Type 2 diabetes and pre-diabetes are more common than ever; however, lifestyle changes and medication can help decrease your risk.
An estimated 20.8 million Americans now have diabetes, increasing their risk of heart disease, blindness, limb amputation and other serious health problems. An additional 41 million are estimated to have "pre-diabetes," meaning that they can expect to develop type 2 diabetes within 10 years unless they change unhealthy habits or receive medical treatment.
"At the rate we’re going," said Adi Mehta, M.D., a staff endocrinologist at the Cleveland Clinic, "we are looking at a very significant problem."
In fact, Dr. Mehta said, unless circumstances change, males born in the United States in 2000 have a 33 percent chance of developing diabetes, which will shorten each man’s life by about 12 years. Females born in 2000 have a 38 percent chance of developing the disease, shortening their lives by 14 to 15 years.
While there are two types of diabetes, the most common is referred to as "type 2." Diabetes occurs because sugar, the energy nutrient, is unable to be transferred into the working cells. In type 2 diabetes, the body does not respond adequately to insulin. Initially, the body tries to compensate for insufficient response by producing more insulin. But when the ability to overproduce insulin can no longer be sustained, sugar collects in the blood and diabetes results. The condition prior to the glucose becoming elevated is termed "insulin resistance" or "dismetabolic syndrome" or more commonly referred to as "pre-diabetes." People with diabetes have blood-sugar levels of 126 milligrams per deciliter or more. People with pre-diabetes have blood-sugar levels of 100 mg/dL to 125 mg/dL.
Signs of the pre-diabetes times
In addition to blood sugar levels, warning signs do exist, Dr. Mehta says. These include the development of dark patches of skin behind the neck and on elbows, knuckles and other areas where skin bends and creases. These dark patches result from excess skin pigment activated by too much insulin in the body, called acanthosis nigricans.
Another important sign is abdominal obesity. "When a patient walks into a doctor’s office, the first thing through the door should be the nose. If the first thing through the door is the tummy," Dr. Mehta said, "then you’ve already got the problem."
For women, additional warning signs may include irregular menstrual cycles, excess facial and body hair, severe acne and even difficulty becoming pregnant.
Finally, family history is important for everyone. Although the American Diabetes Association currently recommends that people over 40 have blood-glucose tests every three to five years, Dr. Mehta likes to expand upon that recommendation. "The abnormality of glucose is a very late development," he said. "If you wait for the glucose to become abnormal, you’ve already lost most of the horse. You’re closing the stable door after it’s escaped. What we need to do is start looking at people first from their family history."
Lifestyle changes most effective treatment
Studies have shown the best way to treat pre-diabetes is through lifestyle change. This includes cutting calories, making healthy food choices and exercising regularly, says Dr. Mehta.
Medications exist – including metformin and a group of drugs called thiazolidinediones ("thigh-a-zo-li-deen-die-owns") – that have been shown to delay the onset of diabetes, but none have been approved by the FDA specifically for this purpose. But, Dr. Mehta noted, these drugs are "a poor, poor second" when compared to the effectiveness of diet and exercise in treating pre-diabetes.
A clinical trial conducted by the National Institutes of Health identified 3,500 Americans with pre-diabetes and randomly assigned each person to one of three groups: those who did nothing about their condition, those who began taking metformin, and those who began watching their diets and exercising for 30 minutes a day, five days a week.
The conversion from pre-diabetes to diabetes for the "doing nothing" group was 33 percent over three years, or 11 percent per year. The conversion to diabetes within the group taking metformin was 22 percent over three years, or 7 percent per year.
"The lifestyle group [diet and exercise] was supposed to lose 7 percent of their body weight in the first year and maintain a 5 percent weight loss for the duration of the program," Dr. Mehta noted. They, in fact, lost only 5 percent the first year and maintained a 3-percent loss for the duration of the program. However in this group the conversion to diabetes was 12 percent, or 4 percent per year.
Medications, bariatric surgery have roles
For now, even though the FDA has not approved drugs specifically to treat pre-diabetes, doctors may prescribe metformin and thiazolidinediones for this reason if they deem the medications appropriate. And although he champions lifestyle changes, Dr. Mehta supports using drug therapies and continuing research efforts to improve these therapies to help control pre-diabetes.
"Unfortunately, our society is driven by drugs," he said. "We would prefer to take a pill rather than to do something simple to fix a problem.
"But," Dr. Mehta continued, "if drugs are the only alternative we have to diet and exercise, we have to become aggressive in, first of all, licensing the present drugs for use with pre-diabetes and, second, in finding other drugs. This is still a poor, poor second. I can’t stress that enough."
Dr. Mehta notes that metformin appears to be safe and effective in treating pre-diabetes, although it can’t be used in patients with liver, kidney or heart failure. Current evidence also indicates that thiazolidinediones are safe and effective, but more research is needed, he said.
"Thiazolidinediones are bioengineered drugs," Dr. Mehta said. "They turn on gene product. We know the gene products they activate from a glucose point of view, and we feel comfortable with that. But we don’t have any long-term studies on all of the other genes they may turn on, which may or may not have a negative effect. These drugs have been around for only about six or seven years. They also have a downside – they tend to make you gain weight."
Dr. Mehta believes bariatric surgery will have a growing role in treating what has been coined "diabesity," or diabetes specifically caused by excessive weight.
"I think diabesity is a true entity," he said. "And, the fact of the matter is, bariatric surgery provides – at least at present – the best short-term to mid-short-term results. In simple terms, bariatric surgery forces you to eat less and makes sure some of what you eat doesn’t get absorbed."
Treating related issues helpful
Doctors also are having success in delaying the onset of type 2 diabetes by treating the multitude of issues that often surround pre-diabetes as well as the pre-diabetes itself. Related issues include high blood pressure, high levels of harmful cholesterol (LDL), low levels of beneficial cholesterol (HDL) and abnormal glucose levels.
"If you treat hypertension with appropriate drugs, the conversion to diabetes seems to decrease by about 20 to 33 percent," Dr. Mehta said. "If you treat the cholesterol with appropriate drugs, the conversion to diabetes decreases 15 to 25 percent. Because these are all parts of the same tree, when you treat one problem you do get some benefit for the other."
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To read more about this and related topics, see:
Diabetes Overview
Metabolic Syndrome
Acanthosis Nigricans
Bariatric Surgery for Morbid Obesity
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 2/1/2006
