/most cereals/sugar-laden sweets and snacks/ fried snacks like samosas, but perhaps less so than green leafy vegetables. Similarly, milk is healthier than colas and sweetened fruit juices, but is less healthy than water or black tea.


In summary, the survival benefits seen with drugs reducing sugar absorption (by increasing glucose in urine) suggest that reducing the intake of refined carbohydrates and sugars should help not only in reducing blood sugars, but also in restoring insulin sensitivity. As IR is the common abnormality in obesity, diabetes and CVD, this should benefit by reducing the risk of the lifestyle diseases.


This is a recurring column published every Sunday. Click here to view my other articles on health, nutrition and exercise.