We are in the midst of a diabetes epidemic in the United States.The prevalence of diabetes has tripled since 1990. 8% of Americans now have diabetes. 20% of Americans have prediabetes. Within 10 years, 20% of these people will have developed diabetes. The good news is that progression to Type 2 diabetes may be slowed, and perhaps prevented.
Multiple studies have been published since 2001 regarding the most effective methods of preventing progression. All studies have been conducted in people with prediabetes. The results from each study have been startingly similar despite very different study locations: China, Finland, and the United States. People who lost weight and exercised show a marked reduction in progression to diabetes.
The largest trial was the Diabetes Prevention Program (DPP) in the United States published in 2009. In that study, 3234 overweight subjects with prediabetes were randomized to standard care, weight loss and exercise, or Metformin 850 mg twice daliy. The exercise reigmen was at the discretion of the patient, but was typically 30 minutes of walking 5 days per week. The diet program was assisted by a diabetes nurse educator and dietitian.
The average weight loss was 5-10% of the starting body weight. Subjects who lost weight and exercised noted a 58% reduction in progression to diabetes in 6 years. Patients treated with Metformin noted a 30% reduction in progression to diabetes in 6 years.
The authors concluded that lifestyle intereventions were an appropriate approach to the prevention of diabetes.
What should you do if you're worried about diabetes?
1)Determine if you are at risk for diabetes.
Risk factors for diabetes include prediabetes, obesity, age 65 years or older, high blood pressure, elevated triglycerides and/or low HDL-cholesterol, a family history of diabetes, a history of pregnancy-induced diabetes (gestational diabetes) or babies larger than 9 pounds.
Ethnic groups at high risk for diabetes include African Americans, Hispanic Americans, Asian Americans, Pacific Islanders, and Native Americans.
If you have one or more of the above risk factors, carefully consider the prevention measures discussed below.
Remember however that only people with prediabetes have been evaluated in the major diabetes prevention trials.
2)Lose weight
It has been consistenlty shown that a modest 5-10% weight loss will significantly reduce your risk for progression to diabetes.
For example, if you weigh 200 pounds, a 10-20 pound weight loss may decrease your risk of progression to diabetes by 58% within 6 years.
Take effective, safe steps towards weight loss: reduce your overall intake with a special emphasis on the reduction of sweets and high fat foods. A reduction in your daily intake by 500-1000 kcal will result in a weight loss of 1-2 pounds per week.
Although there is are many diet programs available online, a visit with a certified dietitian is often helpful.
3)Begin a moderate exercise program
Exercise is important both in reducing progression to diabetes as well as reducing your risk for heart disease. The exercise doesn't have to be intense to have a positive impact.
In the DPP, many subjects walked for 30 minutes per day.
Before beginning an exercise program, exercise stress testing should be obtained if you are 35 years or older.
Remember that exercise alone, without changes in your diet and calorie restriction, is not likely to have a significant impact on your weight.
4)Consider Metformin.
In the DPP, Metformin reduced progression to diabetes by 31%.
Rosiglitazone (Avandia), Pioglitazone (Actos) and Acarbose (Precose) have also been shown to reduce progression to diabetes.
Rosiglitazone and Pioglitazone have the greatest reported reduction in progression to diabetes at 75%. Unfortunately, their use is limited by potentially serious side effects..
Rosigliatzone has been associated with heart disease, and is currently available only a restricted basis.
Pioglitazone has been associated with a slightly increased risk of bladder cancer with prolonged use in one study.
Both drugs are associated with weight gain, congestive heart failure and osteopenia.
Acarbose use is limited by a high rate of bothersome gastrointestinal side effects.
Some blood pressure medications (ARB's and ACE inhibitors) are associated with a modest 14% reduction in progression to diabetes.
Given a good safety profile, as well as potential heart benefits, Metformin is currently the drug of choice for diabetes prevention. It is most effective in younger, more obese subjects.
5)Know your HA1c
There is some support for using elevated HA1c levels as a reason to initiate diabetes prevention measures.
In a Japanese study, people with HA1c levels of >5.6% and a fasting blood glucose of >99 mg/dl, the risk of progression to diabetes was reduced by 76% with only a 3.5% weight loss.
Knowledge is the most effective tool you have to fight diabetes.
Understand if you are at risk for diabetes.
If you are at risk, understand what you can do to lessen your chance of progression to diabetes.
Make a positive difference in your life.
Dr. Michael Dempsey is an endocrinologist with over 20 years of experience caring for people with diabetes. His goal is to improve diabetes control within the parameters of your life. You can learn more about Dr. Dempsey's practice at https://sites.google.com/site/endocrinemetabolicconsultants/home. You can also follow him on Twitter for updates on what is new in diabetes care at https://twitter.com/.
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