How Can We Stop Diabetes?
The American Diabetes Association (ADA) has declared November 2011 “American Diabetes Month.” The slogan is “Stop Diabetes” accompanied by a picture of a lovely, trim, young lady with a hand outstretched like a traffic cop. The ADA maps out a truly ambitious plan for its “Stop Diabetes Movement,” urging people to get involved in multiple ways.
Still, it’s doubtful whether the disease will listen to that young lady. Diabetes – a problem with the way the body processes sugar – is a serious and deadly disease that causes serious and deadly complications. According to the ADA, more people die each year because of diabetes than because of breast cancer and AIDS combined. In addition to potentially life-threatening swings in blood sugar levels, people with diabetes are at greater risk of heart and blood vessel disease, kidney disease, eye disease, slow wound healing, problems with nerves, depression, and multiple other conditions.
Major health monitoring organizations, including the World Health Organization(WHO), the U.S. Centers for Disease Control (CDC), and the International Diabetes Foundation (IDF), project that the already overwhelming burden of diabetes will grow rapidly during the next 10 to 20 years, at great cost to society in money, well-being, and lives.
One of the most startling projections comes from the CDC, which in October 2011 predicted that by the year 2020, fully half of the U.S. population will have diabetes or prediabetes. Global statistics are no better. Data compiled by the IDF show that in 2011, the number of people globally with diabetes reached 366 million, an estimated 4.6 million people will die due to the disease, and health-care spending on diabetes will reach $465 billion in U.S. dollars. The WHO estimates that 3.4 million people died in 2004 from the consequences of diabetes and that diabetes deaths will reach twice that number by 2020.
Diabetes costs are soaring, as well. The CDC estimates costs of diagnosed diabetes were $174 billion in 2007 in the United States; if the costs of undiagnosed diabetes and prediabetes are included, that figure rises to $218 billion. On average, the cost of medical care for a person with diabetes is 2.3 times that of a person without the disease.
The IDF estimates that the total global cost of diabetes was at least 418 billion international dollars (ID) in 2010. (One ID has the same purchasing power as one U.S. dollar in the United States). By 2030, the IDF projects that those costs will reach at least ID 561 billion.
So how do we stop diabetes? ehealthMD spoke with Dr. Joel Zonszein, Director of the Clinical Diabetes Center of Montefiore Medical Center and Professor of Clinical Medicine at the Albert Einstein College of Medicine at Yeshiva University in New York.
ehealthMD: The prediction from the CDC is pretty grim: Half of the U.S. population will have prediabetes or diabetes by 2020, only eight short years from now. Obviously, we have a problem. But what do we do to stop it?
Prevention. We need primary, secondary, and tertiary prevention strategies.
When we talk about primary prevention, that means developing ways to prevent people from having diabetes. In primary prevention, our health-care system plays a minimal role. Major changes can only occur at a public health level and by our society.
Small changes have taken place in the last 5 to 10 years. For instance, nutrition labels with the amount of calories in fast food diets, the way foods are being processed such as the elimination of trans-fat from restaurant and fast food facilities. The message is out in the media that sugary drinks are bad for young people, who drink gallons of soda and other such drinks every day. But these changes are not enough. Much more has to be done.
ehealthMD: What about people who have been diagnosed with diabetes or prediabetes?
That’s where secondary prevention comes into play. By secondary prevention, I mean prevention of the complications of diabetes in people who have the disease. This is the point at which the health-care system kicks in, and we know that if we treat the disease early and aggressively, we can minimize complications.
However, we continue to see complications, although fewer. Proportionally, fewer people with diabetes are going to dialysis or having limbs cut off because of wounds that won’t heal. But the absolute numbers are up, because more people have the disease. Still, half or more than half of people on dialysis have diabetes, and diabetes is the leading cause of non-traumatic amputations.
The results of several large clinical trials add up to one message about secondary prevention: Diabetes is a disease that needs to be diagnosed early and treated aggressively. Too often, we’re making the diagnosis late. The CDC estimates that 20 to 25 percent of people with the disease don’t even know they have diabetes. We cannot stop the train of complications when diabetes is diagnosed late.
Finally, tertiary prevention – and I don’t even want to go there – is the term for controlling complications of advanced disease. Tertiary prevention is very expensive. These are the patients with kidney failure, heart attack, chronic congestive heart failure, or damage to other vital organs. In tertiary prevention, the goal is to improve patient quality of life, and avoid frequent hospitalizations. At this level, there is tremendous expense and suffering.
ehealthMD: You say “aggressive management” is the best secondary prevention strategy. How do you define aggressive management?
Aggressive management starts with a proper diagnosis early in the disease. To diagnose diabetes, we use either a measure called hemoglobin A1c [Editor’s note: hA1c is a measure of how much hemoglobin in the blood is bound up with sugar ; high HA1c levels indicate that blood sugar has been elevated for a prolonged period of time], or a fasting blood sugar or an oral glucose tolerance test.
We also look for people who are at risk. Obesity is the primary risk factor. More obesity, more diabetes; prevent one, prevent the other one. So we look at weight and other risk factors such as hypertension and high cholesterol. Once the diagnosis is made, proper treatment includes lifestyle changes along with medications need to start immediately.
ehealthMD: What are some of the other risk factors you look for developing diabetes?
Family history, age, and race/ethnicity are important. Other risk factors include a history of gestational diabetes, having large babies, and sedentary lifestyle. Hypertension and abnormal cholesterol levels are risk factors for both diabetes and premature cardiovascular disease (heart attacks and stroke). We no longer look at total cholesterol but rather the components. The three major components used to evaluate risk include the low-density lipoproteins (LDL) or “bad cholesterol,” triglycerides (TGL) a fat in the blood that can contribute to plaque formation, and high-density lipoproteins (HDL) known as “good cholesterol” In the old times we used to see patients with elevated LDL-cholesterol levels that usually ran in families, a condition called familial hypercholesteremia. Now we see people with diabetes, some very young, whose LDL is minimally elevated, but whose triglyceride levels are very, very high, and whose HDL levels tend to be very, very low. This profile is now the more common one and often found in obesity and type 2 diabetes.
People who overeat are unable to store the excessive calories into fat cells, the body’s normal process. Instead, the excess fat (triglycerides) is deposited in vital organs that are not meant to store fat –such as the heart, muscles, and liver, causing damage to these organs. We see young kids with “fatty livers” sometimes causing inflammation or hepatitis. We never before saw this type of liver damage in young individuals. Now we’re seeing it more and more.
ehealthMD: So what are the missing pieces in primary and secondary prevention? What should we be doing to help people prevent diabetes and its complications?
We have not been aggressive enough in providing prevention resources, including primary and secondary. Effective prevention of complications and organ damage requires early and aggressive treatment. That has not been taking place.
Education about diabetes is a very important component. Doctors are reimbursed at a very low rate for education services and often lose overhead of keeping a nurse or certified diabetes educator on staff. So there’s a disincentive. Yet several studies show that that education can help people manage their disease and minimize complications. When we measure outcomes such as hemoglobin A1c levels or blood pressure, we see improvement after providing education.
Still, the great majority of people with diabetes never receive any education, or if they do, it might be late, sometimes even 10 years after diagnosis. Education needs to be provided from the moment we diagnose diabetes to allow people to make changes very early.
It’s a constant battle with patients because they feel fine early in their disease and are often not willing to take medications. – concentrating only on lifestyle changes. The evidence however, is that the combination of a healthier diet, more exercise, together with medications when needed for blood pressure, cholesterol, and glucose, is more effective in both preventing complications and using more and more medications later in the disease.
Education about diet, exercise, and other lifestyle changes applies to the entire family, not only the patient. Children of people with diabetes are going to get diabetes sooner or later. If the entire family implements lifestyle changes such as heart healthy eating and exercise, the benefit of education is expanded.
ehealthMD: Why is it so hard for people to eat healthful foods and exercise and maintain a healthy weight?
We have learned a lot about obesity. Now we know that prevention of obesity is easier and better than losing weight. An article recently published in the New England Journal of Medicine confirms that after obese people lose weight, they are fighting many of their own hormones that are telling their brain “Eat more.” So after weight loss, people are suffering with hunger all day. This is just one example of our maladaptation to overnutrition. Results of recent studies by Dr. Michael Schwartz from Seattle, Washington suggest that high caloric intake may actually damage the brain. In experiments with obese mice, Schwartz found irreversible brain damage in the area of the brain that regulates food.
Environment plays a key role, as well. When patients with diabetes come to my office, as a general rule, they don’t come walking, running, or riding a bike. Patients with diabetes often have a more sedentary life. It’s difficult to make “sustained” lifestyle changes, particularly in industrialized societies where people may be working two jobs, or have stressful jobs. Change ,especially late in life, is not so easy.
Studies have shown that people often have success in making short term changes - six months to one year. But the great majority cannot sustain those changes over a period of more than one or two years.
So there are two components: a genetic component and a “toxic environment” one that result in excessive food intake and a maladaptation to overeating. The great majority of people who have gained weight have a big problem losing it and keeping it off. Unfortunately we don’t have effective medications for weight loss. Thus, in summary, it is very difficult to treat obesity.
ehealthMD: What about ethnic disparities? Diabetes prevalence varies widely by ethnic groups in the United States. Rates among African Americans, Hispanics, and American Indians in the U.S. are as much as twice that of Caucasians. Worldwide, developing countries are hit hardest – especially in areas such as the U.S.-Mexico border where people have easy access to junk food but live in impoverished communities. How do you explain these disparities, and what can we do about them?
Ethnic disparities in health care are real, and they’re not going away anytime soon. Certain ethnic groups are more predisposed to get diabetes, and also to get more complications. The care that we provide is far from optimal. In lower socioeconomic populations, this problem is magnified. Patients of ethnic/racial minorities and low socioeconomic class have many barriers. They don’t have time or easy access to visit the doctor. Because diabetes, hypertension and high cholesterol are silent conditions, they dont seek medical care until late in their disease. Other barriers include language, health care beliefs, and affordability to buy medications. These barriers are cluttered together and are not easily teased out. However, results of a recent study published in the New England Journal of Medicine showed that people who lived in poor neighborhoods and moved to better ones improved the incidence of both obesity and diabetes 10 years later.
There are also theories that suggest that some ethnic groups may have a genetic predisposition to obesity and diabetes. For instance, the “thrifty gene hypothesis” proposes that some groups such as the American Pima Indians in Arizona and the Mexican Indians who had historically limited food supplies might have adapted to periods of starvation. A rapid and dramatic change in their environment where exercise and activity decreased, and intake of food, high in calories and saturated fats increased, resulted in obesity and high incidence of diabetes.
But diabetes doesn’t occur because of one single gene. It’s when we put all the genes plus a “toxic environment” that we see it develop. So in a population that’s more susceptible, we see more diabetes.
ehealthMD: So what is the “takeaway” for ehealthMD readers?
Diabetes is a complex disease. Its complications can be devastating. As younger and younger patients develop the disease, it’s beginning to affect the workforce in this country. This is why I call it the “tsunami” of diseases. Diabetes remains a major problem in our society. While small changes are being implemented, they are not enough to stop the growing trend.
American Diabetes Association. (2011). Stop Diabetes. Available at stopdiabetes.diabetes.org
Centers for Disease Control and Prevention. (2011, January 26). 2011 National Diabetes Fact Sheet. Retrieved from http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
IDF. (2011, October 21). Diabetes Evidence Demands Real Action from the U.N. Summit on Noncommunicable Diseases. Press release. Available at http://www.idf.org/diabetes-evidence-demands-real-action-un-summit-non-communicable-diseases
Ludwig, J., Sanbonmatsu, L., Gennetian, L., Adam, E., Duncan, G.J., Katz, L.F., et al. (2011). Neighborhoods, Obesity, and Diabetes — A Randomized Social Experiment. N Engl J Med 365:1509-1519.
Wild, S., Roglic, G. Green, A., Sicree, R., & King, H. (2004). Global Prevalence of Diabetes: Estimates for the Year 2000 and projections for 2030. Global Diabetes Care, 27:5, MAY 2004, 1047-1053. http://www.who.int/diabetes/facts/en/diabcare0504.pdf
World Diabetes Foundation. (2011, May 05). Diabetes facts. Retrieved from http://www.worlddiabetesfoundation.org/composite-35.htm
World Health Organization. (2011). Diabetes. Fact Sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs312/en/
Zonszein, Joel. (2011, November 9). Telephone interview.