72
  • Emailarticle
  • Writecomment

The Good News

Diet and exercise make the difference in diabetes prevention and treatment

By CARMEN MARTI

Think about this: diabetes might be the leading cause of death worldwide, an epidemic of vast proportions that experts believe will only get worse. According to a 2004 study by researchers from the World Health Organization and universities in Scotland, Denmark and Australia, the number of diabetics worldwide will double in the next 25 years. That's not good news for the United States, where more than 18 million people have diabetes, making this country one of the three nations with the highest prevalence of diabetes. The other two are India and China.

In the United States, the number of diabetics could reach 30.3 million by 2030. That could end up being more than a tenth of the population. According to Dr. Vasti Broadstone, medical director of the Joslin Diabetes Center at Floyd Memorial Hospital in New Albany, Ind., "One out of four people over the age of 65 [currently] has diabetes."

Many might not even know they are diabetic. In the United States, 33 to 50 percent of all people with the condition have not been diagnosed. As a result, diabetes can be present for an average of seven years before symptoms appear or anything is done to address it. Oftentimes, these cases are not discovered until a patient is diagnosed with something else caused by the diabetes, such as hypertension, kidney disease, nerve damage, loss of vision or heart disease.

Diabetes is caused when a malfunctioning pancreas doesn't keep the body's blood sugar balanced. Over time, this results in a series of complications. Diabetes is the leading cause of blindness and has a proven link to cardiovascular disease. In fact, adults with diabetes are two to four times more likely to have a heart attack or stroke than those without. "It's the complications that kill you," Broadstone says.

But what she says more often and can't seem to say enough is, "diet and exercise." The good news on the diabetes front is that diet and exercise are the most effective and least expensive treatments for the disease. Nearly 60 percent of the time, people with pre-diabetes are able to prevent its onset by losing just 5 to 10 percent of their body weight and exercising only 150 minutes per week, according to a 20-year study released in 2001 by the Diabetes Prevention Program of the National Institute of Diabetes and Digestive and Kidney Diseases.

"It's amazing how little it takes to make a difference," Broadstone says. "People get disappointed by only losing 10 percent of their weight, but even 10 percent improves you metabolically." For the worst cases, just maintaining weight is good, she says.

That's not to say watching weight and eating right are easy. "It's hard work," Broadstone acknowledges. "It means a lifestyle change ? and we'd rather take a pill."

But there are some pills to be taken. In the past five years, drugs and other therapeutic approaches to diabetes treatment have advanced dramatically, according to Dr. Theodore Mazzone, chief of Diabetes and Metabolism at the University of Illinois Medical Center at Chicago. He says there are now four to six different classes of drugs that can be taken in combination to help a patient control blood sugar. The problem, Mazzone adds, is that drugs are expensive. "They are not the solution."

The solution is prevention. Mazzone points out that one out of three babies will develop diabetes at some point in life. "There's going to be a huge explosion in Type 2 diabetes," which constitutes 95 percent of the cases. "It's because of obesity."

"The diabetes epidemic parallels the epidemic in obesity," Broadstone explains. "The most alarming thing is that Type 2 diabetes is growing tremendously in the under-20 population. We used to never see that. Now kids in their teens have it because of lifestyle.

"Our lifestyles are lousy," she continues. "We're more and more lazy and obese."

To help stem the tide of diabetes through prevention, physicians and educators have recognized the importance of teaching kids about nutrition. The American Society of Endocrinologists, the physicians who treat diabetes, has taken up the cause with the Power of Prevention program. Through POP, doctors visit sixth-grade classrooms to talk with students about lifestyle. They've found that children will not only embrace the tenets of healthy living, they will go home and tell their parents and grandparents what they've learned.

Educating the public about diabetes has become a full-court press. The American Diabetes Association has named November the Diabetes Awareness month. The NIDDK launched an awareness campaign in January targeted to people over 60. targeted to people over 60. The National Diabetes Education Program, a joint project of the Centers for Disease Control and Prevention and the National Institutes of Health, has developed community outreach programs and specialized patient information materials based on race.

The NDEP has focused on ethnic background because, in addition to obesity, the two other leading causes of diabetes are age and race. Statistics show that the trends of diabetes and heart-related complications are differentiated among races and ethnicities. According to the ADA, African Americans are 1.6 times more likely to have diabetes than Non-Hispanic whites, while Native Americans are 2.2 times more likely, and Latinos 1.5 times.

But no matter what a person's heritage, age or weight, there is a risk of diabetes for people who smoke and have a family history of the disease. For a woman, the risk is higher if she had diabetes during pregnancy (gestational diabetes) or a baby more than nine pounds.

The bottom line is everyone over the age of 35 should be tested for diabetes, according to Broadstone. She recommends a fasting blood test every three years for people with no risk factors, more often for those at risk.

And no one should be surprised if they're diagnosed with pre-diabetes. In fact, approximately 41 million Americans have pre-diabetes, where blood sugar is higher than normal, but not high enough to be classified as diabetes. The DPP study showed that early intervention can prevent or delay the progression from pre-diabetes to diabetes by up to 58 percent with lifestyle changes. As Broadstone says, "diet and exercise."

If the condition does progress, patients can look for resources such as the Diabetes Self-Management Program in the Nutrition and Wellness Center at the University of Illinois Medical Center at Chicago. A Center of Excellence certified for diabetes education by the American Diabetes Association, the clinic uses innovative approaches to helping patients develop strategies for sticking to a health program. It has computers for tracking personal data and information about diabetes medical devices. It provides counseling and runs programs in both English and Spanish on topics such as "Food Labels" and "Dining Out." It also helps patients use the latest diabetes technologies, such as the insulin pump. Replacing the need to inject insulin to control blood sugar, the pump is a computerized device about the size of a pager. Worn on a belt or put in a pocket, it allows a continuous flow of rapid- acting insulin to be released into body tissue. To use it, a small catheter with a needle at the end is inserted under the skin of the abdomen and taped into place. "The pump is a boon," says Mazzone, especially for younger patients who are learning to control their disease.

The next boon, according to Broadstone, may be insulin inhalers. After years of testing, a panel of advisers to the Food and Drug Administration recommended their approval in September 2005. Much like asthma inhalers, insulin inhalers enable users to breathe insulin in through the mouth so it can be absorbed through the lungs. Insulin pens, which look a lot like regular pens, except there's a needle under the cap, are pre-filled with insulin. They eliminate the need for carrying bottles of insulin and syringes and measuring doses. Commonly used in Europe, they are becoming more popular in the United States, Broadstone says.

Another trend in this country is the effort by businesses to improve diabetes health care. The disease cost the United States $132 billion in 2002, up from $98 billion in 1997. In an effort to control those costs, programs such as Bridges to Excellence, initiated in 2003, pays physicians an incentive for high performance and ADA recognition. A patient reward program encourages employees and family members to take an active role in managing their condition. Companies such as GE, Proctor & Gamble, UPS, Verizon and Ford have joined the coalition of physicians and health plans in support of the effort. Rewards include employer coverage of medical co-payments as well as prizes, such as palm pilots, to patients who attend recommended check-ups or show measured improvement in blood sugar levels. Some businesses will also cover the cost of health club and gym memberships.

"I think people are beginning to wake up to the benefits of healthy behavior," Broadstone says. It's about time; each year diabetes kills 213,000 people, and more than a million people develop it.

Still, researchers are working hard to find a cure, and there's progress in stem cell, genetic and transplantation therapies. Research dollars dedicated to diabetes have increased consistently over the past decade, and concerted efforts among pharmaceutical companies, big business, educators, researchers and the medical community have spawned innovative programming with a comprehensive reach.

It's a critical time in the evolution of diabetes. A complex public health problem, it's also very simple in a certain way. "Diet and exercise," says Broadstone. "That's the basic treatment." o

Diabetes Definitions

While a first strike approach to the prevention and treatment of diabetes is as simple as diet and exercise, the condition itself is complicated. This short list of definitions helps explain the basics.

Overview: Diabetes mellitus, commonly known as diabetes, is generally broken into three groups: Type 1, Type 2 and pre-diabetes. All forms of diabetes are characterized by an excessively high blood sugar level, caused by an inability to convert that sugar, or glucose, into energy.

Type 1 diabetes, formerly known as juvenile onset or insulin- dependent diabetes, is found in only 5 to 10 percent of patients with diabetes. Predominantly striking children as young as 3-years-old, Type 1 diabetes results from the body's failure to make insulin. Produced by islet cells in the pancreas, insulin converts sugar from the blood into fuel for the body's cells. The only treatment for this kind of diabetes is insulin provided by injection or subcutaneous pump.

Type 2 diabetes, previously known as adult onset, late onset or non-insulin-dependent diabetes, results from insulin resistance, or the body's failure to use insulin properly. Found in 90 to 95 percent of patients with diabetes, Type 2 is usually accompanied by obesity, which can prevent insulin from regulating metabolism, lowering blood sugar and lowering certain kinds of fat. Treatment for Type 2 diabetes can range from improved diet and exercise to diabetes pills to insulin injection by syringe, pump or pen.

Pre-diabetes is a condition that affects 41 million Americans and occurs when a person's blood glucose levels are higher than normal, but not high enough for a diagnosis of Type 2 diabetes.

Gestational diabetes is a form of glucose intolerance that is diagnosed in some women during pregnancy. It occurs more frequently among African Americans, Hispanic Americans and Native Americans. It's also more common among obese women and women with a family history of diabetes.

The pancreas, located behind the lower part of the stomach, is about the size of a hand. One of its functions is to make the hormone insulin. When food is ingested, cells within the pancreas release insulin to help the body use or store the sugar it gets from food.

Diabetes Risk Factors:

  • Weight
  • Smoking
  • Family history of diabetes
  • Low HDL cholesterol and high triglycerides
  • High blood pressure
  • History of gestational diabetes or birth to a baby weighing more than 9 pounds
  • Ethnic background (African Americans, American Indians, Hispanic Americans and Asian American/ Pacific Islanders are at increased risk for Type 2 diabetes)

Symptoms:

While people with diabetes can exhibit noticeable symptoms, such as frequent urination, blurred vision and excessive thirst, most people diagnosed with Type 2 diabetes do not show these overt warning signs at the time they develop the disease. People with Type 2 diabetes can sometimes live for years without realizing they have it.

Side effects of diabetes

In addition to high blood sugar levels, diabetes can lead to numerous other health problems, which include heart disease, nerve disease, kidney disease and high cholesterol and fat. Other effects can be blurred vision, fatigue and excessive thirst. High sugar levels also make it easier to get infections.

More on Type 2:

One of the reasons Type 2 diabetes is no longer called late-onset diabetes is that it is being diagnosed at earlier stages in life, largely due to America's obesity epidemic. But obesity doesn't always cause insulin resistance. Sometimes it's the kind of obesity that makes a difference. The most dangerous is abdominal obesity, the kind characterized by a "pot belly." Therefore, a person doesn't have to be extremely overweight to become insulin resistant. The good news is that some people who are obese can lose weight and reverse insulin resistance and diabetes.

The American Diabetes Association and the American College of Cardiology recommend that people with diabetes pay close attention to:

  • A1C, the test that measures average blood sugar over the past 3 months, should be less than 7 and checked at least twice a year.
  • Blood pressure, which should be below 130/80 and measured at every visit.
  • Cholesterol (LDL or "bad"), which should be below 100 and checked once a year.

A Functional Cure for Diabetes is Racing Through Clinical Trials

The experimental surgery sounds like a miracle. One day 46-year-old Kim Menard is testing her blood sugar constantly and injecting herself three times a day with insulin to control her diabetes. Eight days later, she's effectively cured. Menard has not injected insulin since September 22, 2005. That's after 33 years of constant maintenance of Type 1 diabetes, the most severe form of the disease.

Type 1 diabetes strikes just 5 percent of all people with diabetes, but it impairs its victims more radically than Type 2. Type 1 diabetics produce no insulin, while those with Type 2 produce, but don't use insulin properly.

Menard was diagnosed with Type 1 when she was 13. She weighed sixty-some pounds, but craved candy all the time. She was always thirsty and constantly went to the washroom. Over time, Menard developed hypoglycemia unawareness. Her blood sugar would drop without her realizing it, and she would pass out. Her nerves became damaged, causing numbness in her feet. She was waiting for the onset of kidney failure.

Then, in search of a pancreas transplant, she enrolled in a clinical trial at the University of Illinois Medical Center at Chicago. Under the guidance of Dr. Jose Oberholzer, Menard elected to undergo islet cell transplantation rather than wait for a pancreas.

In the islet cell transplantation surgery, defective pancreas cells, or islets, are replaced with healthy insulin-producing islets from a donor. Menard says she was awake, but under local anesthetic when an incision was made under her breastbone and the cells were pumped through the incision.

"It was so cool," she says. Now she waits to see if her body's immune system is going to reject the transplanted cells. She's on medications to help prevent that, and so far she's had no complications.

"I feel 100 percent better," Menard says. "It's been life-altering."

Today, Menard undergoes relatively rigorous follow-up to her transplant, but within nine months she is expected to be stable. Results from islet cell transplants done in other trials show the surgery has been successful in 80 percent of cases.

Not everyone is eligible for islet cell transplantation because there are so few islet donors. Right now Oberholzer can only take the worst-case scenarios, he says. But that doesn't stop him from dreaming of the day when islet cells can be reproduced in the laboratory and provided to hundreds of thousands of patients each year.

Islet cell transplantation is not a cure, Oberholzer explains, because the body does not begin to produce healthy cells and the transplanted cells could fail. "Our approach is a functional cure," he says. "But in time it could become standard procedure."--C. Marti

Published: December 01, 2005
Issue: Holiday 2005