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Diabetes: Controlling the Uncontrolled with Science

Medical advances in recent years have enabled doctors and other health professionals to better understand the scientific mechanisms behind diabetes, which in turn is enabling them to better treat patients.

Published September 1, 2003

By Rosemarie Foster
Academy Contributor

Image courtesy of thodonal via stock.adobe.com.

A typical supper in Sunflower County Mississippi, might start with a basket of hot fried cornmeal hush puppies, followed by a heaping plate of spicy barbecued ribs or crispy fried catfish, topped off with a hefty slice of sticky pecan pie, and washed down with a frosty glass of generously sweetened iced tea. To many, this mouthwatering meal may sound like heaven, but for the tens of thousands of residents of this Mississippi Delta community, it could also be a recipe for diabetes.

Although the Delta is famed for its blues and gospel music, lush fields of cotton, and delectable culinary contributions, it also has the unfortunate distinction of having the highest per capita incidence of diabetes in the United States. Due to an ill-fated combination of genetics, ethnic factors, poverty, cultural obstacles, and a downright unhealthy diet, 10.3% of Mississippi’s population has diabetes, with 7.7% having the type 2 variety. In Sunflower County alone – home to some 40,000 people – one in five residents has diabetes.

But big changes are afoot in Sunflower County, noted Scott Nelson, MD, a family physician and Mississippi native. Nelson was one of five presenters who spoke at a meeting in June called Addressing the NEW Diabetes Epidemic: Uncontrolled Diabetes. The gathering – a conference for science writers – was supported by an educational grant from Aventis Pharmaceuticals Inc. and was hosted by The New York Academy of Sciences (the Academy).

Overcoming Cultural and Financial Obstacles

Public health programs have been started in an effort to overcome the cultural and financial obstacles that prevent many Sunflower residents from adequately controlling their diabetes. Moreover, these programs may serve as models for nationwide efforts to control the rapidly escalating epidemic of type 2 diabetes. The conference presenters addressed the physiological basis of type 2 diabetes, its potential complications, the importance of self-monitoring, the growing role of insulin in its treatment, and new approaches with a greater chance of helping people manage their disease.

Stephen N. Davis, MD, chief of the Division of Diabetes, Endocrinology and Metabolism at Vanderbilt University School of Medicine, described the differences between type 1 and 2 diabetes. Type 1, the type most commonly seen in children, is characterized by destruction of the insulin-secreting beta cells of the pancreas, and results in a lack of insulin. Type 2 – which is commonly called “adult-onset” diabetes, but is now also being detected in children – may feature resistance to insulin and result in insulin deficiency, with beta cells becoming progressively dysfunctional.

Of the 17 million Americans who are estimated to have diabetes, 90-95% have the type 2 variety, but some 5 to 6 million of them don’t know it. Millions more have impaired glucose tolerance, a form of “prediabetes” that can sometimes lead to diabetes if left unchecked. And the problem is only getting worse, with a five-fold increase in the incidence of type 2 diabetes noted during the latter half of the 20th century in the U.S. “You can appreciate what a large public health problem that is,” asserted Davis.

A Genetic Component

Doctors agree that treating diabetes requires a team approach. At a panel discussion, from left: Stephen N. Davis, Richard S. Beaser, Scott Nelson, Alan M. Jacobson, and Stephen Brunton. Photo by Michael Gaffney.

So what can we do about it? The disease has a strong genetic component, a risk factor that can be compounded by an unhealthy lifestyle. Exercise helps by moving glucose from the bloodstream into the muscles. Since fatty acids decrease glucose uptake by the muscles and increase glucose production by the liver, following a diet low in fat can reduce diabetes risk. And different medications work by helping the body to regulate blood glucose levels.

“Despite great advances over the last 10 years, and despite knowledge that if we can control blood glucose to normal levels we can reduce the complications and burden of diabetes, most people [with type 2 diabetes] do not have good glucose control,” said Davis. “We still have great challenges. We’ve got to understand what’s going on in the body so we can intervene appropriately.”

Although monitoring daily blood glucose is an integral part of diabetes management, it’s not the whole story. A more important number today is glycated hemoglobin, or hemoglobin A1C, which is commonly abbreviated as “A1C.” Blood A1C levels represent average glucose levels during the past two to three months. Combined with vigilant daily glucose monitoring, periodic A1C testing offers “a window into the metabolism,” said Richard S. Beaser, MD, a senior physician at the renowned Joslin Diabetes Center in Boston.

The American Diabetes Association recommends that people with diabetes aim for an A1C of less than 7%, while the American College of Endocrinology suggests an even tighter goal of 6.5%. (People without diabetes usually have an A1C level between 4% and 6%.) But getting people to that point isn’t easy, as demonstrated by the statistic that some 57% of people diagnosed with type 2 diabetes still have an A1C level of more than 7%.

A Host of Complications

That could be exposing them to a host of complications. People with type 2 diabetes may have increased blood clotting, high cholesterol and hypertension. If not adequately controlled, diabetes can cause retinopathy (degeneration of the blood vessels in the eye, leading to blindness), abnormal electrocardiogram readings, kidney disease (leading to the need for dialysis and sometimes kidney transplantation), nerve damage, coronary artery disease (which can result in a heart attack), peripheral vascular disease (resulting in leg and foot ulcers and even amputation in some patients), and stroke.

Even modest improvements in A1C can dramatically reduce the risk of diabetes complications. The United Kingdom Prospective Diabetes Study reported that every 1% decrease in A1C lowered the incidence of microvascular complications by 35%, diabetes-related mortality by 25%, myocardial infarction incidence and mortality by 18%, and total mortality by 7%.

Patients can achieve optimal A1C levels by monitoring blood glucose levels several times a day, as directed by their doctors. This can be done using traditional finger-prick techniques, or newer digital blood glucose testers that enable the patient to draw blood from a less sensitive area, such as the arm, and store the information in the testing unit. Patients should share the results with their healthcare providers as well.

The payoff of such self-monitoring has been clinically proven: Beaser noted a study showing that 70% of people who tracked their blood glucose regularly achieved an A1C level below 8%, compared to only 18% of those who tested irregularly. “So clearly there’s a relationship between frequency of monitoring and results,” he contended.

A significant problem, noted Beaser, is that diagnosis happens too late. He explained that 18% of people with type 2 diabetes already have retinopathy at the time of diagnosis, a disorder that may have begun up to five years before.

“Missing the Boat”

“We’re really missing the boat in terms of diagnosis,” he emphasized. “We need to diagnose diabetes earlier, before it does its damage, and perhaps even diagnose insulin resistance before it causes diabetes.”

He encouraged doctors to screen all adults over age 45 for diabetes every 3 years, and to screen those at increased risk earlier or more frequently. Risk is greater among people with a family history of diabetes, the obese (those who are more than 20% above ideal body weight), those from certain ethnic groups (including Native Americans, Hispanics, and African-Americans), those with high blood pressure or cholesterol, and women who have had gestational diabetes or delivered a baby greater than 9 pounds.

Once type 2 diabetes is diagnosed, Beaser encouraged combination therapy, when necessary, to lower A1C levels. Different oral diabetes medications work through different mechanisms: Some increase insulin secretion by beta cells, others increase the body’s sensitivity to insulin, and a third group slows the breakdown and absorption of starches and sugars. As a result, many patients may need more than one drug to control their blood glucose. “These medications, used alone or in combination, can lead to important improvements in glucose control,” he asserted. Medication in combination with lifestyle changes would be optimal, but Beaser noted that it can take years for many patients to adopt healthier practices – years that may lead to potentially lethal complications.

“Our challenge is to allow people to have a lifestyle that is as normal as possible,” he concluded. “With the tools we have today, we can do that better than ever before.”

“This is Not Your Grandmother’s Insulin”

Despite oral diabetes drugs and lifestyle changes, blood glucose remains uncontrolled in many patients with type 2 diabetes. For these patients, insulin injections may be the answer. But insulin isn’t what it used to be: Today some patients can get by with a single dose of long-acting insulin each night, using a fine-gauge needle that causes little discomfort. “This is not your grandmother’s insulin,” emphasized Scott Nelson.

Some 25% of the patients in Nelson’s Mississippi practice have diabetes, and many of them have been helped by insulin therapy. Until recently, insulin for type 2 diabetes has had a bad rap among doctors, many of whom saw it as a last resort and an indication of treatment failure. But today’s long-acting insulins not only control blood glucose and match normal insulin secretion patterns, but also are easier for patients to take regularly.

Typically, patients with type 2 diabetes begin receiving insulin therapy some 10 to 15 years after their diagnosis, when diabetes complications may have already started. Nelson recommended insulin therapy earlier in the course of the disease, “before the proverbial train has run down the mountain and crashed into the village.” Recent studies have shown that early intervention with insulin therapy may not only control blood glucose in type 2 diabetes, but also may prevent or delay the progressive loss of beta cell function caused by the disease.

A Team Approach

Nelson also supported a team approach to controlling diabetes. The patient must monitor his or her blood glucose several times a day, take any medications as prescribed, and see a healthcare provider regularly. But doctors also need to step up to the plate, ensuring that their patients get the education they need and that those without diabetes are screened periodically to find the disease in its earliest stages. “If we put the team structure in place, there’s a lot that can be done,” stressed Nelson. In Mississippi, such an approach has resulted in programs that help impoverished patients obtain access to care they may not have otherwise been able to receive.

Alan M. Jacobson, MD, senior vice president of the Joslin Diabetes Center, underscored the importance of positive messages to encourage people to take charge of their health. “Changes in care over the last 25 years have changed the course of diabetes in some important ways,” he stated. “The challenge is to get this message out to the broadest audience.”

Patients need to know that better blood glucose control can pay off for them, and that such control needs to start early in the course of the disease. Many patients are fearful of starting the journey to such goals because they fear failure. Jacobson encouraged doctors to help patients separate their goals into “achievable bits,” rather than emphasizing the end result all at once. It’s easier to think of reducing A1C by 1% at a time, for example, rather than immediately going for a 3-4% decrease.

Overcoming Patient Fears

Stephen Brunton, MD, of Stamford Hospital/Columbia University Family Practice Residency Program in Stamford, Connecticut, agreed that there’s a need to overcome patients’ fears. “This disease is so fraught with misconceptions,” he said. “People may not only not want to discuss it, but they may not see their physicians when they need to.” He encouraged the development of programs that teach patients both how to control their glucose and how to maintain their quality of life.

Vital to those programs are resources that healthcare providers need to educate their patients effectively. Continuing medical education courses for doctors and simple tools for patients (such as flip charts, booklets, and videos) could facilitate the process. “Our goal as clinicians is to access patients who have less access to care, and to provide tools they may not have,” Brunton concluded. “This disease, like no other, needs to be managed by a team. As a team, we can get a handle on this epidemic.”

Also read: Challenges in Food and Nutrition Science


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