Type II Diabetes
There are about 10,000,000 diagnosed cases of diabetes mellitus in the United States. This is almost five times as many as 40 years ago and there are approximately an equal number of undiagnosed cases. We are talking about adult onset diabetes, also known as type 2. Childhood onset, or type 1 diabetes accounts for only 5-10% of total cases and is really a separate disease. The increases in the number of children in the United States diagnosed with type 2 diabetes is presumed to be due to increasing obesity and lack of exercise in American youth.
The term “borderline diabetes” is really misleading. The vast majority of “borderline” cases progress to symptomatic cases in a few years and complications of diabetes are frequently the first sign the disease is present. Treatment of borderline cases by lifestyle changes is a real opportunity to postpone and prevent complications. The general public over 45 years of age should have a blood sugar test about every three years. Those with a family history of diabetes or other risk factors should have the test annually.
Two large, integrated trials have been completed in many medical centers in the United States and the United Kingdom. Results of these trials have demonstrated that tight control of blood sugar does improve morbidity and mortality in diabetes and not just a little bit. The most successful patients (those who reduced their hemoglobin A1C to below 7%) had a 50% reduction in deaths and 90% reduction in blindness and kidney failure. Two major advances permitted the detailed data collection required for these large clinical trials. The first factor was the availability of home glucose monitoring that permitted patients to test their own blood sugars. The second factor was glycosylated hemoglobin, nicknamed HgbA1C.
Glucose is reactive chemically and combines with various proteins in our bodies. Hemoglobin and its combination with glucose are easily measured. At normal blood sugars, 4.2% to 5.8% of hemoglobin ends up with a glucose molecule attached before it is replaced in 4 months by new red blood cells coming off the assembly line located in the bone marrow. So hemoglobin A1C can be used as a measure of the average blood sugar over a period of about 2 months. Repeated 3-4 times per year, this test tells the patient and the doctor how close to normal the blood sugar has been over long periods of time which permits accumulation of reliable data for large clinical studies like those discussed earlier. Prior to the availability of HgbA1C, wishful thinking and unconscious manipulation caused a limited number of scheduled blood tests to appear better than they really were which misled patients and their physicians. Hence, it was many decades before the benefits of tight blood sugar control were proven.
In the United States, the average hemoglobin A1C in diabetic patients under treatment is 9%. Tight control is under 7%. Each 1% improvement in HgbA1C results in a 21% reduction to mortality, a 14% reduction in heart attacks and a 37% reduction in incidence of eye and kidney involvement. While tight control of cholesterol and blood pressure is especially important for those diagnosed with diabetes, reduction of elevated cholesterol and blood pressure have major benefits for any person, whether he/she is diabetic or not. Actually, individuals with diabetes do better with tighter than normal control of blood pressure. It is now standard practice to set a blood pressure goal of 130/80 for diabetics instead of the usual 140/90. This helps to prevent some of the extra arteriosclerosis that often occurs in people with diabetes.
The “800 pound gorillas” which often stand in the way of lifestyle changes are diet and exercise. Presumably, the earlier mentioned increase in adult onset diabetes in children is due primarily to television with the related snacks and lack of exercise. Our bodies are tuned for the jungle. If we are active enough so our appetites turn on to prevent starvation we will avoid obesity without willpower. Otherwise, our bodies remain tuned for prompt weight gain after famine. This has survival value if there is another famine around the corner. In essence, all of us need to match our diet to our exercise to be healthy. It is especially important for people with diabetes to eat no more than their level of exercise justifies, because overweight always results in insulin resistance, even in non-diabetics. This insulin resistance aggravates diabetes only when insulin production becomes insufficient to overcome the resistance. Thus, an overweight individual with diabetes will produce more insulin than a normal person will ever need; but this is still not enough to overcome the insulin resistance. Also, food eaten immediately in response to the body’s need for fuel (induced by exercise) does not need insulin to be processed. This is why unusual exercise in a person with diabetes on insulin treatment can cause low blood sugar. Exercise affects the need for insulin. Therefore, the insulin dose appropriate with a normal day’s diet becomes excessive in the presence of exercise not accompanied by food to sustain the exercise. In other words, a diabetic patient without arthritis of the knees is much more likely to be successful in controlling his disease if he uses those healthy legs for regular exercise.
A related problem is that the medications for diabetes (except for Glucophage, brand of metformin) all increase the appetite. The doctor may become enmeshed in an unfortunate cycle where he increases the insulin and other medications to make the blood sugar normal even though he knows the patient is already eating enough food to cause him to gain weight which will affect insulin needs. So, treatment of diabetes involves collaboration between the caregiver and the patient. Successful management of the disease almost always involves changes in lifestyle in addition to following a diet. But, to keep patients motivated to exercise for more than a week or two, the exercise must be suited to the patient’s needs and beliefs. Dancing may not be the right choice for a hard core Baptist and walking to work is probably not a good option if the patient lives more than a mile or two from his place of employment. So, many details of the care plan are subject to negotiation in a mutually resourceful frame of mind. As with the treatment of high blood pressure, frequently several medications with different side effects succeed where one at a time fails.
What does this discussion offer a reader who doesn’t have and may never develop diabetes? A varied diet and regular exercise is healthier for all of us. Those of us who do not have diabetes just have a larger margin for error and don’t have to be quite so careful all the time. If you would like to get started making some of these healthful life changes, take your next vacation doing something agreeable that involves more exercise—like biking or hiking or not using a cart for golf. When you return home, make some small changes in your routine that lead you towards a better diet and more athletic fitness. Then, in following years, use future vacations to build on what you have begun. You will start enjoying your food more, the waistband may get a little loose on your pants, life will start to be more fun, and you may even have younger, more active friends and therefore less loneliness in old age.
John A. Frantz, M.D See also: 1) So You Want to Lose Weight, 2) Diet &
Chairman, Monroe City Council Board of Health Exercise under Staying Healthy and 3) Genetic
December 6, 2001, revised December 10, 2003 Paradoxes under Medical Basic Science