Thursday, 31 December 2009

When would this MADNESS stop?

A colleague of mine, whom I respect very much, for his humanitarian approach to Diabetes Care among Native American Indians, forwarded this to me:

See attached original article from Diabetes Care, January 2010 issue.


More than 96% of individuals with both IFG and IGT are likely to meet ADA consensus criteria for consideration of metformin.

Because >28% of all those with IFG met the criteria, providers should perform oral glucose tolerance tests to find concomitant IGT in all patients with IFG.

To the extent that our findings are representative of the U.S. population, ~1 in 12 adults has a combination of pre-diabetes and risk factors that may justify consideration of metformin treatment for diabetes prevention.

I wrote to him without delay.
my reaction to this article is pure NAUSEA.. let us keep my reaction to ourselves.. if someone asks about this article we have to have an intelligent discourse . i have embarked on a peer to peer education programme in the Indian country, would send you more details, in which already people who have had diabetes for more than 15 years have come off therapy. Based on articles published, we are too eager to put patients on therapy instead of talking to them and the providers keep on adding medications, such that within a couple of years, a patient with Diabetes in America, ends up with up to five different medications.
As you can see so much bad press about sulfonylureas and there are no drug companies to defend the poor drug, but Actos or Byetta you would see them mounting a multimillion dollar challenge to the published findings.
if we are to follow the published findings
sulfonylurea causes CHF
ACTOS ditto
Byetta pancreatitis
lantus breast cancer

we are left with Metformin, old fashioned Regular and NPH insulin..

thanks, mate

I was happy to receive his reply by return email.
So strange how you read my thoughts – I am obliged to pass along noteworthy findings that come from the medical establishment (such as this one),
but in my heart I feel that we cannot “cure” unhealthy lifestyle, poor personal choices, or the malnutrition of poverty WITH A PILL. The answer is not a drug. Natives in America will never accept this as a solution.

The real answers lie in personal change – education, motivation, and dedication between the patient/client and the health team of the clinic and community.
How we accomplish this paradigm shift in our culture, I do not really know.
Perhaps there will be a cardiovascular crisis in our children and youth – I do not wish to witness such a thing!

Is it true that the King of Tonga once decreed a national initiative for his entire kingdom; all of his people to live healthy, lose weight and eat right?
Maybe one day the leaders of the world can really lead, such as this.

Keep the faith, my friend.

It is nice to know that people like my friend are on the side of the Native Americans.. So many hundreds of providers, without analyzing the situation would begin to prescribe medications to a problem which is strictly SOCIAL..
News about King of Tonga:
King of Tonga

Earlier this year, King George V decided to use his patronage for a major initiative to tackle diabetes in Tonga and other Pacific nations where it has become a serious and debilitating problem.

"Tonga and the Pacific have one of the highest rates of diabetes per capita and my vision is to have a centre of excellence in research and treatment of this totally preventable disease." - His Majesty King George V.

Suffering from Type II diabetes himself, His Majesty is somewhat of an expert on the disease. To mark his recent coronation, he has formed a charity, the Royal Endocrinology Society, to help treat and research diabetes. His Majesty said of the disease, “If not properly managed, it can completely and painfully break the health, and lead to the death of its victims. It hurts their families, already puts a strain on overstretched medical services, and has a negative economic effect.”

Tuesday, 22 December 2009

The Origins of Obesity
While I was at The Indian Clinic today, a four day old baby was being proudly paraded around. His 17 year old mother and the beaming grandmother, were not the least concerned about the fact that he was 10 lb 9 oz, ie nearly 5 kilograms in weight at birth.
Gestational Diabetes causes babies to be large, and this young mother didn’t look obese or had GDM.
What could make this baby so big?
The probable answer came to me, within minutes when she began feeding him. It would have given me such great pleasure to see this four day infant sucking at her mothers breast, no, it was not to be.
Out came, a standard issue plastic bottle (possibly with BPA) and formula milk. Infamil, which had been given to her. Palm Oil for sure, if not Corn Syrup..
If the mother’s nutritional knowledge should be gauged by the food she is feeding her infant, what did she eat during her pregnancy. During my next visit I will do a good history of this, but I have no doubt that she was filling herself with Government issued food and food coupons..
I am more and more convinced that the Obesity epidemic in America and the one that is traveling around the Globalized world is due to the overdose of chemicals found in various food, and the increased consumption of such food.
Japanese live longer, they are not obese and they are very faithful to the way of their ancestors in their food. Those who eat McDo and KFC ..are the ones who are becoming Overweight and Obese.
In Malaysia, which has the distinction of being the Fattest country in Asia, KFC, McDo, Wendy’s etc are the favourites of the Yuppie Malaysians.. and on the road there are Dunkin Donuts to be easily had.. what happened to Nasi Lemak? And they blame it on innocent Te Tahrek for their increasing obesity. This is knowledge without context. They blame sugar but sugar is not the culprit but sugar substitutes are ..Sugar additives are…
In 2025, India would be the most populous nation on earth, with it they would also carry the distinction of Diabetes Capital of the World. The Yuppies of India, would like to be seen at the local Starbucks sipping Frappuchinos, paying it with their easily earned “bucks”( imported slang for the revered Rupee!)
Last August, I mourned when I saw a poster in Phnom Penh announcing the first ever KFC in that country. KFC and McDo and their compatriots would prolong the suffering on that country which suffered so much under another ideology of Khmer Rouge..

While in the west people are drinking organic tea with brown sugar, carefully choosing not to eat chemically laden food, corn syrup and its products as well as palm or palm kernel oil and partially hydrogenated oils of any type.. the East is succumbing to blind copying of the superficial western attire.. I warn them, behind your “bucks” and fake Armani shirts, you have the bodies of your ancestors.. so eat like they used to… otherwise .. it certainly be Death for the wrong reason…

Wednesday, 16 December 2009

Cultural Competence can make you a better Doctor

How Cultural Competence can increase your Clinical Acumen?
Mrs JM is 68 year old Indian, who came to see me. We have met along with her children and grandchildren when we did a Peer to Peer Education with her family. Apart from Type 2 Diabetes, she suffers from Rheumatoid Arthritis which has somewhat crippled her. She is mobile, walks with a stick and is very cheerful.
Here is the print out of the Blood Sugar readings over the past one month and the pattern of blood sugar as seen in the graph. She has a long list of medications, including Long and Short Acting Insulins, an oral hypoglycemia agent which she takes twice a day, a medication for BP and three other medications for her Rheumatoid Arthritis.
If you just look at this paper/graph and think of the body in terms of a machine, and not think of the patient or the society she lives in, your medical conclusions would be very different.
She dutifully takes her medications.
The pattern is thus, she wakes up with fairly normal blood sugar ( this morning it was 91 mg/dl) and then the blood sugar begins to climb throughout the morning, reaching around 300 mg/dl around 6 pm, then it comes down slowly through the night, achieving normalcy in the early morning next day.
A mechanical mind would think: she is too much breakfast and lunch; her morning regular insulin is not enough to combat the rise in blood sugar. The evening dosage is good enough to bring the blood sugar down.
They might come to the conclusion, if they only have four or five minutes to spend with the patient, that what she needs is to take more regular insulin in the morning to combat with the increasing blood sugar during the day.
Or they might conclude that the evening dosage of the long acting insulin is only enough to cover the rise in blood sugar after the evening meal and that she may need to take yet another shot in the morning of the long acting insulin.
What does Culture to do with Physiology? Does the culture interact with the medical care of this patient with Type 2 Diabetes?
If you have worked for any time with the native populations of North America, one thing you would begin to notice is that they are not very keen on eating breakfast. So this lady, like most of her generation, does not eat any breakfast, just a cup of coffee. The older Indians also eat very little for lunch, unless they are hungry and this lady usually has another cup of coffee at lunch time and at around 5 30 pm has a large supper.
Other Hours important in her daily schedule is the taking of her medications. She dutifully takes her morning medications between 10 30 and 11 am and the evening medications around the time of her supper.
Feeling reasonably comfortable that I had sleuthed the reason for her rising blood sugar during the day, we began a conversation about her life and the philosophy by which she conducts her life. The longevity among the Indians is much less than the majority population and the fact that she is nearly 70 years old itself is a credit to her determination to live well with her two disease. What will happen to all of us, I said, has already been decided by the Great Spirit, what we now hope is that our time here is without too much suffering. I know, she responded, the Great Spirit is keeping me here to do something, he has some plans for me, and I shall listen to that. She feels that her family, especially her grand children really need her, and that is the reason why she is surviving.
After a pleasant conversation about her daily life and ways of improving it, I explained the physiology of her sugar excursions, which are consistent, day after day, despite no dramatic changes in her daily behavior.
I have noticed that Indians who take Prednisone develop a kind of Insulin Resistance as well as Diabetes Type 2, which is metabolically a little different from the Type 2 Diabetes we see in the younger Indian populations. The Steroid induced Diabetes tend to be much more structural rather than metabolic, in that there is less end organ damages done and that they tend to live longer. But the effect of the Steroids is consistent and ever present with an insulin resistance which is not easily overcome. Thus her morning dosage of prednisone is overcome any efforts by the oral hypoglycemic agent and insulin. By the time evening comes around, the effects of the steroids are beginning to wear off and the insulin begins to work, bringing her blood sugar from the 300 mg/dl level to the normal level.
To decrease the number of pills she is taking, I advised her not to take the oral hypoglycemic agents twice a day, and just rely on the long acting insulin which she may now take in the morning as well. She will monitor her blood sugars as always and her next graph would give us an idea how the physiology has been altered and whether this strategy would slow down the increasing blood sugars during the day.