Diabetes.
Most of us know something about it because, as Americans, we almost certainly know someone who has the disease – or we’re at risk for it ourselves. Diabetes is a metabolic disorder in which people have problems converting food to energy. It is the leading cause of adult blindness, kidney failure, and non-traumatic amputations, and a major cause of heart disease and stroke.
Last month the US Department of Health and Human Services (HHS) released an updated estimate – based on population changes in the most recent U.S. census – indicating that the number of Americans with diabetes has ballooned to 17 million. This represents an increase of 8% from the most commonly-used previous estimate, and another step in the wrong direction for a population increasingly plagued by diseases that reflect our less-than-healthy lifestyles.
In addition, HHS Secretary Tommy G. Thompson warned Americans of the risks of "pre-diabetes," a condition affecting nearly 16 million Americans that sharply raises the risk for developing Type-2 diabetes and increases the risk of heart disease by 50%. (Type-2 diabetes used to be called “Adult Diabetes” because of its preponderance in the older population, but even that parameter is becoming blurred by the increasing number of young people who acquire Type-2 diabetes.)
“Pre-Diabetes” Defined
HHS and the American Diabetes Association (ADA) are using the new term "pre-diabetes" to describe an increasingly common condition in which blood glucose levels are higher than normal but not yet diabetic – known in medicine as impaired glucose tolerance or impaired fasting glucose. HHS-supported research shows that most people with pre-diabetes will likely develop Type-2 diabetes within 10 years unless they make modest changes in their diet and level of physical activity, which can help them reduce their risks and avoid the debilitating disease.
"The good news is if you have pre-diabetes, you can do something about it," Secretary Thompson said. "We want people to know that pre-diabetes is a serious condition that can be reversed or alleviated with modest changes in their daily routines – such as eating fewer calories and walking regularly for exercise."
Expert Recommendations
Secretary Thompson and ADA President-Elect Dr. Francine Kaufman also unveiled an expert panel's new recommendations about pre-diabetes. The panel, convened by the ADA and HHS, calls for physicians to begin screening overweight people age 45 and older for pre-diabetes.
The panel – which includes doctors and other diabetes experts, with representatives from HHS' National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and Centers for Disease Control and Prevention (CDC) – stated that intervention in pre-diabetes is critical for three reasons:
1. First, simply having blood glucose levels in the pre-diabetes range puts a person at a 50% greater likelihood of having a heart attack or stroke.
2. Second, research shows that the development of Type-2 diabetes can be delayed or prevented through modest lifestyle improvements.
3. Third, for many people, modest lifestyle improvements can "turn back the clock" and return elevated blood glucose levels to the normal range.
"This new recommendation gives physicians added incentive to screen their middle-aged, overweight patients for both Type-2 diabetes and pre-diabetes," Dr. Kaufman of the ADA said. "If you have pre-diabetes, you need to know it, so you can learn about the high risk of getting diabetes and the steps you can take to prevent it. If you already have diabetes, you need to be treated early to prevent complications."
The panel recommended that doctors screen overweight people age 45 and older for pre-diabetes during regular office visits using either one of the standard tests that detect diabetes: the fasting blood glucose test, which identifies impaired fasting glucose, or the oral glucose tolerance test, which identifies impaired glucose tolerance.
The panel also recommended that physicians consider screening adults younger than age 45 if they are significantly overweight and have one or more of the following risk factors:
- Family history of diabetes
- Low HDL cholesterol and high triglycerides
- High blood pressure
- History of gestational diabetes or gave birth to a baby weighing more than 9 pounds
- Belong to a minority group (African-Americans, American Indians, Hispanic Americans/Latinos, and Asian American/ Pacific Islanders are at increased risk for Type-2 diabetes.)
The expert panel did not recommend routine use of prescription drugs as initial treatment for people who have pre-diabetes. However, it did suggest that some people benefit from drug therapy, which may be considered when appropriate.
Even Small Weight Loss Can Have Major Health Benefits
The panel's guidelines resulted from its analysis of several major studies that evaluated strategies to prevent Type-2 diabetes, including HHS' Diabetes Prevention Program – a major clinical trial involving more than 3,000 people that showed prevention efforts can be effective. The Diabetes Prevention Program found that diet and exercise resulting in a 5-7% weight loss lowered the incidence of Type-2 diabetes by 58%. Participants lost weight by cutting fat and calories in their diet and by exercising (most chose walking) at least 30 minutes a day, 5 days a week.
The recommendations come as the incidence of obesity continues to rise despite growing evidence about its adverse effects on health and survival. In the United States, nearly 60% of adults are now considered significantly overweight, and in adolescents the prevalence of obesity has nearly tripled in the past 20 years.
"About 16 million people in the country have pre-diabetes and most of them don't know it," said panel member Dr. Judith Fradkin of NIDDK, which is part of HHS' National Institutes of Health. "Now that we have shown that we can prevent or delay diabetes, we need to find the people who can benefit. These new practical recommendations can help."
Diet and Exercise Dramatically Delayed Type-2 Diabetes
The millions of Americans at high risk for Type-2 diabetes can sharply lower their chances of getting the disease with diet and exercise, according to the findings of the Diabetes Prevention Program (DPP), sponsored by the NIDDK.
Of the 3,234 participants enrolled in the DPP, 45% are from minority groups that suffer disproportionately from Type-2 diabetes: African Americans, Hispanic Americans, Asian Americans and Pacific Islanders, and American Indians. The trial also recruited other groups known to be at higher risk for Type-2 diabetes, including individuals age 60 and older, women with a history of gestational diabetes, and people with a first-degree relative with Type-2 diabetes.
"Lifestyle intervention worked as well in men and women and in all the ethnic groups. It also worked well in people age 60 and older, who have a nearly 20% prevalence of diabetes, reducing the development of diabetes by 71%," said DPP study chair Dr. David Nathan.
DPP participants ranged from age 25 to 85, with an average age of 51. Upon entry to the study, all had impaired glucose tolerance as measured by an oral glucose tolerance test, and all were overweight, with an average body mass index (BMI) of 34. About 29% of the DPP standard group developed diabetes during the average follow-up period of 3 years. In contrast, 14% of the diet and exercise arm and 22% of the metformin arm developed diabetes. Volunteers in the diet and exercise arm achieved the study goal, on average a 7% (or 15-pound) weight loss, in the first year and generally sustained a 5% total loss for the study's duration. Participants in the lifestyle intervention arm received training in diet, exercise (most chose walking), and behavior modification skills.
Can the interventions prevent diabetes altogether? "We simply don't know how long, beyond the 3-year period studied, diabetes can be delayed," says Dr. Nathan. "We hope to follow the DPP population to learn how long the interventions are effective." The researchers will analyze the data to determine whether the interventions reduced cardiovascular disease and atherosclerosis, major causes of death in people with Type-2 diabetes.
"Every year a person can live free of diabetes means an added year of life free of the pain, disability, and medical costs incurred by this disease," said Dr. Allen Spiegel, director of the NIDDK. "The DPP findings represent a major step toward the goal of containing and ultimately reversing the epidemic of Type-2 diabetes in this country."
This article contains information from the
US Department of Health and Human Services and
American Diabetes Association.
