Hana:

In Doboj I had a very interesting and important and, above all, a useful conversation with Inga Marković. She’s a specialist nutritionist dietitian and working in a public health institution in the Doboj Hospital in the Counselling Centre for Diabetes and Nutrition. It’s the only institution in the RS that has this type of counselling centre.

I learned a few important things from this conversation. First of all, I finally realised how our body works, and here I’m primarily thinking of how diabetes and insulin resistance occur. Inga explained the whole process in simple terms so I believe all of you will understand it after this explanation.

I’ve also learned the meaning of proper nutrition, and how much of each of us can impact own health through our food choices. I also learned about the link between the financial standing and the quality of nutrition, and it was especially interesting to hear that insulin in our body can even be affected by photos of food we are surrounded with.

What shocked me most is the number of people with diabetes in BiH, and the fact that many patients, due to ignorance, don’t know the proper treatment, and some even end up having severe diabetes-caused conditions, but they don’t even know they have it. This all shows the magnitude of the problems in our healthcare system and how important it is to change some things as soon as possible.

One of the ways for Inga is also her engagement in diabetics associations and that’s surely one of the steps – personal engagement of all those who know and can make some changes.

Each of can listen (or read) all these things and decide for themselves what to eat and how to treat their body.

As Inga puts it, we’d certainly have fewer diabetic patients if people paid attention to what they eat and moved more.

Inga Marković:

The increase in the number of patients is mainly related to chronic non-contagious diseases, with the biggest prevalence in our country compared to the region, namely diabetes, hypertension, cardiovascular diseases and an increasing number of malignancies. As far as work in the Counselling Centre is concerned, most of our patients have chronic non-contagious diseases and are overweight. Here too we are the leaders in the region when it comes to the number of overweight, where obesity is in fact the basic risk factor for all chronic non-contagious diseases. So we are in fact in a vicious circle where we don’t have a good prevention. We have treatment but no prevention, or this kind of treatment as something that is recognised and standardised and introduced in procedures like in other countries in the region. For example, nutritionists, both in Serbia and Croatia, are available in all wards, in all clinical centres, in all hospitals, in all kindergartens, in schools where they have collective nutrition, as well as in student dorms.

In your opinion, why is it that people here only start taking care of their date after it’s not too late, but when the disease forces them to take care of it?

Well, for the very reason that they aren’t educated. These twenty something years after the war led to a total collapse, both in education and healthcare. People have no information. I meet here patients suffering from diabetes for 20 years caused directly by nutrition, and no one has ever warned them of the chronic complications of that illness, nor what they should be eating or not. Nutrition is number one in the treatment of diabetes, medication therapy comes only third. So they have no information, no prevention.

Family medicine is simply inexistent. I wouldn’t say that there is no time, I’d say there is no will to give instructions to the patient as to what is it that they are suffering from and what was the trigger of their illness.

Well, we all have a certain genetic code in our genetics, carrying certain illnesses from our ancestors, but it always takes a trigger to get anything going in the body, either positive or negative. Nutrition is one of the basic triggers.

And then, if we make some major mistakes here, if we feed the body with nutrients that are of no use whatsoever for the body, the body cannot alert us and say, “Get that out, what are you giving me?!” Instead, with its own metabolism it creates more and more free radicals that are carcinogenic to fatty cells that lead to obesity, etc.

Tell me you opinion on relation between these kinds of illnesses caused by nutrition and financial standing.

Very much so. In 2012, the World Health Organisation gave some recommendations to increase physical activity and to somehow alert people to understand what nutrition is and how they can endanger or improve their health. They also said that health is a condition of mental, physical and social well-being. Sometimes in 2012, I think it was that year when the BiH People’s Council made a study and calculated how much a citizen of BiH spends on food daily. Their finding is that 50% of citizens are on the verge of poverty and according to calculations, one family with income spends around USD 2 each day on food per person. Poor population spends less than USD 1.2 for a full-day meal.

Now you can imagine what anyone can afford for oneself or own child for USD 1.2 daily that is to be spent on food. These are the foods that are the cheapest and strongest sense of fullness. We’re not hungry after these. That is why we no longer have children who bring sandwiches to school because it costs around BAM 2.5 to make a sandwich while chips cost BAM 1.

One of the illnesses I didn’t hear of before is insulin resistance that is very common today. How did this disease increase among people?

Look, it’s very easy to explain organically. Whatever I put into the organism, I’ll try to use the simplest terms to try to explain, all food is broken down into three basic elements – carbohydrates, fats and proteins. These macronutrients are delivered in the body to certain parts where needed. At any food intake, pancreas will react by releasing a hormone called insulin. There is a release of insulin that needs to take carbohydrates to all cells in the body. For years, by using foods rich in carbohydrates, we’re pushing our pancreas to constantly release insulin. And then what happens is insulin resistance. We have enough insulin but that insulin can no longer open the cell door and bring the carbohydrate to the cell.

Cannot keep up with the quantity?

It cannot keep up with the quantity. Insulin is also known as the doorkeeper, as the key to a lock. So you have a door that you’re constantly opening and constantly consuming, or you eat in a bigger amount or more often or you’re constantly nibbling on something, and every time, insulin needs to go to the cell, to be release, open the door of the cell as the key to the lock and give it there to the cell. And we simply wear out our pancreas. And so it comes to diabetes and insulin resistance.

When we have a fine meal on a plate consisting of cooked vegetables, meat, salads, limited quantities of bread – of course not white bread, not even semi-white bread, and even as a rule, knowing how bakeries work here, this bread shouldn’t be consumed at all since they put in a lot of additives that are again based on starch and carbohydrates. So when we have such a meal, for example, we have a slice of black bread, some meat, cooked vegetables, salad, then our pancreas is protected because we put in a bigger amount of plant fibres, so it’s slower for body to be absorbed and it requires smaller amounts of insulin. And then it’s like opening a tap for water to drip slowly.

But if we did consume something loaded with plain sugar such as white bread in large quantities, potatoes, rice, pasta, beans, peas, now you see it’s the cheapest food we just talked about, any kind of sweets, any sweet. As this is a huge amount of sugar that raises the blood sugar level and the body does not allow it, the pancreas has to release huge amounts of insulin – much like letting your shower run in the bathroom. And if we keep eating like that all the time, and most, if not 90% of people here have this kind of diet, as a result of economic situation, or ignorance, or because of our traditional diet, our pancreas constantly releases this shower throughout life, it’s shower, shower every meal, huge amounts of insulin that simply cannot open that cell eventually.

And then you go ahead with reduction diet therapy, meaning intake reduction of foods that require increased insulin release and physical activity that will fix these cell receptors in a way.

So, physical activity with dieting is a way out of insulin resistance, as well as a way to control diabetes.  Someone suffering from diabetes can certainly experience life without complications.

It is important for a person to understand what this plate in front of him is – whether it is health or illness. And to start thinking about how the body actually works and not just go to satisfy that feeling of hunger. Because when you look at shopping malls, all that is any worth is usually at the end. By the time you reach the cash register from the far end of the shopping mall, whatever is offered to you is unhealthy. Humans are visual types. Even the idea of ​​a particular food results in insulin release, where we have the need to consume these foods.

You’ve now said that the very thought of food causes insulin release. Is it possible at all that our exposure, from advertising in Facebook newsfeed, where people share photos of various cakes massively, can affect their health?

By all means. As I said – humans are visual types. We simply receive images, absorb pictures, and insulin is released at the thought of such a delicious food because we all know the taste.

In your opinion, how to fix these things?

We really need to understand what is primary to us and what should be the priority. If our priority isn’t to have population that’s unfit to work, working-age population suffering from illnesses, people who are at their prime, who can contribute most to their country, if this is not our goal, then we are really in a major problem because we already have children suffering from diabetes, insulin resistance, etc. What about them when they are grown-ups? Will adults be healthy adults who could contribute to both the local community and the country? It’s a question that everyone in power should ask themselves – what’s it that we want.

If this is to be done in such a way as to really think that the entire population of BiH is a healthy population, then certain measures need to be taken urgently. Education through schools, find an educated pool of nutritionists, come up with rules. We don’t have to reinvent the wheel, it’d suffice to look around to see how others are doing it. Just simply copy paste rules for children’s diet, bring nutritionists to posts, open up primary care counselling in health care centres, private family practice, through the media constantly stress what we’ve discussed today and simply give people the chance to choose which way to go.

As far as health and health care systems are concerned, this can be done with certain measures to follow up on the patient, to see why there’s no improvement or why is it deteriorating and try to ensure that the patient changes his or her life habits. It’s not our goal to spend huge amounts of money and resources on medicines. I don’t know whose goal is that, but obviously it is for someone. It seems to me these pharmaceuticals – that they are somehow in the lead in the health system and they decide what, how much, what will be spent, etc.

You are a health worker and you know that the major trend now is to leave the country and go to Germany. Have you ever thought about leaving, if not, what’s holding you here? What do you think in general how to keep young people at home not to move abroad?

I don’t know what to say. I was thinking about leaving very often. For a while I wasn’t here, I didn’t live here. But as for leaving, certainly financial standing is crucial here and it’s something that every person needs. You need a well-regulated country. A place where you feel safe, where you don’t have to think about what we’re discussing today. Why should a patient have to be so well educated to know his way around these things, to know the name of the drug, to know if there is a substitute, why was it replaced in the pharmacy, why does he have one thing written on his prescription but gets another medicine, you see? So I believe that in a well-regulated country neither a patient nor someone who lives there and has no health problems, there’s absolutely no need for them to know some things – there’s someone out there taking care of him. I think that’s the essence in leaving. Maybe even less than finances.

What are the associations you are active in and what are they essentially dealing with, what is their basic mission?

Sometime in 2014, I joined the association of diabetic patients “Diabeta” Doboj. Also in the Federation of Diabetic Associations of the RS and the Federation of Diabetic Associations of BiH. The primarily goal of any association is to simply help patients through education, information dissemination, distribution of glucometers, strips, and in a way compensate for some of the shortcomings in the health system.

Again, I don’t know is it financial situation or just lack of care, but our patients have very little information about the illness, and on the other hand they have no basic equipment to be able to follow and work on their illness.

In the RS, patients taking insulin are entitled to the medical device, while those who are on oral therapy do not. Someone with diabetes must measure sugar, must have a glucose meter, which the state does not provide. Then we try through our associations and through donations to give the patients the opportunity to get to the glucometer and we teach them to keep the so-called Self-control Log and use it to improve blood glucose.

As for federations at the level of the RS and BiH, throughout the whole country, we have both positive and negative experiences. Mostly, everything well that’s done someone else will try to take down, so it kind of loses its purpose. Also, we have corruption of certain associations working under the patronage of certain pharmaceutical companies and you have those of us who refuse to work like that. We will certainly fight for this, 2018 is coming, it’s an election year and we’ll try to raise awareness on this disease. As you said in your introduction, many suffer from insulin resistance. Reports say some 450,000 diabetic patients at the level of BiH. Do you know how many is that? That’s a lot.

But this is also quite a number of customers for the pharmaceutical industry?

Bravo! So, at the RS level, reports say about 70,000 to 90,000 patients, but please note that we don’t have a register of patients, neither in the RS nor in the FBiH nor at the level of BiH. I’m not a fan of statistics in general and I don’t like seeing people as numbers, especially if this is something that cannot be discussed. Whatever we say is discussed over a certain value, but the situation on the ground is much different and far more serious.

Each year at our hospital in surgery we have an increase in the number of patients with amputations. And if you have an increase, you know that the system is not working.

In my opinion, this suggest that perhaps one of the most difficult diabetes complications occurred, because then you simply become disabled for life. It shortens lifetime, the patient is unfit to work, and also psychological condition of such patients cannot be good, especially when they realise that they could’ve prevented it, that it was possible through good education, through nutrition which is neither expensive nor too complicated, that the patient could prevent this complication by measuring sugar regularly, that there was a possibility to get a glucose meter and stripes … Then this is a problem both for the patient and for the health workers in the department and the system because once a patient comes to realise this, it’s already late. It’s horrible to see someone who could’ve avoided it and simply didn’t because of the system. The same goes for patients in dialysis, the same with diabetes-related blindness, heart attacks, strokes, all complications of diabetes.

Is this complication going to occur after 5, 10, 15, 20 years – it only depends on the patient’s education in these segments as I’ve said. If the patient is well-versed in all of this, has the necessary knowledge, adopted it, he can live his life without complications, or those complications that do occur will certainly be lesser in their extent.

We have patients turning in and getting amputation, while at the same time they had no clue they had diabetes at all.

So we have a problem with thorough medical check-ups. It is either companies that do not pay for it or even if a medical check-up is done, it’s done to a limited extent and very scarce medical tests done for a particular patient, so that’s not something we can say “Well, fine, you did a this medical check-up, findings show this and that.”

We would have fewer patients suffering from diabetes, for sure if people would take care of what they are eating and moved more. Also, one of the goals of associations and federations include prevention and treatment. To impose ourselves somewhere in the system. And also to be partners in making certain decisions about therapy. So, to try to increase the number of straps, to try to provide patients with glucometers, to try to show patients based on concrete cases what are the outcomes if they fail to pay attention to their behaviour.

On the other hand, we also disseminate information on oral therapy, what is insulin therapy. Because many patients think that insulin therapy will solve their problem. However, insulin therapy without a well-educated patient on the amounts of carbohydrate intakes in food is perhaps a double-edged sword. Because those who are uneducated administer themselves certain quantities of insulin, do not behave in accordance with the amount of carbohydrates that insulin requires. There are resulting significant oscillations of sugar which again lead to complication rather than continuing oral therapy with slightly higher sugar levels.

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