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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP
Programme 9. - Diabetes
RADIO 4
THURSDAY 06/04/06 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
MARK VANDERPUMP
PRODUCER:
ERIKA WRIGHT
NOT CHECKED AS BROADCAST
MYERS
Hello. Whenever and whatever we eat causes our blood sugar to rise. Normally it's mopped up by the insulin we produce but too much food over too many years can lead to system failure - blood sugar levels remain high and cause damage to the blood vessels. It may be many years before that becomes apparent but the problem, which is Type II diabetes, can lead to heart disease and stroke or blindness. Up to three million of us have Type II diabetes, so it is a major public health problem, what can we do about it, should we be monitoring our blood sugar - there are tests, there are kits designed for home use? Or would regular use of the tape measure give us the answer?
Well 08700 100 444 is the number to call or you can e-mail your questions to checkup@bbc.co.uk. And our expert today is Dr Mark Vanderpump, he's a diabetes specialist at the Royal Free Hospital here in London.
Mark, you don't go anywhere without your tape measure, so how important is that waist measurement?
VANDERPUMP
Well this is something that I've just started to do and it's really just been emphasised recently by how important the recognition of a syndrome called the metabolic syndrome is. This is a syndrome where people have recognised that their insulin doesn't work so well and would be compatible with a 94 centimetre or 37 inch waist in a man or an 80 centimetre, just over 31 inch in a woman. And basically what people are saying is that once your waist circumference goes above that that you're at risk of getting diabetes in the future.
MYERS
And sucking in your breath and holding your stomach doesn't count.
VANDERPUMP
No I mean I had a depressing note last week of saying well at least my waist size at my common store was 36 centimetres but I wasn't quite measuring or wearing my trousers exactly where one measures the waist and it should be halfway between the lower end of the ribs and the main spines that come from the pelvis. So it is a very definite - slightly higher than people think.
MYERS
You'll have put a lot of people on alert now because 31 inches for a woman - and thinking of my own waist measurement - is not particularly high.
VANDERPUMP
No I was discussing this with the taxi driver on the way over and I was saying I was basically I was doing this and he said well I'm 44 inches and I was able to tell him that that was actually putting him at quite high risk of getting diabetes and indeed heart disease in the future.
MYERS
Well we'll go to our first caller. Pam Irving is in Folkestone and is interested in the question of fat and the role that it plays in the risk of developing diabetes. Pam, what's your concern?
IRVING
Oh hello. Well yes I've heard a bit about this connection between the waistline for diabetes. I was tested by my GP for diabetes a few years ago and I was borderline, it was nothing to worry about, so we decided not to bother. Subsequently packed up smoking and my waistline has shot up, it's all gone on my waist. Now what I'd really like to know is, is the getting rid of the waistline the thing that will reduce the diabetes - is it a cause or is it actually a symptom of the thing that causes the diabetes, is the waist in itself a cause?
MYERS
Excellent question, what's the answer?
VANDERPUMP
Well the first thing to say I have to take when people tell me the tests are borderline because what that could have indicated is that you were at risk, even at some years ago. And so we do know that people, even if they're told their blood sugar is normal, if it's towards the upper end of the normal range they can progress to diabetes later in life. But you're right it is the waist that's the key measurement here and it's thought to be so because it represents the fat we collect inside the tummy, it's not what we collect on the surface of the skin that we imagine and so if you do scans of people who've got fat tummies, they've got lots of fat in their liver and around their bowel and that's basically a sign that your insulin isn't working very well and can be one of the indicators that you're going to get diabetes in the future. So you could increase your overall body mass but as long as you reduce your waist - that's the important thing.
IRVING
So will reducing the waistline actually help to avert possible diabetes?
VANDERPUMP
Well at the moment the studies suggest that it's the association of the waist with the diabetes. What the studies are now trying to show is that actually by reducing the waist you can prevent the onset of diabetes and there is reasonable evidence to suggest that that's going to be the case. So that would be my main message to you.
MYERS
Pam, thank you very much for your question, it does seem a bit unfair when you give up smoking and reduce your risks from smoking you then put on the extra weight. But it doesn't have to follow does it?
VANDERPUMP
No it doesn't but I think from her long term health point of view I think stopping smoking was probably the most important thing and the next thing to tackle is her waist measurement.
MYERS
Alright let's go to Dorset now and Patricia Kennedy with a question about diabetes. You've been diagnosed and have had the condition for three years.
KENNEDY
Yes nearly three years now, yes.
MYERS
Came as a bit of a shock did it?
KENNEDY
Absolutely, absolutely, right out of the blue, no family history.
MYERS
So how are you managing now?
KENNEDY
Well when you were talking about waist measurements I know precisely where I stand now. I need to lose the two stone the doctor told me and then I probably won't need to take medication, he said, so it's up to me isn't it.
MYERS
Okay, how are you going to tackle that?
KENNEDY
Well not by eating fruit I understand. This is the conflicting advice I've been given by doctors. One still treats me like a normal human being and says well of course you must eat fruit, it's good for you. But some others say no, fructose is as bad as any other sugar so you mustn't eat it, although everybody else must eat five a day, you must only eat three.
MYERS
And this is what confuses us all when we've got conflicting reports about these things because we just take it now as a mantra - five portions of fruit and veg a day is an absolute minimum - and yet there is this concern that perhaps too much fruit in this case, if you are diagnosed with diabetes, is perhaps not the right way. Let's try and get a definitive answer on this Mark.
VANDERPUMP
Well I think it's still very important to have your five portions of fruit and vegetables a day. One of the issues is what size is your portion and clearly a handful of grapes would be a portion, whereas other people might consider a whole bowl of grapes to be a portion. So the amount's important. You're right, to some extent, that there is still sugar in the fruit that we think and we like as soft, particularly the soft summer fruits tend to be full of sugar. So you're allowed them, it's just limiting the amount and actually focusing more on maybe the harder fruits and vegetables to keep your portion size. But it's clearly much better eating a portion of fruit than something like a bag of crisps or biscuits. So clearly there are relative things that are not so good for you. And it's important that you focus on other aspects like eating chicken and fish and keeping your carbohydrate portions as low as possible as well, in terms of looking at your plate and thinking well only a quarter of my plate will be the potato component of my meal and making sure I have at least half the plate as vegetables. But I agree with you there is conflicting advise but there is an important point I think that one of your doctors was trying to make is that the softer fruit that you like is sweet and is full of sugar and that still can cause problems in diabetes.
MYERS
And there are those myths around diabetes, it seems to me, and one is that you can't eat sugar, is that an absolute rule and why should that be so if you're otherwise eating quite a healthy diet and losing the weight that you need to lose why not a little bit of sugar?
VANDERPUMP
Well I think that if anyone - I've never believed any patient of mine will walk out of the clinic and say they never eat sugar, we clearly all do. And there are two strategies. One is that you can incorporate it as part of your main meal, so that the absorption of the sugar is much smoother and as part of another meal rather than just say on its own in the afternoon. And secondly that actually you could say well actually I'll go for - I'll have that cake but I'll go for a half an hour walk afterwards and actually try and work it off and actually treat it a bit more like that than actually just having a black and white rule that you can't eat sugar.
MYERS
And what's your view on buying diabetic products?
VANDERPUMP
Well I usually advise my patients never to buy anything that's got diabetes written on it, as a food product, I think you can eat exactly the same as everyone else, it's about the portion size and the amount not the type of food so much.
MYERS
Patricia I hope that's been helpful and we'll go to another caller if we may in Leighton Buzzard, Elaine Goss is waiting to speak to us. Hello there.
GOSS
Hello.
MYERS
Another lady with Type II diabetes, what's the particular concern?
GOSS
Yes I am trying to control it with diet and I will say my waist measurement is in that band that they were talking about. But I have lost two stone. During the day I can keep my blood sugars low and absolutely fine, I go to bed, having read my blood sugars level, wake up in the morning and they've gone up. I don't know what to do about it, I don't know how I can keep on top of it and by going up I mean going over eight.
MYERS
So you've been advised to keep a check on your blood sugars and that's a bit paradoxical - presumably you're not one of these who goes down and raids the fridge overnight are you?
GOSS
Not as far as I know.
MYERS
But the blood sugar seems to go up. Mark, what's your advise?
VANDERPUMP
Well there's a very clear explanation for this and this is another example of where we can use the concept of insulin resistance. And so the liver's function is to keep our blood sugar stable when we're not eating and because your insulin isn't working very well that's why you've got diabetes is that the liver is also not recognising - it's not receiving the signals it normally gets from insulin and so in effect it thinks you're starving and need more sugar in your circulation overnight. So you tend to allow sugar to be released from stores within the liver to allow the sugar - that's why it rises. So it's a well recognised phenomenon in Type II diabetes and it does sometimes allow us to focus therapies, particularly perhaps with the evening meal or last thing at night. But I think from how you're describing your blood sugars they sound very good to me and I think that probably you're within the sort of target range with diet alone that most people would accept as being reasonable.
GOSS
But I'm actually on Metformin.
VANDERPUMP
Oh right, okay.
GOSS
Two tablets a day of 850.
VANDERPUMP
Right, well what I sometimes tell people to do, if they can tolerate it, is to move their evening tablet to last thing at night, rather than with a meal. So some people can take the tablet with a meal or without it and sometimes take it without a meal. So if you just maybe take a smaller dose before you go to bed, you must discuss this with your doctor, but actually you can target the sugars overnight. And Metformin has got quite a short life of working, so if you're taking it quite early in the evening ...
GOSS
Well I'm taking them 12 hours apart.
VANDERPUMP
Yeah well it maybe that it's just not working long enough for you overnight, so the effect of the Metformin is starting to wear off, say come the early hours of the morning. So it might just be worth thinking about either splitting or adding a bit more Metformin before you go to bed to really target that fasting blood sugar.
MYERS
So obviously from what we've heard, Elaine is using a drug to control this. At what point do you have to give up trying lifestyle changes, when you've been diagnosed with Type II diabetes, and have to move on to medication?
VANDERPUMP
Well we have measures of how well people are doing in terms of particularly their blood tests and other factors but in terms of the sugar we have a measurement called the HbA1c or glycosylated haemoglobin which looks at your sugar levels over the last three months and really sees how well you've been doing. And so we assess people according to their diet and lifestyle and the effect on that particular blood test and if it's clear that you're doing all you can and yet your test is not improving it's at that point that we can support you with tablets.
MYERS
And how many people can control it, if you like, with these lifestyle changes and how many have to go on to drugs?
VANDERPUMP
Okay, well that's quite a difficult question to answer because I think that increasingly because of all the screening that's going on in primary care for cardiovascular disease and cholesterol that a lot of people are being found a lot earlier in the stage of their disease. And so I think you might say up to 20%-25% of the population might be controlled on so-called diet alone.
MYERS
So that's good news.
VANDERPUMP
Well it is a good news but it's also important to recognise that for them the sugar problem may not be the biggest problem that they've got. The other issue, that we were talking about with this metabolic syndrome, is that it's the blood pressure and the cholesterol that's very important as well. And so we really hate the term "mild diabetes" because some people think that just because their sugars are controlled on diet alone that actually they're okay but actually the syndrome we're talking about is much more the heart attack/stroke syndrome and looks at other risk factors, other than just purely sugar alone. So we try to move away now from diabetes as being a solely a sugar problem.
MYERS
Thank you very much, we'll go to another caller - Antonia, she's in Weymouth in Dorset, Antonia, question please for our expert today Mark Vanderpump.
ANTONIA
Hello, I'm 65 years old and my blood pressure is fine, my body mass index is fine, I have a healthy vegetarian diet, I keep fit by walking at least an hour a day, there's no family history of diabetes, my waist measurement is 28 but I have Type II diabetes. Am I just unlucky?
MYERS
Well it sounds as though you are unlucky, that seems very unfair doesn't it. Why would that be Mark?
VANDERPUMP
Well in terms of the genetics of Type II diabetes aren't clearly understand but clearly the way I think of it is that there's a group of people who are slim and whose genes are strong enough that they're going to get diabetes no matter what they do and clearly some people have not such a genetic tendency - they're overweight and they might get diabetes much earlier than other people. So I think in your particular case that probably what you've done is put off the diagnosis of diabetes for many years and actually by having your particular lifestyle you may well have prevented the onset of diabetes much earlier than it might have done. So I think all you've done in the past is fantastic and you need to keep it going and I think that the importance is that it's where you are now, from now on, that you have to keep your sugars controlled. But I wouldn't think - I don't think you've got yourself to blame, I don't think there's any problem here, I think it's just you are unlucky, you've been given the problem, it's probably within your genes and it was just too tough for you to overcome with your lifestyle.
MYERS
Are you aware of family members with diabetes?
ANTONIA
I've asked around and nobody has any recollection of it. I wondered if there could be some other cause of blood sugars going high?
VANDERPUMP
Well that's a very good point and there are certainly other conditions that can cause blood sugars to go high but they do tend to be relatively rare and usually associated with other symptoms as well. So I think that would be something for you to discuss with your family doctor, just to make sure that all other things have been considered. But I see a lot of people with diabetes in exactly the same situation as you and it just comes on for no reason and it's just bad luck.
ANTONIA
I am taking Atorvastatin, just a mild dose, and I've noticed on the information that comes with it that it can cause increases and decreases in blood sugar and I'm wondering if that could be a factor.
VANDERPUMP
No, I mean Atorvastatin is one of the group of cholesterol lowering drugs called statins, which is one of the commonest used drugs in diabetes and so there's no impact on your blood sugar with that drug.
MYERS
Okay, thanks for that call. I've got an e-mail, which I think is along the same lines, from Roy Butterfield, who's saying he's fit, healthy, takes lots of exercise, not overweight but has been diagnosed with Type II. His question though is does he need to cut out fat from his diet or is it just sugar in order to reduce his blood glucose or blood sugar levels?
VANDERPUMP
Well I suppose the key would be to reduce fat anyway, that's a given, and I think that it's limiting the amount of sugar as much as possible and also making your carbohydrate more complex - so it's concentrating on the more slowly absorbed carbohydrates and this is where the glycemic index has got some popularity.
MYERS
Well it certainly has, you hear quite a lot about the GI diet, is that actually relevant then for people with diabetes and in fact for everyone?
VANDERPUMP
Well it certainly is because it just means that your particular carbohydrate that you're eating is much more slowly absorbed and so you don't see such a high peak of sugar in the bloodstream after you've eaten. So it's allowing your body to have a much smoother excursion of blood sugars after a particular meal. So all the sort of foods that are recommended with the glycemic index diet would be an advantage.
MYERS
A quick time check - it's 18 minutes past 3, this is Check Up with me Barbara Myers and with my expert today - he's a diabetes expert, Dr Mark Vanderpump.
And we've got another caller, we'll go to Raymond, Raymond's in Broadstairs, hello Raymond, your question please.
RAYMOND
Hello. I've had diabetes - well I was diagnosed about 20 years ago in Paris at a public laboratory which came as a complete surprise to me. When I came back to this country I went straight on to medication and that continued until about two years ago. Now just towards the end of that time I managed to lose a little bit of weight - about half a stone - which I was quite proud of but I now think that was actually a side effect of the worsening diabetes. So then insulin was added, so I now take a mixture of medication and insulin. And since going on to the insulin I've found that in fact I've added that weight back on again, so I'm now a stone and a half heavier than I was at that point.
MYERS
Alright, let's see what Mark's got to say about that - putting weight on whilst on medication, is that something that you've come across?
VANDERPUMP
Well there's an important point here - is the natural history of Type II diabetes. And so what you've demonstrated Raymond is how you've probably been picked up at a screening test before you had symptoms, you initially could be managed on a diet and tablets have been added in. But after about 15 years it's thought that at least half the patients with Type II diabetes will need insulin, either in addition to their tablets or replacing their tablets. So you've followed the expected progression that one would see. And one of the problems we have with insulin as a therapeutic tool or as a treatment is that weight gain is almost an expected happening and so most people tend to find they gain up to five kilograms in the first year after therapy.
RAYMOND
Well no one ever warns you of this.
VANDERPUMP
Well I would have done. And I think that - there may be reasons for this, it may be that you gain muscle and you certainly leading up to that time you probably would have been passing lots of sugar in your urine and suddenly you're not doing so anymore and that sugar's got to go somewhere and it's usually stored as fat. And so in order to limit that problem people will be recommending that you use as little as possible and that you take even more active measures in terms of diet and exercise at that time, so you try and limit the impact of the weight gain. But unfortunately it is seen as probably a fairly inevitable consequence of going on insulin.
MYERS
Raymond makes an interesting point there about perhaps not being well advised. How well advised are people when they're given this diagnosis, do you think the system really is in place to make sure that everyone understands and knows quite what they can do as well as what medication they need to take?
VANDERPUMP
I mean my perception is that there is a lot more knowledge about diabetes in primary care, there's a lot more practice nurses delivering diabetes care, people are being diagnosed earlier, they're being offered treatments earlier. And certainly within the new NICE guidelines and in GP targets diabetes is one of the key indicators for GPs' practices. And so they're very much focused now on making people as well treated as possible and not just targeting their blood sugar but targeting their blood pressure and their cholesterol as well.
MYERS
Because we are talking about a national epidemic aren't we.
VANDERPUMP
Well this - I mean it depends, if you're talking about the number - you mentioned there might be three million of us with diabetes and there's a group that we don't know about yet and there's also the group of people with say the waist circumference being high with blood pressure and cholesterol being high as well, who are yet an unknown group, who may be up to a quarter of the population. So there's a massive group of people who are out there who have not yet got diabetes who may be at risk in the future. And that goes back to the sedentary nature of our lives now and our change in diet.
MYERS
And the symptoms are just not really apparent, you can't tell if you're beginning to get diabetes.
VANDERPUMP
Well in terms of - I mean diabetes when it presents as a clear syndrome is obviously associated with thirst and passing lots of urine and weight loss sometimes. But what we're talking about is the stage well before you get frank diabetes where you definitely won't have symptoms. And so that's the importance of screening and picking up people at that stage. It was always said that people who develop diabetes would have had it for about four to seven years before they knew they had it. And that partially explains why a lot of people - patients who are diagnosed - do have complications at the time of their diagnosis. So it's very sad to see someone entering a coronary care unit with a myocardial infarction or a heart attack and they're told they've got diabetes at that particular point and you sort of know that they've probably had it for five years leading up to that point and they presented with the disaster of a heart attack rather than being caught five years earlier, when they might have been able to do something about getting the heart attack in the first place.
MYERS
And so there's another of those myths that you can dispel, when people say well you don't die of diabetes, the fact is you die of things that are caused by diabetes, that connect with diabetes.
VANDERPUMP
Yes, I mean I think people have to think of it as a cardiovascular syndrome and there's this big emphasis now on hitting all the various cardiovascular risk factors - so that's really treating the blood pressure, the cholesterol, adding aspirin and getting the blood sugars as low as possible. And there's good evidence now that if you're diagnosed with diabetes you may be reducing your mortality - your death - your life expectancy by 10 years. And so it is a very important cause of morbidity and mortality and we haven't even talked about the impact in terms of blindness, nerve damage and kidney damage, which is also another big impact of diabetes.
MYERS
I've kept James Clarkson waiting in Birmingham, James your turn.
CLARKSON
Hello.
MYERS
Hello.
CLARKSON
I was diagnosed when I was 55 as Type II diabetes, I'm in my early 60s now. It is controlled by a mixture of medication and diet. But it came as a tremendous shock because from my late teens I cut out sugar, jams, cakes, sweets and biscuits, so I thought it was something that I could avoid. But I have been told that there was one sign that I had that wasn't picked up - I have had a major problem with heavy sweating for 30 years, it's been tremendously inconvenient all the time. I tried various medications to control it and nothing works - does the doctor know anything about heavy sweating related to diabetes?
VANDERPUMP
Well in terms of predicting diabetes I'm afraid it doesn't really help us because I mean sweating can be a complication of diabetes and there are effects on the nervous system and it can be a complication of treating diabetes and it can be a sign of hypoglycaemia when you've been over treated with tablets or insulin. It's important that, as well in diabetes, that there are other medical conditions that can cause sweating, particularly say with the thyroid. So those are the other issues to describe more generally. In your specific case I don't think there's any association with the sweating that you've experienced over your life and with the development of diabetes at this time.
MYERS
Okay, thank you for that. I'd like to just read an e-mail from Nigel at the end here. He's saying that yes people try to eat less but the fact is to lose weight you shouldn't diet - shouldn't crash diet - in fact you should be eating small amounts every two and a half hours so the body doesn't think it's being deprived and going into starvation mode. Would you agree with that?
VANDERPUMP
Well I think two and a half hours is probably a bit generous. I think the basic principle is that it's small meals regularly, rather than large meals intermittently, is the key message. And also make sure you've measured your waist.
MYERS
Keep an eye on that waist. Thank you very much indeed. Thanks to Dr Mark Vanderpump and thank you to all of you out there for your calls and your e-mails, not just today but over the past three months. This is the last in the present series of Check Up. If you want any further information about any of the topics that we've covered then do call our action line - 0800 100 400. Calls are free and confidential. Or you can go to our Check Up website, that's at bbc.co.uk/radio4, where you can listen to any of our programmes again. And until we're back in August may I wish you very good health.
ENDS
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