Diabetes: Separating fact from fiction

Diabetes is alarmingly increasing worldwide, having more than quadrupled since 1990. According to the World Health Organization (WHO), the prevalence of diabetes among adults rose from 7% in 1990 to 14% in 2022, with around 800 million people living with it. The latest figures from the International Diabetes Federation indicate that 11.1% of the global adult population (20-79 years) has diabetes, with 4 in 10 unaware of their condition.

In Lebanon, 10.5% of the population has diabetes, as reported in the 2017 WHO STEPwise approach to noncommunicable disease risk factor surveillance (STEPS) report.

Yet, despite its soaring prevalence, misconceptions about the disease still prevail. To help separate fact from fiction, Dr. Carole Saade-Riachy, specialist in endocrinology and metabolic diseases, answers The Beiruter’s questions.

Diabetes isn’t a disease of the elderly

True. Diabetes can affect people of all ages. There are two main types. Type 1 diabetes is an autoimmune condition, in which the body’s immune system attacks its own insulin-producing cells. It often develops in children – sometimes even in newborns – as well as in teenagers and young adults.

Type 2 diabetes, the most common form, accounting for nearly 90% of all cases, has a strong genetic component, contrary to popular belief. Diet plays a significant role in its development, as do obesity, particularly around the abdomen, and sedentariness.

Historically, this form of diabetes was most often diagnosed in people over 40. However, for at least two decades now, we have been witnessing a rise in its prevalence among younger adults, those in their thirties and even in their twenties.

A person is considered diabetic if their HbA1c level is above 6.5%. HbA1c, or glycated hemoglobin, is a blood test that measures the average of the blood sugar over the previous three months. A level below 5.7% is considered normal, while a level between 5.7% and 6.5% indicates prediabetes. Fasting blood sugar level is considered normal when below 100 mg/dL. In prediabetic individuals, it ranges between 100 and 125 mg/dL. Above these levels, a person is considered diabetic.

A new concept has been introduced: Time in Range (TIR) for diabetes. This refers to the percentage of time a person with diabetes maintains their blood glucose within a target range, typically between 80 and 180 mg/dL. The disease is well controlled if the patient’s TIR remains within this range for at least 17 hours per day.

Only overweight and obese individuals have diabetes

False. Diabetes can also occur in people of normal weight. In such cases, genetic factors play a major role in the development of the disease. However, abdominal obesity, fatty liver, metabolic syndrome and an unhealthy lifestyle, increase significantly the risk of developing the disease. A person suffers from metabolic syndrome if they have at least three of the following: abdominal obesity, high triglyceride levels, low HDL (good) cholesterol, elevated fasting blood sugar levels and high blood pressure.

Diabetes may be reversible

True. When diagnosed at an early stage, diabetes can be reversible. However, it is likely to worsen if not well managed. Thanks to the latest oral antidiabetic medications, it is now possible to regulate blood sugar and HbA1c levels effectively. But patient has an important part to play. They must adopt a healthy lifestyle, including a diet rich in fibers and vitamins and low in fat, and engage in regular physical activity, especially cardiovascular exercise. According to WHO, people should exercise around 150 minutes per week. If these measures are followed, remission of type 2 diabetes can be achieved.

Stress can provoke diabetes

False. Severe stress can, however, unbalance diabetes. If a person with a weak pancreas and abdominal obesity experiences severe stress (medical, emotional or psychological), counter-regulatory hormones may rise. Consequently, diabetes may be diagnosed. But stress isn’t the leading cause. The same applies to sleep. Disrupted sleep may affect diabetes.

Taking insulin means that my diabetes is severe, and I can become addicted to this medicine

False. Insulin is an effective treatment for diabetes. It is prescribed when the patient suffers from insulopenia, a condition characterized by a lack of insulin in the body. Some patients mistakenly believe they can become addicted to it. In certain cases, insulin is prescribed temporarily.

Ozempic and similar GLP-1 drugs are strictly prescribed for diabetic patients

True and False. Ozempic belongs to the class of medicines known as GLP-1 receptor agonists. These drugs work by mimicking a natural hormone produced in the gut, leading to a sensation of satiety. This class of medicines has been on the market since 2010, revolutionizing the management of type 2 diabetes. Indeed, it improves glycemic control and provides cardiovascular and renal protection. Studies have shown that some medicines of this class also help with weight loss. As a result, the Food and Drug Administration has authorized its prescription for obese people, even if they are not diabetic.

The problem is that people are using it in an anarchic way, without any medical indication or advice. This is very dangerous, because this molecule may have very serious side effects, as is the case with all medicines. However, the benefits of this drug family outweigh the risks, unless it is taken without any medical supervision and without undergoing a full medical check-up, including blood tests.

GLP-1 receptor agonists are an excellent treatment, but they must be used properly. People should not take them, simply because some influencers recommend them on social media, just to lose two kilos to fit into the dress they intend to wear for a special occasion.

Berberine and ashwagandha can cure diabetes

False. Some studies suggest a moderate effect of berberine on blood sugar levels, but there are no standardized doses and the amount tested vary from one study to another. Therefore, berberine isn’t a recognized treatment for diabetes. Patients shouldn’t stop their medications, as medical folow-up is vital in their cases.

The same applies to ashwagandha. This plant-based supplement may help individuals relax, but it doesn’t cure diabetes in any way.

Living with diabetes: What to eat

Diet plays a central role in managing diabetes, but it doesn’t have to feel restrictive. According to Dr. Nathalie Asmar Yaghi, a balanced, varied, and individualized diet remains the cornerstone of good management.

Whole grains, like bulgur, freekeh and quinoa, should replace refined cereals, such as white rice, white pasta and white breads, in most meals as they help control blood sugar more effectively. Legumes, including beans, chickpeas and lentils, are also excellent choices. They are rich in fiber and vitamins and provide a lasting feeling of fullness. However, the exact portions should be determined based on each person’s medication and calorie requirements.

Vegetables, rich in fibers and vitamins, are best included in every meal. “Yet most of us don’t eat enough vegetables because they require a lot of preparation,” Yaghi remarks. “Frozen vegetables can be an easy option, as can the pre-washed varieties sold in most supermarkets,” she added.

When it comes to protein, lean options, such as fish, chicken breast and lean red meat, are best. The cooking method also matters. It is advisable to avoid using high saturated fats, such as margarine, butter and coconut oil, which despite its healthy reputation, is high in saturated fat, even when it’s liquid. It’s also recommended to avoid deep-fried foods.

The same applies to sweets. As in a healthy diet, sugar intake must be kept to a minimum, as its impact on the blood glucose is greater for those living with diabetes. Sugar-free products are an option, but it is important to read the labels carefully and look out for hidden fats such as palm oil or margarine. If a sugar-free product contains these ingredients, it’s best to avoid it.

On another hand, all sugar-free products, such as sodas, candies, chocolate and biscuits, must be consumed with moderation.

Reduce the glycaemic spike

Glycaemic spikes, a rapid rise in blood sugar after meals, are what trouble most person living with diabetes. And no, drinking vinegar before a meal doesn’t help reduce them. The golden rule is to have a nutritious balanced meal, and distribute carbohydrates properly throughout the day. Mixing adequate quantity of carbohydrates with other components of the meal helps avoid spikes.

The choice of carbohydrate type is just as important. White rice increases blood sugar more than whole grains, for the same portion. This also holds true for refined flour and cereals.

Therefore, it is recommended to opt for whole grains, as these contribute to a slower and more stable rise in blood sugar and provide a lasting sense of satiety. They are also rich in vitamins, particularly B vitamins.

The plate of a diabetic person, as with anyone following a healthy diet, should include a large portion of green vegetables, carbohydrates and lean source of protein, with quantities determined by the dietitian in consultation with their doctor.

Sugar intake must remain occasional, and sweets should not exceed 5% of one’s daily caloric intake. A serving of sweets will also replace the fruit portion normally allowed. However, it is advisable to control the portion size of sweets and have them right after a meal. When eaten alone, insulin doses should be adapted, especially for insulin dependent patients. Desserts could also contain unhealthy fats that should be particularly controlled in a diet for diabetes.

A simple tip, however: when you feel like eating something sweet, try to distract yourself for 10 to 15 minutes, the craving will usually pass. And, most importantly, don’t keep sweets within easy reach in your daily environment.

According to Yaghi, one should not feel guilty when eating, to avoid swinging to the other extreme. This is why it is important to learn how to eat a balanced diet, while including sweets, whether one has diabetes or want to have a healthy lifestyle.

In conclusion, Yaghi stresses the importance of avoiding overly Westernized eating habits and returning to the basics of Lebanese traditional cuisine. Rich in vegetables and legumes, and naturally healthy if prepared with reasonable amount of olive oil, this cuisine supports blood sugar control, while still allowing room for occasional treats.